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Background: Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management., Objective: To examine the association between the Braden score and delirium., Methods: A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated., Results: The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001)., Conclusions: The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke., Implication for Clinical Practice: The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: To explore the differences in post-intensive care unit memory and posttraumatic stress disorder symptoms between patients with and without delirium, and assess the correlations between the two., Design: Prospective cohort observation study., Setting: A cardiac intensive care unit of a tertiary hospital in China. We enrolled 318 consecutive patients after cardiac surgery between December 2017 and March 2019., Main Outcome Measures: Delirium was assessed using the Confusion Assessment Method for the ICU from intensive care unit admission to discharge. Intensive care unit memory was assessed using the ICU-Memory Tool through face-to-face interviews one week after discharge. Posttraumatic stress disorder was measured telephonically using the Impact of Events Scale-revised questionnaire at three months post-discharge., Results: Eighty patients each in the delirium and non-delirium groups were enrolled for follow-up interviews. Patients with delirium had vaguer memories of pre-intensive care unit admission and of their stay, and recollected more memories of feelings (vs. without delirium). Posttraumatic stress disorder was diagnosed in 14 patients with and in seven without delirium, with non-significant differences between groups. Delirium did not influence post-intensive care unit factual, feeling, and delusional memories, nor posttraumatic stress disorder and hyperarousal, intrusion, and avoidance. The memories of feelings were positively correlated with the last three (r = 0.285, r = 0.390 and r = 0.373, respectively)., Conclusion: Patients with delirium had vague intensive care unit memories. Memories of feelings were positively correlated with symptoms of hyperarousal, intrusion, and avoidance. Delirium did not influence factual, feeling, or delusional memories nor posttraumatic stress disorder incidence and symptoms., Implications for Clinical Practice: Interventions are needed to reduce the impact of vague memory in patients with post-intensive care unit delirium. Memories of feelings should be focused on because of their correlation with hyperarousal, intrusion, and avoidance. Delirium prevention and early recognition measures are suggested., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: To investigate whether steep Trendelenburg in a major urologic surgery is associated with postoperative delirium, and to examine other potential clinical and radiologic factors predictive of postoperative delirium., Methods: 182 patients who received a major urologic surgery and underwent a 3.0-T brain MRI scan within 1 year prior to the date of surgery were retrospectively enrolled. Preoperative brain MRIs were used to analyze features related to small vessel disease burden and mesial temporal atrophy. Presence of a significant mesial temporal atrophy was defined as Scheltens' scale ≥ 2. Patients' clinico-demographic data and MRI features were used to identify significant predictors of postoperative delirium using the logistic regression analysis. Independent predictors found significant in the univariate analysis were further evaluated in the multivariate analysis., Results: Incidence of postoperative delirium was 6.0%. Patients with postoperative delirium had lower body mass index (21.3 vs. 25.0 kg/m 2 , P = 0.003), prolonged duration of anesthesia (362.7 vs. 224.7 min, P < 0.001) and surgery (302.2 vs. 174.5 min, P < 0.001), and had more significant mesial temporal atrophy (64% vs. 30%, P = 0.046). In the univariate analysis, female sex, type of surgery (radical prostatectomy over cystectomy), prolonged duration of anesthesia (≥ 6 h), and presence of a significant mesial temporal atrophy were significant predictors (all P-values < 0.050), but only the presence of significant mesial temporal atrophy was significant in the multivariate analysis [odds ratio (OR), 3.69; 95% CI 0.99-13.75; P = 0.046]., Conclusion: Steep Trendelenburg was not associated with postoperative delirium. Significant mesial temporal atrophy (Scheltens' scale ≥ 2) in preoperative brain MRI was predictive of postoperative delirium., Trial Registration: Not applicable., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Coronavirus disease 2019 (COVID-19) due to a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection can include various systemic organ disorders including endocrinopathies and neurological manifestations. We report the case of a 65-year-old Japanese man who developed isolated adrenocorticotropic hormone (ACTH) deficiency and encephalopathy following SARS-CoV-2 infection. Two weeks after his COVID-19 diagnosis, he was emergently admitted to our hospital because of subacute-onset delirium. On admission, he presented hyponatremia (128 mEq/L) and secondary adrenal insufficiency (ACTH <1.5 pg/mL, cortisol 0.53 μg/dL). Brain imaging and laboratory examinations including SARS-CoV-2 polymerase chain reaction testing in the cerebrospinal fluid revealed no abnormalities. His consciousness level worsened despite the amelioration of hyponatremia by intravenous hydrocortisone (100 mg/day), but his neurological presentations completely resolved after three consecutive days of high-dose (400 mg/day) hydrocortisone. His encephalopathy did not deteriorate during hydrocortisone tapering. He continued 15 mg/day hydrocortisone after discharge. His encephalopathy might have developed via a disturbance of the autoimmune system, or a metabolic effect associated with adrenal insufficiency, although the time lag between the hyponatremia's improvement and the patient's neurological response to the steroid was incompatible with common cases of delirium concurrent with adrenal insufficiency. At 13 months after his hospitalization, the patient's neurological symptoms have not recurred and he has no endocrinological dysfunctions other than the remaining ACTH deficiency. A thorough consideration of the immunological and metabolic characteristics of SARS-CoV-2 is advisable when clinicians treat patients during and even after their COVID-19 disease period.

Objectives: Delirium is a form of brain dysfunction with high incidence and is associated with many negative outcomes in the intensive care unit. However, few studies have been large enough to reliably examine the associations between body mass index (BMI) and delirium, especially in critically ill patients. The objective of this study was to investigate the association between BMI and delirium incidence in critically ill patients., Design: A retrospective cohort study., Setting: Data were collected from the Medical Information Mart for Intensive Care-IV V2.0 Database consisting of critically ill participants between 2008 and 2019 at the Beth Israel Deaconess Medical Center in Boston., Participants: A total of 20 193 patients with BMI and delirium records were enrolled in this study and were divided into six groups., Primary Outcome Measure: Delirium incidence., Results: Generalised linear models and restricted cubic spline analysis were used to estimate the associations between BMI and delirium incidence. A total of 30.81% of the patients (6222 of 20 193) developed delirium in the total cohort. Compared with those in the healthy weight group, the patients in the different groups (underweight, overweight, obesity grade 1, obesity grade 2, obesity grade 3) had different relative risks (RRs): RR=1.10, 95% CI=1.02 to 1.19, p=0.011; RR=0.93, 95% CI=0.88 to 0.97, p=0.003; RR=0.88, 95% CI=0.83 to 0.94, p<0.001; RR=0.94, 95% CI=0.86 to 1.03, p=0.193; RR=1.14, 95% CI=1.03 to 1.25, p=0.010, respectively. For patients with or without adjustment variables, there was an obvious U-shaped relationship between BMI as a continuous variable and delirium incidence., Conclusion: BMI was associated with the incidence of delirium. Our results suggested that a BMI higher or lower than obesity grade 1 rather than the healthy weight in critically ill patients increases the risk of delirium incidence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: HFE haemochromatosis genetic variants have an uncertain clinical penetrance, especially to older ages and in undiagnosed groups. We estimated p.C282Y and p.H63D variant cumulative incidence of multiple clinical outcomes in a large community cohort., Design: Prospective cohort study., Setting: 22 assessment centres across England, Scotland, and Wales in the UK Biobank (2006-2010)., Participants: 451 270 participants genetically similar to the 1000 Genomes European reference population, with a mean of 13.3-year follow-up through hospital inpatient, cancer registries and death certificate data., Main Outcome Measures: Cox proportional HRs of incident clinical outcomes and mortality in those with HFE p.C282Y/p.H63D mutations compared with those with no variants, stratified by sex and adjusted for age, assessment centre and genetic stratification. Cumulative incidences were estimated from age 40 years to 80 years., Results: 12.1% of p.C282Y+/+ males had baseline (mean age 57 years) haemochromatosis diagnoses, with a cumulative incidence of 56.4% at age 80 years. 33.1% died vs 25.4% without HFE variants (HR 1.29, 95% CI: 1.12 to 1.48, p=4.7×10 -4 ); 27.9% vs 17.1% had joint replacements, 20.3% vs 8.3% had liver disease, and there were excess delirium, dementia, and Parkinson's disease but not depression. Associations, including excess mortality, were similar in the group undiagnosed with haemochromatosis. 3.4% of women with p.C282Y+/+ had baseline haemochromatosis diagnoses, with a cumulative incidence of 40.5% at age 80 years. There were excess incident liver disease (8.9% vs 6.8%; HR 1.62, 95% CI: 1.27 to 2.05, p=7.8×10 -5 ), joint replacements and delirium, with similar results in the undiagnosed. p.C282Y/p.H63D and p.H63D+/+ men or women had no statistically significant excess fatigue or depression at baseline and no excess incident outcomes., Conclusions: Male and female p.C282Y homozygotes experienced greater excess morbidity than previously documented, including those undiagnosed with haemochromatosis in the community. As haemochromatosis diagnosis rates were low at baseline despite treatment being considered effective, trials of screening to identify people with p.C282Y homozygosity early appear justified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Malnutrition is associated with clinical outcomes in several diseases. However, the role of malnutrition in the risk of delirium in elderly patients in intensive care units (ICU) remains unclear. This study aimed to elucidate the association between the Geriatric Nutritional Risk Index (GNRI) and the risk of delirium in elderly patients in the ICU., Methods: Elderly patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD) were included in this study, totaling 11,310 and 5,627, respectively. All subjects were stratified according to their GNRI score: those with no nutritional risk (GNRI > 98), mild nutritional risk (92 ≤ GNRI ≤ 98), moderate nutritional risk (82 ≤ GNRI ≤ 92), and severe nutritional risk (GNRI < 82). The primary outcome was delirium., Results: The GNRI in MIMIC-IV and eICU-CRD were 93.82 (84.88, 101.26) and 83.39 (75.95, 89.35), respectively. Compared to the cohort without nutritional risk, there was an increased risk of delirium in patients with mild nutritional risk (OR: 1.39, 95 % CI: 1.23-1.58), moderate nutritional risk (OR: 1.72, 95 % CI: 1.52-1.95), and severe nutritional risk (OR: 2.07, 95 % CI: 1.79-2.39). Inclusion of the GNRI score in the multivariate models improved the prediction of delirium. Similar results were found in the eICU-CRD database., Conclusions: Nutritional assessment using the GNRI may be an independent predictor of the development of delirium in elderly patients in the ICU. The addition of the GNRI score to the delirium prediction model improves its predictive accuracy., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia., Methods: A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4)., Results: Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group., Conclusion: The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors., (© 2024. The Author(s).)

