Abstract Introduction As the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study. Methods SAGES is an ...ongoing study involving 560 adults age 70 years or more without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly were assessed preoperatively then repeatedly out to 36 months. Results On average, patients with postoperative delirium had significantly lower preoperative cognitive performance, greater immediate (1 month) impairment, equivalent recovery at 2 months, and significantly greater long-term cognitive decline relative to the nondelirium group. Proxy reports corroborated the clinical significance of the long-term cognitive decline in delirious patients. Discussion Cognitive decline after surgery is biphasic and accelerated among persons with delirium. The pace of long-term decline is similar to that seen with mild cognitive impairment.
Delirium disorder: Unity in diversity Oldham, Mark A.
General hospital psychiatry,
January-February 2022, 2022 Jan-Feb, 2022-01-00, 20220101, Letnik:
74
Journal Article
Recenzirano
The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing ...them through the model of delirium disorder.
This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets.
Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies.
Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.
A Clinical Approach to Diagnosing Encephalopathy Erkkinen, Michael G.; Berkowitz, Aaron L.
The American journal of medicine,
October 2019, 2019-10-00, 20191001, Letnik:
132, Številka:
10
Journal Article
Recenzirano
Encephalopathy refers to dysfunction of the level or contents of consciousness due to brain dysfunction and can result from global brain insults or focal lesions. The underlying causes of ...encephalopathy include both primary neurologic and systemic conditions. This article discusses the differential diagnosis of encephalopathy, with a focus on primary neurologic causes. A practical schema for organizing the differential diagnosis is to group etiologies by their pace of onset and evolution (eg, sudden, acute, subacute, chronic).
A 54-year-old woman was admitted to the emergency department for an acute, fluctuating altered mental status and reduced perceptual awareness of her surroundings as well as disorganized thinking. ...Blood tests, including for drugs, were normal. A CT scan of the brain was normal. Magnetic resonance imaging and CT angiography of the supra-aortic vessels were both were consistent with moyamoya disease. The patient was hospitalized for further investigations.
Moyamoya disease should be considered in the differential diagnosis of middle-aged patients presenting with an acute confusional state of unknown aetiology in the emergency department.The absence of focal examination findings does not exclude neurological disease as the cause of acute confusion, requiring further neuroimaging tests.
Background:
Delirium is a neuropsychiatric condition that commonly occurs in medical settings, especially among older individuals. Despite the lack of strong evidence in the literature, haloperidol ...is considered the first-line pharmacological intervention. Unfortunately, its adverse effects can be severe, and psychiatrists are considering the use of alternative drugs targeting dopamine and serotonin domains (atypical antipsychotics). Among them, aripiprazole is considered to have one of the safest pharmacological profiles.
Aims:
The purpose of this study is to examine the studies on aripiprazole as a pharmacological treatment of delirium present in today’s literature.
Methods:
We carried out systematic research of MedLine, PubMed, Cochrane, Embase, and ScienceDirect examining articles written between January 2002 and September 2023, including experimental studies published in peer-reviewed journals.
Results:
The 6 final included studies examined a total of 130 patients, showing a delirium resolution in a 7-day span of 73.8% of patients treated with aripiprazole.
Conclusions:
Considering the limited data currently available, we can assert that aripiprazole is at least as efficient as haloperidol, the true point is that it has a far better tolerability and safety profile. Nonetheless, further studies are necessary to provide more compelling data, together with a more precise indication regarding minimum efficient dose, as the main limitations of our review are the very small sample size, the small percentage of subjects with preexisting dementia, and the fact that most studies used scales with low specificity for the examined condition.
The acute confusional state is one of the most common reasons for neurologic consultation in the hospital setting and the plethora of causes can truly be daunting. The etiology can vary from ...structural, metabolic, toxic to systemic infections. Our purpose is to present a rare case of acute confusional state in a patient with bilateral thalamic ischemic stroke due to occlusion of the artery of Percheron (AOP). A 79-year-old woman with a history of hypertension and surgery for lumbar disc herniation, managed on antiplatelet therapy, angiotensin receptor blocker and diuretics, was admitted for acute confusion and paresthesia of all four limbs. She had disorientation in time and space, abnormal behavior, decreased muscle strength in both lower limbs (paraparesis 2/5 MRC since the surgery), paresthesia in all four limbs and was unable to walk due to generalized weakness. Laboratory analysis showed high blood levels of cholesterol and glucose. Both head CT and cerebral MRI showed bilateral ischemic changes in the thalami, suggesting an infarct along the artery of Percheron territory. However, no clear cause for the stroke could be identified. Screening for coagulation abnormalities and autoimmune disorders (lupus anticoagulant, anti-beta-2 glycoprotein, anti-cardiolipin, anti-nuclear and anti-ds DNA antibodies) came back negative. There were no pathological finds on the echocardiogram and electrocardiogram, while cervical Doppler ultrasound showed atherosclerosis without stenosis.
Objective: People in Post-Traumatic Confusional State (PTCS) present with communication difficulties that are well described in literature. However, limited study has been conducted on the ...experiences of their communication partners. The current study aimed to understand the experience of rehabilitation staff of their communication with patients in PTCS prior to communication partner training (CPT).
Methods: Staff on a subacute inpatient TBI rehabilitation unit were invited to complete a 10-item questionnaire. The questionnaire contained quantitative and open-ended text response formats, analyzed with descriptive statistics and content analysis, respectively.
