Importance Major postoperative complications and delirium contribute independently to adverse outcomes and high resource utilization in patients undergoing major surgery; however, their inter-relationship is not well-examined. Objective To evaluate the association of major postoperative complications and delirium, alone and in combination, with adverse outcomes after surgery. Design Prospective cohort study. Setting Two large academic medical centers. Participants Patients without recognized dementia or history of delirium, age 70 and older who underwent elective major orthopedic, vascular, and abdominal surgeries with a minimum 3-day hospitalization. Main Outcome and Measures Major postoperative complications, defined as life altering or threatening events (Accordion Severity ≥ grade 2), were identified by expert panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated chart review method. Four subgroups were analyzed: (1) no complications, no delirium; (2) complications alone; (3) delirium alone; and (4) both complications and delirium. Adverse outcomes included length of stay (LOS) > 5 days, institutional discharge, and rehospitalization within 30 days of discharge. Results Of 566 participants, mean age (±SD) was 76.7± 5.2 years, 42% male and 92% white. Forty-seven (8%) developed major complications, and 135 (24%) developed delirium. When compared to no complications, no delirium as the reference group, major complications alone contributed only to prolonged LOS (RR 2.8, 95% CI 1.9–4.0); by contrast, delirium alone significantly increased all adverse outcomes, including prolonged LOS (RR 1.9, 95% CI 1.4–2.7), institutional discharge (RR 1.5, 95% CI 1.3–1.7), and 30-day readmission (RR 2.3, 95% CI 1.4–3.7). The subgroup with both complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR 3.4, 95% CI 2.3–4.8), institutional discharge (RR 1.8, 95% CI 1.4–2.5) and 30-day readmission (RR 3.0, 95% CI 1.3–6.8). Delirium exerted the highest attributable risk at a population level (5.8%, 95% CI 4.7–6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). Conclusions and Relevance Major postoperative complications and delirium are separately associated with adverse events and demonstrate a strong combined effect. Delirium occurs more frequently, and has greater impact at the population level than other major complications.
A facilitated discussion about end-of-life care between patients and their health care agents helps define and document the patient's wishes for both patient and agent.
Importance: Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity will enable development and monitoring of more effective treatment approaches for delirium. Objective: This study had 3 major goals: to present a comprehensive review of delirium severity instruments; to conduct a methodologic quality rating of the original validation study of the most commonly used instruments; and to select a group of top-rated instruments. Evidence Review: Using key words, subject headings, and full text approaches, we conducted a systematic review of the following databases,
Background and Objectives: While there are qualitative studies examining the delirium-related experiences of patients, family caregivers, and nurses separately, little is known about common aspects of delirium burden among all three groups. We describe common delirium burdens from the perspectives of patients, family caregivers, and nurses. Research Design and Methods: We conducted semistructured qualitative interviews about delirium burden with 18 patients who had recently experienced a delirium episode, with 16 family caregivers, and with 15 nurses who routinely cared for patients with delirium. We recruited participants from a large, urban teaching hospital in Boston, Massachusetts. Interviews were recorded and transcribed. We used interpretive description as the approach to data analysis. Results: We identified three common burden themes of the delirium experience: Symptom Burden (Disorientation,
ORIGINAL RESEARCHwith a model developed using traditional stepwise logistic regression (AUC = 0.69, 95% CI 0.57-0.82). Calibration for all models and feature sets was poor. CONCLUSIONS: We developed machine learning prediction models for post-operative delirium that performed better than chance and are comparable with traditional stepwise logistic regression. Delirium proved to be a phenotype that was difficult to predict with appreciable accuracy.
Background Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk. Methods We enrolled 459 persons without dementia aged ≥70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0–10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms. Findings Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1·6, 95% confidence interval, CI, 1·2–2·3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1·07–1·08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0·049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance. Interpretation Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery. Funding U.S. National Institute on Aging.
The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom developed guidelines for the diagnosis, prevention, and management of delirium in July, 2010, which included 10 recommendations for delirium prevention. The Hospital Elder Life Program (HELP) is a targeted multicomponent strategy which has proven effective and cost-effective to prevent functional and cognitive decline in hospitalized older persons. HELP provided much of the basis for 7/10 (70%) of the NICE recommendations. Given interest by new HELP sites to meet NICE guidelines, we developed 3 new protocols which were not previously included in the HELP program, addressing hypoxia, infection, and pain. Additionally, the NICE dehydration guideline included constipation, which was not specifically addressed in the HELP protocols. This project describes the systematic development of 3 new protocols (hypoxia, infection, and pain) and the expansion of an existing HELP protocol (constipation/dehydration) to achieve alignment between the HELP protocols and NICE guidelines. Following the Institute of Medicine recommendations for developing trustworthy guidelines, we undertook a systematic review of current literature by an interdisciplinary group of experts, rated the quality of the evidence, developed intervention protocols based on the highest quality evidence, and submitted the protocols first to internal review, then external review by an interdisciplinary panel of experts. The protocols were revised based on the review process, and were incorporated into the HELP materials. Inclusion of these protocols enhances the scope of the HELP program, and allows fulfillment of NICE guideline recommendations for delirium prevention. The rigorous process we applied may provide a useful example for updating existing guidelines or protocols, which may be applicable to a broad range of clinical applications.
BACKGROUND/OBJECTIVES Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research. DESIGN We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords “delirium” and “instruments,” along with their known synonyms. We selected only systematic reviews, meta‐analyses, or narrative literature reviews including multiple delirium identification instruments. MEASUREMENTS Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus‐based Standards for the Selection of Health Measurement Instruments (COSMIN) framework. RESULTS Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)‐III through DSM‐5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM‐5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale‐Revised‐98, and Memorial Delirium Assessment Scale. CONCLUSION Four commonly used and well‐validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.
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