OBJECTIVES
To evaluate the relationship between frailty and delirium.
DESIGN
Systematic review and meta‐analysis.
SETTING
MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases ...were searched for articles on frailty and delirium published on or before October 31, 2017.
PARTICIPANTS
Individuals aged 65 and older.
MEASUREMENTS
Two authors independently reviewed all English‐language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random‐effects or fixed‐effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I2 statistics.
RESULTS
We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta‐analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65–2.91). There was low variability among studies in the measures of association between frailty and delirium (I2 2.24, p‐value Q‐statistic = .41) but high heterogeneity in the methods used to assess the two conditions.
CONCLUSION
This systematic review and meta‐analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.
Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations ...of age and duration of delirium with mental health and functional disabilities in this group.
In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795.
We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes.
Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care.
National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of ...developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.
To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early ...mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines.
Worldwide online survey.
Intensive care.
A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle.
There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits.
The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.
Objectives
To evaluate the association between number of days with delirium and 6‐month mortality in elderly adults after hip fracture surgery.
Design
Prospective cohort study with 6‐month follow‐up.
...Setting
Orthogeriatric Unit (OGU).
Participants
Individuals (mean age = 84.3 ± 6.4) admitted to the OGU between October 2011 and April 2013 with hip fracture (N = 199).
Measurements
Postoperative delirium (POD) was assessed daily using the Confusion Assessment Method algorithm and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria. Multivariable Cox regression models were used to evaluate the association between POD of and 6‐month mortality after surgery, after adjustment for covariates including age, prefracture residence, Katz activity of daily living score, New Mobility score, diagnosis of prefracture dementia, American Society of Anesthesiologists score, albumin serum levels, Charlson Comorbidity Index, and length of OGU stay.
Results
Fifty‐seven participants (28.6%) developed POD. In the 6‐month period after surgery, 35 (17.6%) participants died: 16 of 57 (28.1%) with POD and 19/ of 142 (13.4%) with no POD. The average duration of POD was 2.0 ± 3.2 days for participants who died and 0.7 ± 1.8 days for those who survived (P < .001). After adjusting for covariates, each day of POD in the OGU increased the hazard of dying at 6 months by 17% (hazard ratio = 1.17, 95% confidence interval = 1.07–1.28).
Conclusion
In older adults undergoing hip fracture surgery, duration of POD is an important prognostic factor for 6‐month mortality. Efforts to reduce duration of POD are therefore crucial for these individuals.
Background
Delirium is associated with a variety of adverse healthcare outcomes but is highly predictable, preventable and treatable. For this reason, numerous guidelines have been developed for ...delirium recognition, prevention and management across different countries and disciplines. Although research is adduced as evidence for these guidelines, a constant finding is the lack of implementation if they exist at all. Implementation is a human behaviour that can be influenced by various factors including culture at a micro- and macro-level. Hofstede’s model proposes that national cultures vary along six consistent dimensions.
Aim
Using this model, we examined the nature of delirium guidelines across countries in relation to Hofstede’s six cultural dimensions.
Methods
Data collected for each country on: the six dimensions of Hofstede’s model, number of delirium guidelines approved by a National professional body of each country (through searching databases), the annual old-age dependency ratio for each country.
Results
Sixty-four countries had the completed six dimensions of Hofstede’s model. Twenty of them (31%) had one or more delirium guidelines. The total number of different delirium guidelines was 45. Countries with formal delirium guidelines have significantly lower power distance among their members, are more individualistic societies, have lower levels of uncertainty avoidance and higher old-age dependency ratio compared to those without delirium guidelines.
Discussion/conclusion
The development and implementation of delirium guidelines vary across countries. Specific combinations of cultural dimensions influence the production of delirium guidelines. Understanding these important cultural differences can facilitate more widespread acceptance and implementation of guidelines.
Background
There is currently no international recommendation for the admission or treatment of the critically ill older patients over 80 years of age in the intensive care unit (ICU), and there is ...no valid prognostic severity score that includes specific geriatric assessments.
Main body
In this review, we report recent literature focusing on older critically ill patients in order to help physicians in the multiple-step decision-making process. It is unclear under what conditions older patients may benefit from ICU admission. Consequently, there is a wide variation in triage practices, treatment intensity levels, end-of-life practices, discharge practices and frequency of geriatrician’s involvement among institutions and clinicians. In this review, we discuss important steps in caring for critically ill older patients, from the triage to long-term outcome, with a focus on specific conditions in the very old patients.
Conclusion
According to previous considerations, we provide an algorithm presented as a guide to aid in the decision-making process for the caring of the critically ill older patients.
Objective
Delirium superimposed on dementia (DSD) is common and associated with adverse outcomes. Current evidence indicates that some patients with dementia may recall delirium with distress for ...them and their caregivers. The aim of this study is to identify predictors of distress in informal caregivers of older patient with DSD.
Methods
A total of 33 caregivers of 33 patients with DSD were interviewed 3 days after the resolution of delirium (T0) and at 1-month follow-up (T1) to describe their level of distress related to the delirium episode. A linear regression was used to identify predictors of caregivers’ distress at T0 and T1 defined a priori: age, sex, level of education, employment status, delirium subtypes, delirium severity, type and severity of dementia, and the time spent with the patient during the delirium episode.
Results
Caregivers were mostly female (81%), 59 (± 13.0) years old on average. The predictors of distress at T0 were the patient’s severity of both dementia and delirium. Moderate dementia was associated with lower distress, whereas higher delirium severity was associated with greater distress. At 1-month follow-up, the predictors of distress were the age of caregiver and time spent in care; the distress level was higher when caregivers were older, and they spent less time with their loved one.
Conclusions
These preliminary findings underline the importance of providing continuous training and support for the caregivers, especially in coping strategies, in order to improve the care of DSD patients and prevent the caregivers’ distress in long time period.
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