Age is a significant but heterogeneous risk factor for acute neuropsychiatric disturbances such as delirium. Neuroinflammation increases with aging but the determinants of underlying risk for acute dysfunction upon systemic inflammation are not clear. We hypothesised that, with advancing age, mice would become progressively more vulnerable to acute cognitive dysfunction and that neuroinflammation and neuronal integrity might predict heterogeneity in such vulnerability. Here we show region-dependent differential expression of microglial transcripts, but a ubiquitously observed primed signature: chronic Clec7a expression and exaggerated Il1b responses to systemic bacterial LPS. Cognitive frailty (vulnerability to acute disruption under acute stressors LPS and double stranded RNA; poly I:C) was increased in aged animals but showed heterogeneity and was significantly correlated with reduced myelin density, synaptic loss and severity of white matter microgliosis. The data indicate that white matter disruption and neuroinflammation may be key substrates of the progressive but heterogeneous risk for delirium in aged individuals., (© 2024. The Author(s).)

Background: Cancer affects mental health in older adults with cancer (OAC), affecting almost 50% of the patients. There are only a few studies on psychiatric disorders in OAC, especially in low resource settings. We report on our real-world experience of prevalence of and factors associated with psychiatric disorders in OAC referred to a psycho-oncology service in an Indian tertiary care cancer institute., Methods: We retrospectively analysed medical and psycho-oncology records of patients aged 60 + on cancer-directed treatment or follow-up for < 2 years after treatment completion, referred to psycho-oncology services in a tertiary care cancer centre in Mumbai, India, from Jan 2011-Dec 2017. We recorded sociodemographic, clinical, and treatment-related variables, as well as past psychiatric disorders. The ICD-10 was used to record current psychiatric disorder type and presence. IBM SPSS version 24 (Armonk, NY, USA) was used for descriptive measures, tests of association, and logistic regression analysis. The study protocol was approved by Institutional Ethics Committee and registered with the Clinical Trials Registry-India (CTRI/2020/06/026095)., Results: Of 763 patients included in the study, 475 (62.3%) were males and 436 (57.1%) were inpatients, with a median age of 65 years. 93% of the patients had a solid tumour and 207 (27.1%) had a history of psychiatric disorder. A current psychiatric diagnosis was noted in 556 patients (72.9%) on initial presentation, of which adjustment disorders, delirium and depression and anxiety disorders were most frequently seen in 25.2%, 21% and 11.1%, respectively. On univariate analysis, a past history of psychiatric disorders (χ2 = 34.6, p < 0.001), lower performance status (χ2 = 9.9, p = 0.002) and haematolymphoid malignancy (χ2 = 4.08, p = 0.04) significantly increased the risk of current psychiatric diagnosis. Logistic regression confirmed these variables as significant., Conclusion: Older adults with cancer referred to psycho-oncology services have high rates of psychiatric disorders at their initial presentation, mainly adjustment disorders, delirium and depression and anxiety. A past history of psychiatric disorders, lower performance status and haematolymphoid cancers significantly increased the risk of psychiatric disorders. Multidisciplinary psycho-oncology teams including a psychiatrist should be integrated in comprehensive care of this group of patients. Further research outcomes and effect of psycho-oncological interventions is required in older adults with cancer in LMIC settings., (© 2024. The Author(s).)

Purpose: Although comprehensive geriatric assessment (CGA) has been used widely, its impact on adverse events in elderly patients has not been fully examined. The present study aimed to investigate the relationships between subcomponents of CGA and adverse events (AEs) in elderly patients undergoing posterior lumbar fusion surgery., Methods: A total of 242 eligible elderly patients enrolled. Our CGA included activities of daily living, instrumental activities of daily living, nutritional status, cardiac function, pulmonary function, renal function, frailty, cognition, anxiety, depression, delirium, chronic pain score, comorbidity and polypharmacy. Comprehensive complication index was used to summarize postoperative complications and its severity. Logistic regression was performed to determine the relationships between subcomponents of a CGA and postoperative AEs., Results: Present study found that female were more vulnerable to have AEs. Postoperative major AEs were associated with delirium (odds ratio (OR): 4.302, 95% confidence interval (CI) 1.720-10.761, p = 0.002), nutritional status (OR: 3.030, 95%CI 1.218-7.541, p = 0.017), cognitive impairment (OR: 4.122, 95%CI 1.179-14.407, p = 0.027), Charlson comorbidity index (CCI) (OR: 4.800, 95%CI 1.852-12.440, p = 0.001) and severe dependent (OR: 3.772, 95%CI 1.116-9.841, p = 0.007). Further analysis showed that delirium (OR: 2.824, 95%CI 1.068-7.467, p = 0.036) and CCI (OR: 3.221, 95%CI 1.184-8.766, p = 0.022) were independently related to major AEs., Conclusions: These results indicate that preoperative screening preoperative delirium, cognitive, nutrition and CCI are essential to prevent postoperative major AEs of the surgical elderly., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

There is a growing body of evidence about physiological changes with age that impact fluid and electrolyte balance. It is important that infusion nurses have knowledge in managing care for geriatric patients so they can identify these changes when they are exhibited. Knowing how to minimize the effect of these changes on the health of older adults is critical. The infusion nurse with knowledge of geriatric-focused care can avoid complications and critical illness in older adults. In addition, it is important to provide specific patient education that is grounded in geriatric best practices. This information will assist older adults to better protect themselves from dehydration, kidney injury, and other complications associated with fluid balance, such as delirium. This article reviews the literature on specific changes with aging that predispose older adults to adverse complications with fluid imbalance. New technology in geriatrics that can improve management of fluid status, such as dehydration and electrolyte monitors, are also discussed. This review included searches of the Medline®/PubMed® Database using MeSH terms (National Library of Medicine). Search terms included the following: aging-biological; aging kidney; water-electrolyte imbalance; dehydration; hypo-hypernatremia; hypo-hyperkalemia; delirium; wearable technology; and hydration monitors., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Infusion Nurses Society.)