Results: 78 interdisciplinary staff members completed the questionnaire. The majority of staff found communication to be difficult and time-consuming with half not feeling comfortable communicating with patients in PTCS. Confidence in communication was not associated with length of clinical experience. The majority of staff reported utilizing strategies to support communication, largely focused on augmenting activities with supportive objects and ensuring patient's comprehension through modification of verbal language.
Conclusions: Staff are aware of the need for creating a structured environment for patients in PTCS and less aware of communication-specific strategies aiming at helping patients' expression, which underlines the need to emphasize these strategies as part of CPT in this type of setting.
Objectives
Delirium is an acute neuropsychiatric condition associated with increased morbidity and mortality. There is increasing recognition of delirium as a substantial health burden in younger ...patients, although few studies have characterized its occurrence. This study analyzes the occurrence of delirium diagnosis, its comorbidities, and cost among youth hospitalized in the United States.
Methods
The Kids' Inpatient Database, a national all‐payers sample of pediatric hospitalizations in general hospitals, was examined for the year 2019. Hospitalizations with a discharge diagnosis of delirium among patients aged 1–20 years were included in the analysis.
Results
Delirium was diagnosed in 43,138 hospitalizations (95% CI: 41,170–45,106), or 2.3% of studied hospitalizations. Delirium was diagnosed in a broad range of illnesses, with suicide and self‐inflicted injury as the most common primary discharge diagnosis among patients with delirium. In‐hospital mortality was seven times greater in hospitalizations caring a delirium diagnosis. The diagnosis of delirium was associated with an adjusted increased hospital cost of $8648 per hospitalization, or $373 million in aggregate cost.
Conclusions
Based on a large national claims database, delirium was diagnosed in youth at a lower rate than expected based on prospective studies. The relative absence of delirium diagnosis in claims data may reflect underdiagnosis, a failure to code, and/or a lower rate of delirium in general hospitals compared with other settings. Further research is needed to better characterize the incidence and prevalence of delirium in young people in the hospital setting.
Denosumab is a human monoclonal antibody indicated for patients with osteoporosis and a high risk of fractures. It targets RANKL, the receptor activator of NF-κB (RANK) ligand, blocking RANKL-RANK ...interaction and leading to rapid osteoclast-mediated bone resorption inhibition. But RANK is widely expressed in neurons, microglia, and astrocytes. RANKL/RANK/NF-κB system can play an important role in the neuroinflammatory response, depressive behavior, memory impairments, and neurotrophism. We present two well-documented case reports of recurrent neuropsychiatric manifestations in patients treated with denosumab and a descriptive review of similar cases reported to the Food and Drug Administration Adverse Event Reporting System (FAERS) database between 2012 and 2022. Only those reported by healthcare professionals, coding denosumab as the only suspected drug, were retained. An 81-year-old woman with pre-existing mild cognitive impairment suffered two acute confusional episodes and another 81-year-old woman with depression in remission suffered two depressive recurrences with anxiety and psychomotor inhibition, in both cases following sequential administrations of denosumab without underlying calcium/phosphate imbalance. Scores on Naranjo Adverse Drug Reaction Probability Scale were 6 and 7, respectively, suggesting a probable causal relationship. Of the 91,151 cases with denosumab exposure reported to FAERS, 5.7% were related to psychiatric/neurological disorders and 23.8% of these corresponded to cognitive impairment, depressive/mood disturbances, or psychomotor retardation. Denosumab may cause transient but severe neuropsychiatric symptoms by several mechanisms involving RANKL blockade and subsequent immuno-inflammatory changes, at least in subjects with pre-existing neurobiological vulnerability. We recommend caution and careful monitoring of these patients following denosumab administrations.
Non-convulsive status epilepticus (NCSE) is a potentially treatable condition that poses considerable diagnostic challenges. NCSE is thought to be more common in the elderly than in the general ...population, however additional diagnostic challenges complicate its recognition in older patients, because of the wide differential diagnosis with common underlying causes of acute confusional state in this age group. We set out to review the existing evidence on the clinical correlates of NCSE in the elderly population. A systematic literature review was conducted according to the methodological standards outlined in the PRISMA statement to assess the clinical correlates of NCSE in patients aged 60 or older. Our literature search identified 11 relevant studies, which confirmed that the incidence of NCSE increases with age, in particular with regard to focal forms with impairment of consciousness. Female gender, history of epilepsy (or a recently witnessed seizure with motor features), and abnormal ocular movements appeared to correlate with the diagnosis of NCSE in the elderly, prompting prioritization of electroencephalography tests for diagnostic confirmation. Epidemiological data in the elderly vary widely because of the heterogeneity of definitions and diagnostic criteria applied across different studies. Based on our findings, it is recommended to keep a low threshold for requesting electroencephalography tests to confirm the diagnosis of NCSE in elderly patients with acute confusional state, even in the presence of a presumed symptomatic cause.
•Non-convulsive status epilepticus (NCSE) poses considerable diagnostic challenges.•NCSE is more common in the elderly than in the general population.•Female gender correlates with the diagnosis of NCSE in the elderly.•A history of epilepsy correlates with the diagnosis of NCSE in the elderly.•Abnormal ocular movements correlate with the diagnosis of NCSE in the elderly.
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