Delirium in Hospitalized Older Adults

Marcantonio, Edward R.

doi:10.1056/nejmcp1605501

Cited by 740 publications

(772 citation statements)

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“…Older age, dementia, alcohol misuse, major surgery, comorbidities and severity of illness have been reported as strong risk factors for delirium . We also found that ward patients with delirium were older, more likely to have dementia and close to 10 times more likely to be receiving chronic psychotropic drugs supporting the need for a multicomponent approach to delirium …”

Section: Discussionsupporting

confidence: 68%

“…Knowledge on delirium in hospitalised patients is limited to specific populations (geriatric wards, palliative care units, ICU and major surgery wards) all reporting a high incidence . However, various diagnostic tools were used which are not sufficiently versatile to be applied to every setting, making comparisons difficult and large‐scale investigations of delirium difficult.…”

Section: Discussionmentioning

confidence: 99%

“…Delirium is increasingly recognised as a common condition in hospitalised patients. It is associated with significant adverse outcomes such as mortality, institutionalisation and long‐term cognitive impairment . Its definition was updated in 2013 by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and includes acute disturbances in cognition and attention not fully explained by an underlying neurocognitive disorder…”

Section: Introductionmentioning

confidence: 99%

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Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients

Canet

Amjad

Robbins

et al. 2019

Internal Medicine Journal

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Background Delirium is common in hospitalised patients but its epidemiology remains poorly characterised. Aims To test the hypothesis that patient demographics, clinical phenotype, management and outcomes of patient with delirium in hospital ward patients differ from intensive care unit (ICU) patients. Methods Retrospective cohort of patients admitted to an Australian university‐affiliated hospital between March 2013 and April 2017 and coded for delirium at discharge using the International Classification of Diseases System, 10th revision, criteria. Results Among 61 032 hospitalised patients, 2864 (4.7%) were coded for delirium. From these, we studied a random sample of 100 ward patients and 100 ICU patients. Ward patients were older (median age: 84 vs 65 years; P < 0.0001), more likely to have dementia (38% vs 2% for ICU patients; P < 0.0001) and less likely to have had surgery (24% vs 62%; P < 0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P < 0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, P < 0.0001). On multivariable analysis, age and dementia predicted persistent delirium, while surgery predicted recovery. Conclusions Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by dementia and is less likely to recover at hospital discharge. Therefore, delirium prevention, detection and goals of care should be adapted to the environment in which it occurs.

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Section: Discussionsupporting

confidence: 68%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients

Canet

Amjad

Robbins

et al. 2019

Internal Medicine Journal

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“…POD is an acute brain dysfunction associated with increased morbidity and healthcare costs (Marcantonio, 2017, Palanca et al , 2017). It is unclear whether intraoperative burst-suppression causes POD or merely reflects susceptibility to POD.…”

Section: Introductionmentioning

confidence: 99%

“…A history of POD has been strongly associated with a long-term cognitive decline (Saczynski et al , 2012, Inouye et al , 2016, Marcantonio, 2017). Further, patients with cognitive impairment on cognitive screening tests are more likely to be diagnosed with POD (Kalisvaart et al , 2006, Robinson et al , 2012, Saczynski et al , 2012, Inouye et al , 2016, Culley et al , 2017).…”

Section: Introductionmentioning

confidence: 99%

Electroencephalogram dynamics during general anesthesia predict the later incidence and duration of burst-suppression during cardiopulmonary bypass