Objectives: Apathy is a frequent neuropsychiatric syndrome after stroke. We determined whether pre-morbid and early post-stroke apathy predicts dementia 3 months after stroke., Methods: We included ischemic stroke patients without dementia who participated in the Prospective Observational Polish Study on post-stroke delirium. We used the Neuropsychiatric Inventory and clinician-reported version of Apathy Evaluation Scale to score apathy symptoms before stroke and on day 8 after stroke. Patients underwent neuropsychological examination 3 months after stroke., Results: Of 422 patients with ischemic stroke and without pre-stroke dementia, 194 patients (mean age: 67.5 ± 12.3; 45.9% female) underwent neuropsychological examination. Dementia was diagnosed in 21.6% of them. Patients with dementia had higher apathy scores before stroke (mean: 0.9 ± 1.7 vs. 0.2 ± 0.9, p < 0.01) and on day 8 (mean: 37.2 ± 9.3 vs. 29.0 ± 9.6, p < 0.01). Depressive symptoms did not differ between groups. In multivariate analysis adjusted for age, diabetes mellitus, stroke severity and in-hospital delirium, apathy symptoms before stroke and on day 8 after stroke predicted post-stroke dementia (adjusted OR: 1.59, 95%CI: 1.13-2.26, p = 0.01 and OR: 1.06, 95%CI: 1.01-1.11, p = 0.03, respectively)., Conclusions: Pre-stroke and early post-stroke apathy independently from age, stroke severity and delirium predicted dementia 3 months after stroke. Apathy might be useful in identifying at-risk patients., (© 2023 John Wiley & Sons Ltd.)

We report about a man in his mid-50s who was prescribed pregabalin (150 mg/day) for neuropathic pain due to a herniated intervertebral disc. Four weeks later, he presented to the emergency room with symptoms consistent with delirium. After ruling out acute intoxication with a substance and neurological causes, collateral information from the family and review of his medical chart indicated potential discontinuation syndrome owing to pregabalin. Following the successful treatment and resolution of delirium, the patient revealed he had been consistently consuming pregabalin doses upwards of 2 g/day over the past 2 weeks, leading to the premature exhaustion of his prescription and an abrupt cessation. The case findings underscore the necessity for physicians to recognise the potential for pregabalin misuse and the associated withdrawal risks, including delirium., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP)., Objective: The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP., Methods: A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria., Results: Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms., Conclusions: This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly., (Copyright © 2023 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to evaluate 1) patient- and anesthesiologist-reported rates of postoperative delirium (POD) risk discussion during preoperative meetings, 2) patients' and anesthesiologists' ratings of the importance of POD, and 3) predictors of patient-reported discussion of POD risk during preoperative meetings., Methods: In this multicentre two-part cross-sectional survey study, patients ≥ 65 yr scheduled to undergo elective noncardiac surgery completed a five-minute survey after preoperative anesthesia consultation. Patients were asked about their perception of POD importance, and whether they discussed or were assessed for POD risk. Anesthesiologists were surveyed using self-administered surveys circulated via institutional email lists. Anesthesiologists were asked about the frequency of POD risk assessment and discussion in older adults, tools used, and perception of POD-screening barriers., Results: Four hundred and twelve (of 510 approached) patients (50% male; mean age, 73 yr) and 267 anesthesiologists (of 1,205 invited via e-mail) participated in this study conducted in five Canadian hospitals. Postoperative delirium screening and discussion was reported by 88/412 (22%) patients and 229/267 (86%) anesthesiologists. Postoperative delirium was rated as "somewhat-extremely" important by 64% of patients. A previous history of delirium, higher education, the number of daily medications, and longer surgical duration were associated with POD discussion. On average, anesthesiologists rated the importance of POD at 8/10, and 42% ranked "patient risk factors" as the top reason prompting discussion., Conclusion: The combined evaluation of patients' and anesthesiologists' perspectives provides valuable information on preoperative POD screening and risk assessment, and highlights areas for improvement in the current practice. Most factors we identified to be associated with higher odds of POD discussion are recognized risk factors of POD., (© 2023. Canadian Anesthesiologists' Society.)

Objective: Occurrence of hyperactive postoperative delirium (POD) with agitation after head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with the risk of life-threatening complications. The relationships between occurrence of hyperactive POD after HNS-FTTR and inflammatory markers reflecting the surgical stress response, represented by postoperative interleukin-6 levels, are not fully understood., Methods: A retrospective study was conducted on 221 consecutive patients who underwent HNS-FTTR at our department between September 2016 and December 2021. Potential risk factors for POD were examined, including age, operation time, intraoperative blood loss, and postoperative serum levels of blood parameters such as interleukin-6, C-reactive protein, and neutrophil-to-lymphocyte ratio., Results: Hyperactive POD with agitation was observed in 54 subjects (24.4%). The postoperative hospital stay in the POD group was significantly longer than that in the non-POD group (median: 32.5 days vs. 28 days; p=0.0129). Multivariate logistic regression analysis identified age (in years) (odds ratio: 1.102; p<0.0001), operation time (min) (odds ratio: 1.004; p=0.0359), and postoperative serum interleukin-6 level (pg/mL) (odds ratio: 1.005; p=0.0384) as significant risk factors for development of POD. In a receiver operating characteristic curve and area under the curve analysis, the cut-off value for postoperative serum interleukin-6 level to predict POD development was 82.5 pg/mL. The postoperative serum interleukin-6 ≥82.5 pg/mL group developed hyperactive POD with agitation significantly more often than the postoperative serum IL-6 <82.5 pg/mL group (odds ratio: 4.400; p<0.0001). The postoperative serum IL-6 ≥82.5 pg/mL group also had significantly longer postoperative hospital stay (41.58 ± 33.42 days vs. 31.73 ± 22.89 days; p=0.0151), older age (68.60 ± 9.99 years vs. 64.30 ± 12.58 years; p=0.0054), and longer operation time (625.4 ± 114.05 min vs. 575.5 ± 98.73 min; p=0.0009) than the postoperative serum IL-6 <82.5 pg/mL group., Conclusion: Postoperative serum interleukin-6 level, as well as age and operation time, were identified as significant independent risk factors for development of hyperactive POD with agitation after HNS-FTTR. Inflammation is a potential target for the prevention and treatment of POD after HNS-FTTR., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper., (Copyright © 2023. Published by Elsevier B.V.)

To investigate the incidence rate and risk factors of postoperative delirium in middle-aged and elderly patients with fracture. A total of 648 middle-aged and elderly fracture patients who underwent surgical treatment in our hospital from January 2018 to December 2020 were included in the study, aged 50-103 years, mean 70.10 ± 11.37 years. The incidence of postoperative delirium was analyzed. Univariate analysis was used to screen the risk factors of gender, age, interval between injury and operation, preoperative complications, fracture site, anesthesia method, operation time, intraoperative blood loss, hidden blood loss and hormone use. For the factors with P < 0.05, multivariate logistic regression analysis was used to determine the main independent risk factors. 115 cases (17.74%) of 648 patients had postoperative delirium. Univariate analysis showed that patients with delirium and patients without delirium had significant correlation in age, medical disease comorbidity, fracture type, anesthesia method, operation time and perioperative blood loss (P < 0.05). Multivariate logistic regression analysis showed that age (OR = 1.061), preoperative complications (OR = 1.667), perioperative blood loss (OR = 1.002) were positively correlated with postoperative delirium. It shows that older age, more preoperative complications, longer operation time and more perioperative bleeding are more likely to lead to postoperative delirium; patients with general anesthesia were more likely to develop postoperative delirium than patients with local anesthesia (OR = 1.628); and patients with hip and pelvic fractures are more likely to develop a postoperative delirious state (OR = 1.316). Advanced age, complex orthopedic surgery, more medical comorbidities, general anesthesia and greater perioperative blood loss may be independent risk factors for the development of delirium after internal fixation of fractures in middle-aged and elderly patients., (© 2023. Springer Nature Limited.)

