How can delirium best be prevented and managed in older patients in hospital?

Holroyd‐Leduc, Jayna; Khandwala, Farah; Sink, Kaycee M.

doi:10.1503/cmaj.080519

Cited by 47 publications

(34 citation statements)

References 33 publications

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“…However, several recent meta-analyses have not identified consistent risk factors for delirium. Advanced age, dementia, and electrolyte imbalance have been reported as risk factors uniformly, but other factors including sex, medical illness, and psychological problems have been reported discrepantly [89101112]. To date, studies of delirium risk factors have only been conducted for specific diseases without considering each disease as a potential risk factor.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

et al. 2016

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ObjectiveTo assess the risk factors for delirium in patients admitted to a rehabilitation unit for acute or subacute neurological or musculoskeletal disorders.MethodsWe reviewed the medical records of 537 patients admitted to a rehabilitation unit and selected 398 patients in the acute or subacute stage of various neurological or musculoskeletal disorders. Among them, patients who had suffered from delirium were categorized into the delirium group (n=65), and the other patients were categorized into the non-delirium group (n=333). As potential risk factors for delirium, the patients' diagnosis, underlying disease, demographic data, hospital stay duration, surgery, and laboratory findings were reviewed, and the differences between the two groups with respect to independent risk factors were analyzed.ResultsThe average age in the delirium group was higher; the hospital stay and pre-transfer periods were longer. A large proportion of the patients were admitted for musculoskeletal disorders, and many patients had diabetes mellitus, dementia, and depression as underlying diseases. Laboratory tests revealed increases in the white blood cells (WBC), glucose, blood urea nitrogen (BUN), total bilirubin, aspartate transaminase (AST), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in the delirium group, while the hemoglobin, calcium, phosphorus, protein, albumin, and potassium levels were decreased. Depression, musculoskeletal disorders, traumatic brain injury, elevated WBC, BUN, AST, and CRP levels, and decreased potassium and phosphorus levels were identified as independent risk factors for delirium.ConclusionRisk factors treatable before delirium onset were identified in rehabilitation patients in acute and subacute stages of various disorders. Early diagnosis and prevention of these risk factors could decrease delirium occurrence and increase rehabilitation effectiveness.

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Section: Introductionmentioning

confidence: 99%

Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

et al. 2016

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“…45 Use of multidisciplinary interventions, via geriatric consultation or admission to a geriatric unit, has also been shown to reduce the incidence of delirium in postoperative patients following hip fracture repair, with an NNT of 7 patients to prevent 1 case of delirium. 46 The National Institute for Health and Clinical Excellence (NICE) developed a guideline on delirium with recommendations to administer a tailored multicomponent intervention to all at-risk older hospitalized patients to prevent delirium, as enough high-quality evidence has accrued to conclude that prevention of delirium is feasible and cost-effective ( Figure 1). 14,15 Adapted with permission from the National Institute for Health and Clinical Excellence.…”

Section: Multidisciplinary Interventions To Prevent Deliriummentioning

confidence: 99%

A Review of Recent Clinical Trials and Guidelines on the Prevention and Management of Delirium in Hospitalized Older Patients

Rathier

Baker

2011

Hospital Practice

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Treatment of acute illness in older adults is frequently complicated by the presence of delirium. Delirium is characterized by the development of an altered mental status over the course of hours to days, and can have a fluctuating course. Patients with delirium have difficulty paying attention to their environment, have disorganized thinking, and usually have an altered level of consciousness. While scientists continue to elucidate the pathophysiologic mechanisms associated with delirium, clinicians can identify patients at risk for delirium and diagnose it using valid instruments, such as the Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit. Delirium is an independent risk factor for death, institutionalization, and dementia, and resolves in many patients by the time of hospital discharge. For patients admitted to medical units, optimal management of delirium includes reassessment of medications, pain, sleep, nutrition, mobility, need for physical restraints, and bowel and bladder function. The use of antipsychotic medication to sedate delirious patients should be restricted to patients in danger of harming themselves or others and should be used when nonpharmacologic means fail. Multicomponent interventions performed by the hospital care team that address risk factors can prevent delirium in patients in medical units and those undergoing hip fracture repair. This includes attention to the depth of sedation during spinal anesthesia and the addition of regional nerve blocks to patient-controlled analgesia in orthopedic patients, both of which may reduce postoperative delirium. Perioperative use of antipsychotics may further reduce the incidence of delirium, although hospital length of stay has not been routinely reduced. Appropriate management of analgesia, sedation, and delirium in the intensive care unit is also associated with reduced duration of mechanical ventilation, as well as intensive care unit and hospital length of stay. The use of dexmedetomidine, an α-adrenergic receptor agonist, for sedation may reduce intensive care unit length of stay when compared with use of benzodiazepines.

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“…Sedation and delirium are common side effects of systemic opioids when given to an older population. 5 The prevalence of delirium amongst hip fracture patients has been shown to range from 13% to 61% 6 Furthermore, the occurrence of delirium has been shown to increase the incidence of adverse outcomes post fracture, including functional decline, permanent cognitive impairment, and death. [7][8][9][10][11] These data highlight the acute need for alternative methods of pain management in elderly patients suffering from hip fracture.…”

Section: Introductionmentioning

confidence: 99%

Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review

Riddell

Ospina

Holroyd‐Leduc

2015

CJEM

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Objective: Hip fractures are a common source of acute pain amongst the frail elderly. One potential technique to adequately manage pain in this population is the femoral nerve block. The objective of this systematic review was to provide updated evidence for the use of femoral nerve blocks as a pain management technique for older hip fracture patients in the emergency department (ED). Data Sources: Searches of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were conducted between December 2010 and May 2014. The reference list of a previous systematic review was also searched. Study Selection: We included randomized control trials examining the use of femoral nerve blocks in the ED among older adults (65 years of age or older) with acute hip fracture. Data Extraction: Among 93 citations reviewed, seven trials were included. Four studies employed a single femoral nerve block, while three studies employed continuous (catheterplaced) femoral blocks. All but one of the studies were found to have a high risk of bias. Data Synthesis: All studies reported reductions in pain intensity with femoral nerve blocks. All but one study reported decreased rescue analgesia requirements. There were no adverse effects found to be associated with the femoral block procedure; rather, two studies found a decreased risk of adverse events such as respiratory and cardiac complications. Conclusions: Femoral nerve blocks appear to have benefits both in terms of decreasing the pain experienced by older patients, as well as limiting the amount of systemic opioids administered to this population. RÉSUMÉObjectif: Les fractures de la hanche sont une cause fréquente de douleur aiguë chez les personnes âgées fragiles. L'un des moyens possibles de soulager efficacement la douleur dans ce groupe de personnes est le bloc fémoral. La revue systématique visait à recueillir des données probantes à jour sur le bloc fémoral comme moyen de soulagement de la douleur causée par les fractures de la hanche, chez les personnes âgées, au service des urgences (SU). Aucun effet indésirable n'a été associé au bloc fémoral; au contraire, les auteurs ont même constaté, dans deux études, une diminution du risque d'événement indésirable tel que des complications cardiaques ou respiratoires. Conclusions: Les blocs fémoraux semblent avantageux tant sur le plan du soulagement de la douleur chez les personnes âgées que sur celui de l'administration d'opioïdes à action générale, dans ce segment de la population.

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How can delirium best be prevented and managed in older patients in hospital?

Cited by 47 publications

References 33 publications

Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

A Review of Recent Clinical Trials and Guidelines on the Prevention and Management of Delirium in Hospitalized Older Patients

Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review

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