Plummer

Ibala

Hahm

et al. 2019

Clinical Neurophysiology

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Objective: Electroencephalogram burst-suppression during general anesthesia is associated with post-operative delirium (POD). Whether burst-suppression causes POD or merely reflects susceptibility to POD is unclear. We hypothesized decreased intraoperative alpha (8–12 Hz) and beta (13–33 Hz) power prior to the occurrence of burst-suppression in susceptible patients. Methods: We analyzed intraoperative electroencephalogram data of cardiac surgical patients undergoing cardiopulmonary bypass (CPB). We detected the incidence and duration of CPB burst-suppression with an automated burst-suppression detection algorithm. We analyzed EEG data with multi-taper spectral estimation methods. We assessed associations between patient characteristics and burst-suppression using Binomial and Zero-inflated Poisson Regression Models. Results: We found significantly decreased alpha and beta power (7.8–22.95 Hz) in the CPB burst-suppression cohort. The odds ratio for the association between point estimates for alpha and beta power (7.8–22.95 Hz) and the incidence of burst-suppression was 0.88 (95% CI: 0.79 to 0.98). The incidence rate ratio for the association between point estimates for power between the alpha and beta range and the duration of burst-suppression was 0.89 (95% CI: 0.84 to 0.93). Conclusion: Decreased intra-operative power within the alpha and beta range was associated with susceptibility to burst-suppression during CPB. Significance: This dynamic may be used to develop principled neurophysiological-based approaches to aid the preemptive identification and targeted care of POD vulnerable patients.

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Anesthesia Dose and Delirium—A Picture Coming Into Focus

Berger,

Neuman

2024

JAMA

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In this issue of JAMA, 1 Deschamps and colleagues report results of the Electroencephalographic Guidance of Anesthesia to Alleviate Geriatric Syndromes-Canada (ENGAGES-Canada) trial. ENGAGES-Canada compared rates of postoperative delirium among 1140 patients 60 years or older undergoing cardiac surgery who were randomly assigned to 1 of 2 strategies to prevent excessive dosing of inhaled general anesthetics: electroencephalogram (EEG)-guided dosing vs usual care, in which anesthesia dose was guided by expired anesthesia gas levels and hemodynamic measurements. Although some previous studies have found an association between deep general anesthesia and postoperative delirium, 2,3 it remains unknown whether using EEG guidance to minimize time with intraoperative EEG suppression-a marker of deep anesthesia-might reduce delirium compared with usual care.Conducted at 4 Canadian hospitals, ENGAGES-Canada achieved an 18% reduction in median inhaled anesthesia dose with an EEG-guided strategy, accompanied by a reduction of total time with EEG suppression from 12 to 4 minutes. However, the study found no difference in delirium incidence by group, with 18% of patients in each group experiencing this outcome; other outcomes-including awareness under anesthesia, length of hospital stay, ICU utilization, and mortalityalso did not differ by group.These findings add detail to a growing literature investigating the relationship between general anesthesia dose and postoperative delirium. The results of ENGAGES-CANADA mirror those of the earlier ENGAGES trial. 4 This prior study enrolled patients undergoing both cardiac and noncardiac surgical procedures and found that an EEG-guided strategy led to an approximately 14% reduction in anesthesia dose and a reduction in EEG suppression from 13 to 7 minutes, but no change in delirium incidence compared with usual care.In contrast, a substudy of the international Anesthetic Depth and Complications After Surgery (BALANCED) 2 trial compared 2 EEG-guided anesthesia dosing strategies among 655 older adults undergoing primarily noncardiac surgical procedures. Patients were assigned to receive either deep vs light general anesthesia, based on 2 different target values of the bispectral index, a numerical EEG parameter that can be used to guide anesthesia dosing. BALANCED successfully reduced the median anesthesia dose by 25% between the 2 study groups, along with a reduction in EEG suppression time from 5 minutes to 2 minutes. Yet, unlike in ENGAGES-Canada, these changes in the BALANCED trial were associated with a decrease in postoperative delirium, from 28% to 19% among patients assigned to deeper vs lighter anesthesia. Similarly, 2 randomized trials pub-

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Delirium in Hospitalized Older Adults

Cited by 740 publications

References 50 publications

Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients

Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients

Electroencephalogram dynamics during general anesthesia predict the later incidence and duration of burst-suppression during cardiopulmonary bypass

Anesthesia Dose and Delirium—A Picture Coming Into Focus

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