Background: Previous population-based, longitudinal studies have shown that delirium is associated with an increased risk of dementia and cognitive decline. However, the underlying biological mechanisms are largely unknown. We aimed to assess the effects of delirium on both cognitive trajectories and any neuronal injury, measured via neurofilament light chain (NfL)., Methods: In this analysis of a prospective, 2-year follow-up, cohort study of participants aged 65 years or older living in Sandefjord municipality, Norway, we included cohort participants who were receiving domiciliary care services at least once per week between May 12, 2015, and July 8, 2016. Individuals with a life expectancy of less than 1 week, with Lewy body dementia, with psychiatric illness (except dementia), or for whom substance misuse was the principal indication for domiciliary services were excluded. Participants had a comprehensive assessment at 6-month intervals for 2 years, which included the Montreal Cognitive Assessment (MoCA) and a blood sample for NfL to measure neuronal injury. All information on clinical diagnoses and medications were cross-referenced with medical records. During any acute change in mental status or hospitalisation (ie, admission to hospital), participants were assessed once per day for delirium with Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria. We also measured NfL from blood samples taken from participants who were acutely hospitalised., Findings: Between May 12, 2015, and July 8, 2016, 210 participants were eligible for inclusion and assessed at baseline (138 [66%] of whom were female and 72 [34%] of whom were male), 203 completed cognitive assessment, and 141 were followed up for 2 years. 160 (76%) of 210 had moderate or severe frailty and 112 (53%) were living with dementia. During the 2-year follow-up, 89 (42%) of 210 participants were diagnosed with one or more episodes of delirium. Incident delirium was independently associated with a decrease in MoCA score at the next 6-month follow-up, even after adjustment for age, sex, education, previous MoCA score, and frailty (adjusted mean difference -1·5, 95% CI -2·9 to -0·1). We found an interaction between previous MoCA score and delirium (β -0·254, 95% CI -0·441 to -0·066, p=0·010), with the largest decline being observed in people with better baseline cognition. Participants with delirium and good previous cognitive function and participants with a high peak concentration of NfL during any hospitalisation had increased NfL at the next 6-month follow-up. Mediation analyses showed independent pathways from previous MoCA score to follow-up MoCA score with contributions from incident delirium (-1·7, 95% CI -2·8 to -0·6) and from previous NfL to follow-up MoCA score with contributions from acute NfL concentrations (-1·8, -2·5 to -1·1). Delirium was directly linked with a predicted value of 1·2 pg/mL (95% CI 1·02 to 1·40, p=0·029) increase in NfL., Interpretation: In people aged 65 years or older, an episode of delirium was associated with a decline in MoCA score. Greater neuronal injury during acute illness and delirium, measured by NfL, was associated with greater cognitive decline. For clinicians, our finding of delirium associated with both signs of acute neuronal injury, measured via NfL, and cognitive decline is important regarding the risk of long-term cognitive deterioration and to acknowledge that delirium is harmful for the brain., Funding: South-Eastern Norway Health Authorities, Old Age Psychiatry Research Network, Telemark Hospital Trust, Vestfold Hospital Trust, and Norwegian National Centre for Ageing and Health., Translation: For the Norwegian translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests HZ has been on scientific advisory boards for AbbVie, Acumen, Alector, Alzinova, ALZPath, Annexon, Apellis, Artery Therapeutics, AZTherapies, CogRx, Denali, Eisai, Nervgen, Novo Nordisk, Optoceutics, Passage Bio, Pinteon Therapeutics, Prothena, reMYND, Roche, Samumed, Siemens Healthineers, Triplet Therapeutics, and Wave; been a consultant for Red Abbey Labs; and has given lectures in symposia sponsored by Fujirebio, Alzecure, Cellectricon, Biogen, and Roche. HZ is a co-founder of Brain Biomarker Solutions in Gothenburg, Sweden, part of the University of Gothenburg Ventures Incubator Program. GS has participated in an advisory board for anti-dementia drugs for Roche and Biogen. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The debate over the optimal type of anesthesia for hip fracture surgery continues to rage. While retrospective evidence in elective total joint arthroplasty has suggested a reduction in complications with neuraxial anesthesia, previous retrospective studies in the hip fracture population have been mixed. Recently, two multicenter randomized, controlled trials (REGAIN and RAGA) have been published that examined delirium, ambulation at 60 days, and mortality in patients with hip fractures who were randomized to spinal or general anesthesia. These trials enrolled a combined 2,550 patients and found that spinal anesthesia did not confer a mortality benefit nor a reduction in delirium or greater proportion who could ambulate at 60 days. While these trials were not perfect, they call into question the practice of telling patients that spinal anesthesia is a "safer" choice for their hip fracture surgery. We believe a risk/benefit discussion should take place with each patient and that ultimately the patient should choose his or her anesthesia type after being informed of the state of the evidence. General anesthesia is an acceptable choice for hip fracture surgery., Competing Interests: Competing interests: ESS was a coinvestigator for the REGAIN trial and a coauthor for the published manuscript., (© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60 year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1 year (± 8.6) and 82.5 year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3 weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30 days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research., (© 2023. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Objectives: We examined whether preadmission history of depression is associated with less delirium/coma-free (DCF) days, worse 1-year depression severity and cognitive impairment., Design and Measurements: A health proxy reported history of depression. Separate models examined the effect of preadmission history of depression on: (a) intensive care unit (ICU) course, measured as DCF days; (b) depression symptom severity at 3 and 12 months, measured by the Beck Depression Inventory-II (BDI-II); and (c) cognitive performance at 3 and 12 months, measured by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global score., Setting and Participants: Patients admitted to the medical/surgical ICU services were eligible., Results: Of 821 subjects eligible at enrollment, 261 (33%) had preadmission history of depression. After adjusting for covariates, preadmission history of depression was not associated with less DCF days (OR 0.78, 95% CI, 0.59-1.03 p = 0.077). A prior history of depression was associated with higher BDI-II scores at 3 and 12 months (3 months OR 2.15, 95% CI, 1.42-3.24 p = <0.001; 12 months OR 1.89, 95% CI, 1.24-2.87 p = 0.003). We did not observe an association between preadmission history of depression and cognitive performance at either 3 or 12 months (3 months beta coefficient -0.04, 95% CI, -2.70-2.62 p = 0.97; 12 months 1.5, 95% CI, -1.26-4.26 p = 0.28)., Conclusion: Patients with a depression history prior to ICU stay exhibit a greater severity of depressive symptoms in the year after hospitalization.

