Summary Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that ...dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.
IMPORTANCE: Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has ...serious adverse effects on the individual’s function and quality of life, as well as broad societal effects with substantial health care costs. OBJECTIVE: To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field. EVIDENCE REVIEW: Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non–English-language articles were excluded. FINDINGS: Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A’s Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method–Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies. CONCLUSIONS AND RELEVANCE: Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
In this prospective study of older patients undergoing cardiac surgery, 46% had postoperative delirium. Patients with delirium had larger declines in cognitive function: at 6 months, only 60% were at ...their preoperative level, as compared with 76% of those without delirium.
Cognitive impairment is common after cardiac surgery, and prevention efforts have not always been successful.
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Although a large proportion of patients return to their preoperative level of cognitive function within 3 months,
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many do not. Older age, lower educational level, and the presence of one or more coexisting conditions are risk factors for postoperative cognitive decline, but few potentially reversible risk factors have been identified.
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We hypothesized that patients with postoperative delirium, a potentially preventable, acute confusional state, would have a more precipitous drop in cognitive function immediately after surgery and a slower rate of cognitive recovery . . .
Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and ...often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.
IMPORTANCE: Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make ...delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care. OBJECTIVE: To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020. EXPOSURES: Major elective surgery and hospitalization. MAIN OUTCOMES AND MEASURES: Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method–Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics. RESULTS: Of the 566 patients who were eligible for the study, a total of 497 patients (mean SD age, 76.8 5.1 years; 281 women 57%; 461 White participants 93%) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean SD cost, $146 358 $140 469 vs $94 609 $80 648). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year. CONCLUSIONS AND RELEVANCE: These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.
OBJECTIVES: To determine whether patients who developed delirium after cardiac surgery were at risk of functional decline.
DESIGN: Prospective cohort study.
SETTING: Two academic hospitals and a ...Veterans Affairs Medical Center.
PARTICIPANTS: One hundred ninety patients aged 60 and older undergoing elective or urgent cardiac surgery.
MEASUREMENTS: Delirium was assessed daily and was diagnosed according to the Confusion Assessment Method. Before surgery and 1 and 12 months postoperatively, patients were assessed for function using the instrumental activities of daily living (IADL) scale. Functional decline was defined as a decrease in ability to perform one IADL at follow‐up.
RESULTS: Delirium occurred in 43.1% (n=82) of the patients (mean age 73.7±6.7). Functional decline occurred in 36.3% (n=65/179) at 1 month and in 14.6% (n=26/178) at 12 months. Delirium was associated with greater risk of functional decline at 1 month (relative risk (RR)=1.9, 95% confidence interval (CI)=1.3–2.8) and tended toward greater risk at 12 months (RR=1.9, 95% CI=0.9–3.8). After adjustment for age, cognition, comorbidity, and baseline function, delirium remained significantly associated with functional decline at 1 month (adjusted RR=1.8, 95% CI=1.2–2.6) but not at 12 months (adjusted RR=1.5, 95% CI=0.6–3.3).
CONCLUSION: Delirium was independently associated with functional decline at 1 month and had a trend toward association at 12 months. These findings provide justification for intervention trials to evaluate whether delirium prevention or treatment strategies might improve postoperative functional recovery.
Delirium: The Next Frontier Fong, Tamara G; Inouye, Sharon K
The journals of gerontology. Series A, Biological sciences and medical sciences,
03/2022, Letnik:
77, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Delirium, a clinical syndrome characterized by a disturbance in attention and cognition with acute onset and fluctuating course, is a common, serious, and highly morbid condition affecting up to 60% ...of hospitalized seniors. Delirium is associated with increased rates of institutionalization and mortality and costs the US health care system over $118 billion per year for all older adults and over $33 billion per year for older surgical patients. Importantly, delirium is preventable in 30%-50% of cases. While the past 3 decades have witnessed tremendous advances in delirium research, major gaps in their understanding persist and will require concerted research to move the field ahead. While many adverse clinical outcomes of delirium have been well-described, functional outcomes--particularly, the impact on balance, gait, and mobility--have not been well examined. Here, Fong and Inouye provide 7 important research studies addressing the major gaps.
Examining the associations of social determinants of health (SDOH) with postoperative delirium in older adults will broaden our understanding of this potentially devastating condition. We explored ...the association between SDOH factors and incident postoperative delirium.
A retrospective study of a prospective cohort of patients enrolled from June 18, 2010, to August 8, 2013, across two academic medical centers in Boston, Massachusetts. Overall, 560 older adults age ≥70 years undergoing major elective non-cardiac surgery were included in this analysis. Exposure variables included income, lack of private insurance, and neighborhood disadvantage. Our main outcome was incident postoperative delirium, measured using the Confusion Assessment Method long form.
Older age (odds ratio, OR: 1.01, 95% confidence interval, CI: 1.00, 1.02), income <20,000 a year (OR: 1.12, 95% CI: 1.00, 1.26), lack of private insurance (OR: 1.19, 95% CI: 1.04, 1.38), higher depressive symptomatology (OR: 1.02, 95% CI: 1.01, 1.04), and the Area Deprivation Index (OR: 1.02, 95% CI: 1.01, 1.04) were significantly associated with increased risk of postoperative delirium in bivariable analyses. In a multivariable model, explaining 27% of the variance in postoperative delirium, significant independent variables were older age (OR 1.01, 95% CI 1.00, 1.02), lack of private insurance (OR 1.18, 95% CI 1.02, 1.36), and depressive symptoms (OR 1.02, 95% CI 1.00, 1.03). Household income was no longer a significant independent predictor of delirium in the multivariable model (OR:1.02, 95% CI: 0.90, 1.15). The type of medical insurance significantly mediated the association between household income and incident delirium.
Lack of private insurance, a social determinant of health reflecting socioeconomic status, emerged as a novel and important independent risk factor for delirium. Future efforts should consider targeting SDOH factors to prevent postoperative delirium in older adults.
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