Post-operative delirium (POD) is a state of mental and neurocognitive impairment characterized by disorientation and fluctuating levels of consciousness. POD in the context of esophageal surgery may herald serious and potentially life-threatening post-operative complications, or conversely be a symptom of severe underlying pathophysiologic disturbances. The aim of the present systematic review and meta-analysis is to explore risk factors associated with the development of POD and assess its impact on post-operative outcomes. A systematic literature search of the MedLine, Web of Science, Embase and Cochrane CENTRAL databases and the clinicaltrials.gov registry was undertaken. A random-effects model was used for data synthesis with pooled outcomes expressed as Odds Ratios (OR), or standardized mean differences (WMD) with corresponding 95% Confidence Intervals. Seven studies incorporating 2449 patients (556 with POD and 1893 without POD) were identified. Patients experiencing POD were older (WMD 0.29 ± 0.13 years, P < 0.001), with higher Charlson's Comorbidity Index (CCI; WMD 0.31 ± 0.23, P = 0.007) and were significantly more likely to be smokers (OR 1.38, 95% CI 1.07-1.77, P = 0.01). Additionally, POD was associated with blood transfusions (OR 2.08, 95% CI 1.56-2.77, P < 0.001), and a significantly increased likelihood to develop anastomotic leak (OR 2.03, 95% CI 1.25-3.29, P = 0.004). Finally, POD was associated with increased mortality (OR 2.71, 95% CI 1.24-5.93, P = 0.01) and longer hospital stay (WMD 0.4 ± 0.24, P = 0.001). These findings highlight the clinical relevance and possible economic impact of POD after esophagectomy for malignant disease and emphasize the need of developing effective preventive strategies., (© The Author(s) 2023. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: We aimed to characterize the association between BMI as a continuous variable and 30-day postoperative outcomes following hip fracture surgery through (1) 30-day readmission and reoperation; (2) local wound-related; and (3) systemic complications., Methods: The National Surgical Quality Improvement Program database (January 2016-December 2019) was queried for patients undergoing hip fracture open reduction and internal fixation. Baseline patient demographics, comorbidities, and patient outcomes were recorded. Multivariable regression models accounted for baseline demographics, comorbidities, and fracture patterns. Significant associations were analyzed using spline regression models to evaluate the continuous association between BMI and the aforementioned outcomes., Results: Spline models demonstrated a U-shaped curve for the odds of 30-day readmission and 30-day reoperation with nadirs at the BMI of 27.5 and 22.0 kg/m 2 . The odd ratios of superficial infection, deep infection, any wound complication, and inability to weight bear on POD 1 rose progressively starting at a BMI of 25.6, 35.5, 25.6, and 32.7 kg/m 2 respectively. Odds of 30-day mortality, transfusion, pneumonia, and delirium were greatest at the lowest recorded BMI (11.9 kg/m 2 )., Conclusion: BMI has a U-shaped association with 30-day readmission and reoperation. Conversely, the highest risk of mortality and systemic complications (transfusion, pneumonia, and delirium) were within the lower BMI range, with diminishing risk as BMI increased. Local wound complications and systemic sepsis exhibited a third unique pattern with progressive rise in odds as BMI increased. The odds of any complications demonstrated a U-shaped pattern with a nadir in the overweight to obese I categories, suggesting that patients may be at lowest risk within this range., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium., Methods: We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively., Results: There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups., Conclusions: We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Patients with anti- N -methyl-d-aspartate (NMDA) receptor encephalitis (ANMDARE) show a wide range of behavioral abnormalities and are often mistaken for primary psychiatric presentations. We aimed to determine the behavioral hallmarks of ANMDARE with the use of systematic neuropsychiatric and cognitive assessments., Methods: A prospective study was conducted, with 160 patients admitted to the National Institute of Neurology and Neurosurgery of Mexico, who fulfilled criteria for possible autoimmune encephalitis and/or red flags along a time window of seven years. Cerebrospinal fluid (CSF) antibodies against the NR1 subunit of the NMDAR were processed with rat brain immunohistochemistry and cell-based assays with NMDA expressing cells. Systematic cognitive, neuropsychiatric, and functional assessments were conducted before knowing NMDAR antibodies results. A multivariate analysis was used to compare patients with and without definite ANMDARE according to antibodies in CSF., Results: After obtaining the CSF antibodies results in 160 consecutive cases, 100 patients were positive and classified as having definite ANMDARE. The most frequent neuropsychiatric patterns were psychosis (81%), delirium (75%), catatonia (69%), anxiety-depression (65%), and mania (27%). Cognition was significantly impaired. A total of 34% of the patients had a predominantly neuropsychiatric presentation without seizures. After multivariate analysis, the clinical hallmarks of ANMDARE consisted of a catatonia-delirium comorbidity, tonic-clonic seizures, and orolingual dyskinesia., Conclusions: Our study supports the notion of a neurobehavioral phenotype of ANMDARE characterized by a fluctuating course with psychotic and affective symptoms, catatonic signs, and global cognitive dysfunction, often accompanied by seizures and dyskinesia. The catatonia-delirium comorbidity could be a distinctive neurobehavioral phenotype of ANMDARE.

Background: Geriatric trauma patients represent a special challenge in postoperative care and are prone to specific complications. The goal of this study was to analyse the predictive potential of a novel nursing assessment tool, the outcome-oriented nursing assessment for acute care (ePA-AC), in geriatric trauma patients with proximal femur fractures (PFF)., Methods: A retrospective cohort study of geriatric trauma patients aged ≥ 70 years with PFF was conducted at a level 1 trauma centre. The ePA-AC is a routinely used tool that evaluates pneumonia; confusion, delirium and dementia (CDD); decubitus (Braden Score); the risk of falls; the Fried Frailty index (FFI); and nutrition. Assessment of the novel tool included analysis of its ability to predict complications including delirium, pneumonia and decubitus., Results: The novel ePA-AC tool was investigated in 71 geriatric trauma patients. In total, 49 patients (67.7%) developed at least one complication. The most common complication was delirium (n = 22, 44.9%). The group with complications (Group C) had a significantly higher FFI compared with the group without complications (Group NC) (1.7 ± 0.5 vs 1.2 ± 0.4, p = 0.002). Group C had a significantly higher risk score for malnutrition compared with Group NC (6.3 ± 3.4 vs 3.9 ± 2.8, p = 0.004). A higher FFI score increased the risk of developing complications (odds ratio [OR] 9.8, 95% confidence interval [CI] 2.0 to 47.7, p = 0.005). A higher CDD score increased the risk of developing delirium (OR 9.3, 95% CI 2.9 to 29.4, p < 0.001)., Conclusion: The FFI, CDD, and nutritional assessment tools are associated with the development of complications in geriatric trauma patients with PFF. These tools can support the identification of geriatric patients at risk and might guide individualised treatment strategies and preventive measures., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Berk et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Older patients with preoperative cognitive impairment are at risk for increased postoperative complications after noncardiac surgery. This systematic review and meta-analysis aimed to determine the association between preoperative cognitive impairment and dementia and postoperative outcomes in older surgical patients after cardiac surgery., Methods: Eight electronic databases were searched from inception to January 4, 2022. Inclusion criteria were cardiac surgery patients ≥60 years of age; preoperative cognitive impairment; ≥1 postoperative complication reported; comparator group with no preoperative cognitive impairment; and written in English. Using a random-effects model, we calculated effect sizes as odds ratio (OR) and standardized mean differences (SMDs). Risk of random error was assessed by applying trial sequential analysis., Results: Sixteen studies (62,179 patients) were included. Preoperative cognitive impairment was associated with increased risk of delirium in older patients after cardiac surgery (70.0% vs 20.5%; OR, 8.35; 95% confidence interval [CI], 4.25-16.38; I 2 , 0%; P < .00001). Cognitive impairment was associated with increased hospital length of stay (LOS; SMD, 0.36; 95% CI, 0.20-0.51; I 2 , 22%; P < .00001) and intensive care unit (ICU) LOS (SMD, 0.39; 95% CI, 0.09-0.68; I 2 , 70%; P = .01). No significant association was seen for 30-day mortality (1.7% vs 1.1%; OR, 2.58; 95% CI, 0.64-10.44; I 2 , 55%; P = .18)., Conclusions: In older patients undergoing cardiac surgery, cognitive impairment was associated with an 8-fold increased risk of delirium, a 5% increase in absolute risk of major postoperative bleeding, and an increase in hospital and ICU LOS by approximately 0.4 days. Further research on the feasibility of implementing routine neurocognitive testing is warranted., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)

Background: People aging with and without HIV (PWH and PWoH) want to avoid neurocognitive dysfunction, especially delirium. Continued use of alcohol in conjunction with neurocognitively active medications (NCAMs) may be a largely underappreciated cause, especially for PWH who experience polypharmacy a decade earlier than PWoH. We compare absolute and relative risk of delirium among PWH and PWoH by age, level of alcohol use, and exposure to NCAMs., Methods: Using the VACS cohort, we compare absolute and relative risk of inpatient delirium among PWH and PWoH by age, level of alcohol use, and exposure to NCAMs between 2007 and 2019. We matched each case based on age, race/ethnicity, sex, HIV, baseline year, and observation time with up to 5 controls. The case/control date was defined as date of admission for cases and the date corresponding to the same length of time on study for controls. Level of alcohol use was defined using Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). Medication exposure was measured from 45 to 3 days prior to index date; medications were classified as anticholinergic NCAM, non-anticholinergic NCAM, or non NCAM and counts generated. We used logistic regression to determine odds ratios (ORs) for delirium associated with medication counts stratified by HIV status and adjusted for demographics, severity of illness, and related diagnoses., Results: PWH experienced a higher incidence of delirium (5.6, [95% CI 5.3-5.9/1000 PY]) than PWoH (5.0, [95% CI 4.8-5.1/1000 PY]). In multivariable analysis, anticholinergic and non-anticholinergic NCAM counts and level of alcohol use demonstrated strong independent dose-response associations with delirium., Conclusions: Decreasing alcohol use and limiting the use of neurocognitively active medications may help decrease excess rates of delirium, especially among PWH., (© 2023 The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objective: Delirium in the intensive care unit (ICU) is a common and critical condition that leads to poor prognosis in older patients, but the association between body mass index (BMI) and the incidence of delirium remains unclear., Methods: We retrospectively analyzed 5,622 patients admitted to the ICU of a tertiary referral hospital between 2013 and 2022. We collected sociodemographic data, vital signs, laboratory results, and delirium scale scores. We subdivided the patients into four categories: underweight (<18.5 kg/m 2 ), normal weight (18.5-22.9 kg/m 2 ), overweight (23-24.9 kg/m 2 ), and obese (>25 kg/m 2 ). The primary outcome was the incidence of delirium according to the BMI categories. We performed multivariable logistic regression analysis, adjusted for sex, age, past smoking and alcohol history, benzodiazepine use, and laboratory abnormalities., Results: Among the 5,622 patients in the ICU (mean age, 72.9 years; male, 60.1%; mean BMI, 24.2 kg/m 2) , the incidence of delirium was 19.0% (1,069 patients). The mean modified incidence of delirium was higher among underweight patients (odds ratio [OR]=1.51, confidence interval [CI]=1.07-2.12, p = 0.02) than among normal-weight patients. Overweight and obese status were not independently associated with delirium (OR=0.90, CI=0.70-1.17, p = 0.43; OR= 0.97; CI=0.77-1.21, p = 0.78, respectively). The area under the receiver-operating characteristic curve of the multivariable logistic regression model was 0.71 (95% CI=0.69-0.73)., Conclusions: Underweight status is an independent risk factor for delirium in the ICU. Additional caution is required when evaluating underweight patients for delirium. Obese or overweight status are not associated with delirium, providing evidence for the obesity paradox., Competing Interests: Declaration of Competing Interest The authors declare no actual or potential conflicts of interest related to this study., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI)., Methods: We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI., Results: The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92)., Conclusions: The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI., (© 2022 The Authors. Acta Psychiatrica Scandinavica published by John Wiley & Sons Ltd.)

Objective: To investigate the relationship between history of anti-inflammatory medication use and delirium risk, as well as long-term mortality., Methods: In this retrospective cohort study, subjects recruited between January 2016 and March 2020 were analyzed. Information about anti-inflammatory medication use history including aspirin, NSAIDs, glucosamine, and other anti-inflammatory drugs, was collected. Logistic regression analysis investigated the relationship between anti-inflammatory medications and delirium. Log-rank analysis and cox proportional hazards model investigated the relationship between anti-inflammatory medications and one-year mortality., Results: The data from 1274 subjects were analyzed. The prevalence of delirium was significantly lower in subjects with NSAIDs usage (23.0%) than in those without NSAIDs usage (35.0%) (p < 0.001). Logistic regression analysis controlling for age, sex, dementia status, and hospitalization department showed that the risk of delirium tended to be reduced by a history of NSAIDs use (OR, 0.76 [95% CI, 0.55 to 1.03]). The one-year mortality in the subjects with NSAIDs (survival rate, 0.879 [95% CI, 0.845 to 0.906]) was significantly lower than in the subjects without NSAIDs (survival rate, 0.776 [95% CI, 0.746 to 0.803]) (p < 0.001). A history of NSAIDs use associated with the decreased risk of one-year mortality even after adjustment for age, sex, Charlson Comorbidity Index, delirium status, and hospitalization department (HR, 0.70 [95% CI, 0.51 to 0.96])., Conclusion: This study suggested that NSAIDs usage was associated with decreased delirium prevalence and lower one-year mortality. The potential benefit of NSAIDs on delirium risk and mortality were shown., Competing Interests: Declaration of Competing Interest Gen Shinozaki is co-founder of Predelix Medical LLC and has pending patents as follows: “Non-invasive device for predicting and screening delirium”, PCT application no. PCT/US2016/064937 and US provisional patent no. 62/263,325; “Prediction of patient outcomes with a novel electroencephalography device”, US provisional patent no. 62/829,411; “Epigenetic Biomarker of Delirium Risk” in the PCT Application No. PCT/US19/51276, and in U.S. Provisional Patent No. 62/731,599. All other authors have declared that no conflict of interest exists., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In older people, chronicity is associated with delirium, which in turn increases the risk of developing poor clinical outcomes like nursing home admission and death. The aim is to determine whether chronicity, as assessed by Clinical Risk Groups (CRG), is an independent predictor of mortality in older adults with delirium seen in the emergency department (ED)., Methods: Prospective study with 18-month follow-up. Included patients were aged 65 years or older, admitted from 1 January to 31 December 2020, and diagnosed and coded for delirium in the ED of a secondary hospital. Patients were followed for 18 months. A survival analysis was performed using the Kaplan-Meier method and a multivariate Cox proportional hazards model., Results: The study included 125 patients (56 % men, mean age 81.2 years, standard deviation [SD] 7.5). At baseline, level 0 chronicity was present in 4.7 % of the patients; level 1, 23.4 %; level 2, 32.8 %; and level 3, 39.1 %. By study end, 29.68 % (n = 38) had died. Mean survival in the total sample was 176.6 (standard error 25.8) days. Level 3 chronicity was associated with a significantly higher risk of mortality (hazard ratio 3.41, 95 % confidence interval 1.31-8.96)., Conclusions: Level 3 chronicity, as assessed by Clinical Risk Groups, is an independent predictor of mortality in older ED patients with delirium. Delirium leads to an increased level of chronicity over the following months., Competing Interests: Conflict of interest The authors have no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hospitalized persons with dementia are at risk of delirium with behavioral symptoms, predisposing them to a higher rate of complications and caregiver distress. The purpose of this study was to examine the relationship between delirium severity in patients with dementia upon admission to the hospital and the manifestation of behavioral symptoms, and to evaluate the mediating effects of cognitive and physical function, pain, medications, and restraints., Methods: This descriptive study used baseline data from 455 older adults with dementia enrolled in a cluster randomized clinical trial that tested the efficacy of family centered function-focused care. Mediation analyses were conducted to determine the indirect effect of cognitive and physical function, pain, medications (antipsychotics, anxiolytics, sedative/hypnotics, narcotics, and number of medications), and restraints on behavioral symptoms, controlling for age, sex, race, and educational level., Results: The majority of the 455 participants were female (59.1%), had an average age of 81.5 (SD=8.4), were either white (63.7%) or black (36.3%), and demonstrated one or more behavioral symptoms (93%) and delirium (60%). Hypotheses were partially supported in that physical function, cognitive function, and antipsychotic medication partially mediated the relationship between delirium severity and behavioral symptoms., Conclusion: This study provides preliminary evidence identifying antipsychotic use, low physical function, and significant cognitive impairment as specific targets for clinical intervention and quality improvement in patients with delirium superimposed on dementia at hospital admission., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery were explored with the Beck Anxiety Inventory (BAI) scale, 10-point Visual Analogue Scale (VAS), and Confusion Assessment Method Chinese Reversion (CAM-CR) scale., Methods: A total of 120 patients aged 65 years old who receiving gastrointestinal cancer surgery were enrolled in the study. Perioperative anxiety, pain, and delirium were assessed by the BAI scale, VAS scale, and CAM-CR scale, respectively. The correlation and influencing factors of preoperative high anxiety, postoperative high pain, and postoperative delirium were analyzed., Results: Preoperative high anxiety had a moderate positive correlation with postoperative high pain (P < 0.001, r = 0.410), and had a weak positive correlation with postoperative delirium (P = 0.005, r = 0.281). postoperative high pain had a weak positive correlation with postoperative delirium (P = 0.017, r = 0.236). Type of cancer and surgical approach were considered to be independent risk factors of preoperative high anxiety (P = 0.006 and P = 0.021). Preoperative high anxiety was considered to be an independent risk factor of postoperative high pain (P< 0.001). Age and preoperative high anxiety were considered to be independent risk factors of postoperative delirium (P< 0.001 and P = 0.010)., Conclusions: Elderly patients undergoing gastrointestinal cancer surgery had a higher incidence of preoperative anxiety, as well as first-day postoperative pain and first-day postoperative delirium. Factors such as type of cancer, surgical approach and preoperative anxiety had been identified as influencing preoperative anxiety levels; preoperative anxiety had been linked to postoperative pain; and age and preoperative anxiety have been identified as influencing factors of postoperative delirium., Trial Registration: hiCTR2000032008, 17/04/2020, Title: "Effects of different analgesic methods on postoperative recovery of elderly patients with digestive tract tumor". Website: https://www.chictr.ogr.cn ., (© 2023. The Author(s).)

Objectives: Efforts to conceptualize risk factors for postoperative delirium in older adults have focused on the time proximate to the episode, but how early-life exposures influence delirium risk is poorly understood., Methods: An observational cohort of 547 patients aged 70+undergoing major non-cardiac surgery at two academic medical centers in Boston. Demographic characteristics, cognition, parental education, health, and participation in cognitively stimulating activities were assessed prior to surgery. Delirium incidence and severity were measured daily during hospitalization., Results: Higher paternal education was associated with significantly lower incidence of delirium ( X 2 (1, N =547)=8.35, p <.001; odds ratio OR=.93, 95% CI, .87 to .98) and inversely associated with delirium severity ( r(545) =-.13, p <.001). Higher maternal education was associated with lower delirium incidence but did not reach statistical significance. The effect of paternal education on delirium incidence was independent of the patient's education, estimated premorbid intelligence, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities ( X 2 (2, N =547)=31.22, p <.001)., Conclusions: Examining early-life exposures may yield unique insights into the risks and pathogenesis of delirium., Clinical Implications: Evaluating long-term factors that increase vulnerability to delirium may improve our ability to calculate risk. It may guide clinical decision-making and inform pre- and post-operative recommendations.

Background: Respiratory infections can be complicated by acute brain failure. We assessed delirium prevalence, predictors and outcomes in COVID-19 ED patients., Methods: This was a retrospective observational study conducted at the San Raffaele ED (Italy). Patients age >18 years attending the ED between 26 February 2020 and 30 May 2020 and who had a positive molecular nasopharyngeal swab for SARS-CoV-2 were included. The Chart-Based Delirium Identification Instrument (CHART-DEL) was used to retrospectively assess delirium. Univariable and multivariable logistic regression analyses were used to evaluate delirium predictors. Univariable binary logistic regression analyses, linear regression analyses and Cox regression analyses were used to assess the association between delirium and clinical outcomes. Age-adjusted and sex-adjusted models were then run for the significant predictors of the univariable models., Results: Among the 826 included patients, 123 cases (14.9%) of delirium were retrospectively detected through the CHART-DEL method. Patients with delirium were older (76.9±13.15 vs 61.3±14.27 years, p<0.001) and more frequently living in a long-term health facility (32 (26%) vs 22 (3.1%), p<0.001). Age (OR 1.06, 95% CI 1.04 to 1.09, p<0.001), dementia (OR 17.5, 95% CI 7.27 to 42.16, p<0.001), epilepsy (OR 6.96, 95% CI 2.48 to 19.51, p<0.001) and the number of chronic medications (OR 1.09, 95% CI 1.01 to 1.17, p=0.03) were significant predictors of delirium in multivariable analyses. Delirium was associated with increased in-hospital mortality (adjusted HR 2.16, 95% CI 1.55 to 3.03, p<0.001) and with a reduced probability of being discharged home compared with being institutionalised (adjusted OR 0.39, 95% CI 0.25 to 0.61, p<0.001)., Conclusions: Chart review frequently identified ED delirium in patients with COVID-19. Age, dementia, epilepsy and polypharmacy were significant predictors of ED delirium. Delirium was associated with an increased in-hospital mortality and with a reduced probability of being discharged home after hospitalisation. The findings of this single-centre retrospective study require validation in future studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Postoperative delirium (POD) is a common complication in older adults, with unknown epidemiology and effects on surgical outcomes in Asian geriatric cancer patients. This study evaluated incidence, risk factors, and association between adverse surgical outcomes and POD after intra-abdominal cancer surgery in Taiwan., Methods: Overall, 345 patients aged ≥65 years who underwent elective abdominal cancer surgery at a medical center in Taiwan were prospectively enrolled. Delirium was assessed daily using the Confusion Assessment Method. Univariate and multivariate logistic regression analyses investigated risk factors for POD occurrence and estimated the association with adverse surgical outcomes., Results: POD occurred in 19 (5.5%) of the 345 patients. Age ≥73 years, Charlson comorbidity index ≥3, and operative time >428 min were independent predictors for POD occurrence. Patients presenting with one, two, and three risk factors had 4.1-fold (95% confidence interval [CI], 0.4-35.8, p = 0.20), 17.4-fold (95% CI, 2.2-138, p = 0.007), and 30.8-fold likelihood (95% CI, 2.9-321, p = 0.004) for POD occurrence, respectively. Patients with POD had a higher probability of prolonged hospital stay (adjusted odds ratio [OR] 2.8; 95% CI, 1.0-8.1; p = 0.037), intensive care stay (adjusted OR: 3.9; 95% CI, 1.5-10.5; p = 0.008), 30-day readmission (adjusted OR 3.1; 95% CI, 1.1-9.7; p = 0.039), and 90-day postoperative death (adjusted OR: 4.2; 95% CI, 1.0-17.7; p = 0.041)., Conclusion: POD occurrence was significantly associated with adverse surgical outcomes in geriatric patients undergoing elective abdominal cancer surgery, highlighting the importance of early POD identification in geriatric patients to improve postoperative care quality., Competing Interests: Declaration of competing interest Authors declare no Conflict of Interests for this article., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Background: Now the occurrence of delirium is more concerning to clinicians and psychiatrists. It has been reported that vitamin D deficiency may be a relevant factor in the development of delirium in hospitalized patients., Study Objective: To investigate the association between vitamin D concentration and delirium in hospitalized patients., Design: Meta-analysis., Methods: A systematic literature search was conducted using PubMed, EMBASE, and the Cochrane Library. The primary outcome was the occurrence of delirium in the inpatient setting. Odds ratios (OR) were calculated with random or fixed effects models., Results: In this article, we define the normal range of vitamin D concentrations as greater than 75 nmol / L, 50-75 nmol / L as vitamin D insufficiency, 25-50 nmol / L as vitamin D deficiency, and less than 25 nmol / L as vitamin D severe deficiency. The Results showed that severe vitamin D deficiency (OR: 1.98 [1.41-2.79], P<0.001) and vitamin D deficiency (OR: 1.50 [1.12-2.00], P = 0.006) were more likely to develop delirium than normal vitamin D levels. Subgroup analysis also revealed that low vitamin D concentrations were associated with a higher incidence of delirium, whether the cutoff point was 25 nmol/L (OR: 1.52 [1.40-1.64], P<0.001), 50 nmol/L (OR: 1.47 [1.19-1.82], P<0.001), or 75 nmol/L (OR: 1.54 [1.21-1.96], P<0.001). The included studies scored medium and high on the Newcastle-Ottawa quality assessment scale., Conclusion: Compared with normal vitamin D levels, severe vitamin D deficiency and vitamin D deficiency, but not vitamin D insufficiency, are associated with a higher incidence of delirium in hospitalized patients., Trial Registration: This review was registered in the PROSPERO database under identifier CRD42021271347. https://www.crd.york.ac.uk/prospero/display&#95;record.php?ID=CRD42021271347., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Fu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study., Methods: The SAGES II study is a 5-year prospective observational study of 400-420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months., Results: This study describes the hospital and surgery-related variables, delirium, long-term cognitive decline, clinical outcomes, and novel biomarkers. In inter-rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74-1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94-1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid-19 adaptations., Conclusions: This complex study presents an innovative effort to advance our understanding of the inter-relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high-quality longitudinal data., (© 2022 The American Geriatrics Society.)

Background: The term sundowning is used to describe the emergence or worsening of neuropsychiatric symptoms in late afternoon or early evening in people with dementia., Objective: Our aim was to evaluate sundowning's prevalence and clinical manifestations among patients attending a tertiary memory clinic and to investigate its clinical and neuropsychological correlates., Methods: Patients with dementia attending our memory clinic were enrolled in the study. Sundowning was identified through a specifically designed questionnaire. Sociodemographic and clinical features of sundowners and non-sundowners were compared, and a logistic regression was performed to identify the variables associated with the phenomenon. A subgroup of patients underwent a complete neuropsychological assessment., Results: Among 184 recruited patients, 39 (21.2%) exhibited sundowning, mostly expressed as agitation (56.4%), irritability (53.8%), and anxiety (46.2%). Sundowners were significantly older, had a later dementia onset, exhibited more severe cognitive and functional impairment, more frequent nocturnal awakenings, and hearing loss relative to non-sundowners. They were also more likely to use anticholinergic medications and antipsychotics, and less likely to use memantine. In a multi-adjusted model, the factors significantly associated with sundowning were the Clinical Dementia Rating score (OR 3.88; 95% CI 1.39-10.90) and the use of memantine (OR 0.20; 95% CI 0.05-0.74). Participants with and without sundowning obtained similar results in single domain neuropsychological tests., Conclusion: Sundowning is commonly experienced by patients with dementia and appears as a multiply determined condition. Its presence should always be evaluated in clinical practice and a multidimensional approach should be adopted to identify its predictors.

Background: Delirium is a frequent and serious acute neuropsychiatric syndrome leading to worse prognosis including mortality. Patients with ischaemic and/or haemorrhagic stroke are vulnerable to delirium. However, predisposing and precipitating factors have not been fully discovered to date, leaving this area of practice under-represented in available guidelines., Aims: To describe the prevalence, associated factors and main in-hospital outcomes of post-stroke delirium., Methods: A multi-centre observational study was conducted from 2019 to 2020 and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data were collected in stroke units located in two large hospitals in the North-East region of Italy. Consecutive adult patients with ischaemic and/or haemorrhagic stroke with a Glasgow Coma Scale > 5, who were willing to participate, were included. Data at admission, during the in-hospital stay and at discharge were collected by trained nurses, not involved in the care of patients, with (a) validated tools, (b) direct observation, and (c) access of patients' records., Results: A total of 78 patients were enrolled (mean 73.1 years; 59% male), and 70.5% of them had suffered an ischaemic stroke. The mean National Institutes of Health Stroke Scale (NIHSS) at admission was 8.2 ± 7.0. A total of 34.6% of patients developed post-stroke delirium; the onset was mainly on the first day of admission (70.4%) and the condition lasted for an average of 3.7 days (SD 2.6). In the multivariate logistic regression, 64.1% of the delirium variance was explained by the NIHSS scores (RR 1.259, 95%CI 1.035-1.533; p = 0.022). Patients with post-stroke delirium reported higher functional dependence at discharge and the need for more delaying of hospital care to be admitted in rehabilitation units., Conclusions: At admission, higher scores in the NIHSS evaluation might suggest which patients are at an increased risk of delirium. Avoiding interventions that could potentially increase this risk, together with continuous surveillance, become imperative for nurses who are constantly and closely present by their patients' side, in order to prevent this serious complication., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2022. Published by Elsevier Inc.)

More than one-third of the cases of infective endocarditis (IE) occur in older patients. The disease is often characterized by atypical symptoms. The incidence of neurological complications is high and represents a strong independent predictor of severe outcomes and mortality. IE is a rare but serious complication of transcatheter aortic valve implantation (TAVI). A persistent delirium as a unique manifestation of post-TAVI IE in an older patient is presented in this clinical case., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose of Review: This review aims to summarize the current research on postoperative cognitive complications, such as delirium and cognitive dysfunction. This includes discussion on preoperative preventive strategies, such as physical and nutritional prehabilitation as well as up-to-date information on neuroprehabilitation., Recent Findings: Current recommendations for prevention of postoperative delirium have focused on multicomponent interventions. The optimal composition of surgical prehabilitation programs targeting exercise and nutrition has not yet been established. The Neurobics Trial shows that cognitive prehabilitation improves cognitive reserve and may be a useful addition to multimodal surgical prehabilitation. Perioperative management of oncologic patients is often associated with a myriad of challenges, such as the management of tumor-related pathologies, adverse events from neoadjuvant therapy, and chronic metabolic and immunological changes associated with malignancy. In addition, oncologic patients are at increased risk of developing frailty, which adversely affects postoperative recovery and further cancer treatment. As a result, oncologic patients are at considerable risk of developing postoperative cognitive complications, such as delirium and cognitive dysfunction. In this review, we discuss the effect of prehabilitation on postoperative cognitive outcomes., (© 2022. The Author(s).)

Objective: This study aimed at identifying the incidence, predictors, and impact on long-term mortality and dementia of early-onset delirium in a cohort of patients with spontaneous intracerebral hemorrhage., Methods: We prospectively recruited consecutive patients in the Prognosis of InTra-Cerebral Hemorrhage (PITCH) cohort and analyzed incidence rate of early-onset delirium (i.e. during the first seven days after intracerebral hemorrhage onset) with a competing risk model. We used a multivariable Fine-Gray model to identify baseline predictors, a Cox regression model to study its impact on the long-term mortality risk, and a Fine-Gray model adjusted for pre-specified confounders to analyze its impact on new-onset dementia., Results: The study population consisted of 248 patients (mean age 70 years, 54% males). Early-onset delirium incidence rate was 29.8% (95% confidence interval (CI) 24.3-35.6). Multivariate analysis showed that pre-existing dementia (subhazard ratio (SHR) 2.08, 95%CI 1.32-3.32, p = 0.002), heavy alcohol intake (SHR 1.79, 95%CI 1.13-2.82, p = 0.013), and intracerebral hemorrhage lobar location (SHR 1.56, 95%CI 1.01-2.42, p = 0.049) independently predicted early-onset delirium. Median follow-up was 9.5 years. Early-onset delirium was associated with higher mortality rates during the first five years of follow-up (HR 1.52, 95%CI 1.00-2.31, p = 0.049), but did not predict new-onset dementia (SHR 1.31, 95%CI 0.60-2.87)., Conclusion: Early-onset delirium is a frequent complication after intracerebral hemorrhage; it is associated with markers of pre-existing brain vulnerability and with higher mortality risk, but not with higher dementia rates during long-term follow-up.

Introduction: Following the hyperacute phase of spontaneous intracerebral hemorrhage (SICH), the severest form of stroke, pneumonia emerges as the leading cause of morbidity and mortality. Prevention of stroke associated pneumonia (SAP) is fundamental to improve the prognosis of SICH patients., Aim: Identify clinical, sociodemographic and process of care factors associated with occurrence of SAP after SICH in Algarve, southern Portugal., Methods: Observational, retrospective study of community representative consecutive case series of patients with SICH admitted to the sole public hospital in the region. Logistic regression was used to identify predictors of SAP after SICH., Results: A total of 525 patients were included. The mean age was 71 ( ± 13) years and 64% were men. SAP occurred in 165 (31.5%). Lower Glasgow Coma Scale score (GCS score): ≤ 8 (OR= 2.087; 95% CI= [1.027;4.424]; p = 0.042) and GCS 9-12 (OR= 1.775; 95% CI= [1.030;3.059]; p = 0.039); prolonged emergency room stay (OR= 8.066; 95%CI=[3.082;21.113]; p < 0.001) and hyperactive delirium (OR=2.860; 95% CI= [1.661;4.925]; p < 0.001) increased the likelihood of SAP. Being younger, ≤ 59 years (OR= 0.391; 95% CI= [0.168; 0.911]; p = 0.029) and 60-71 years (OR= 0.389; 95% CI= [0.185; 0.818]; p = 0.013); and having less severe SICH/intracerebral hemorrhage score (ICH score) ≤ 2 (OR=0.601; 95% CI= [0.370; 0.975]; p = 0.039), decreased the risk of SAP., Conclusion: After SICH, SAP occurs in approximately a third of patients. Non preventable (admission severity, ageing) and potentially preventable (prolonged emergency room stay, hyperactive delirium) determine the occurrence of SAP. Intensification of preventive intervention in high-risk patients, delirium prevention and improvement of the process of care can potentially reduce the occurrence of SAP after SICH., (Copyright © 2022 Elsevier B.V. All rights reserved.)