ContextDelirium is a common problem in the intensive care unit (ICU). Accurate
diagnosis is limited by the difficulty of communicating with mechanically
ventilated patients and by lack of a validated delirium instrument for use
in the ICU.ObjectivesTo validate a delirium assessment instrument that uses standardized
nonverbal assessments for mechanically ventilated patients and to determine
the occurrence rate of delirium in such patients.Design and SettingProspective cohort study testing the Confusion Assessment Method for
ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based
medical center.ParticipantsA total of 111 consecutive patients who were mechanically ventilated
were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%)
were evaluable for the development of delirium and 15 (13.5%) were excluded
because they remained comatose throughout the investigation.Main Outcome MeasuresOccurrence rate of delirium and sensitivity, specificity, and interrater
reliability of delirium assessments using the CAM-ICU, made daily by 2 critical
care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, criteria.ResultsA total of 471 daily paired evaluations were completed. Compared with
the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU
had sensitivities of 100% and 93%, specificities of 98% and 100%, and high
interrater reliability (κ = 0.96; 95% confidence interval, 0.92-0.99).
Interrater reliability measures across subgroup comparisons showed κ
values of 0.92 for those aged 65 years or older, 0.99 for those with suspected
dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation
II scores at or above the median value of 23 (all P<.001).
Comparing sensitivity and specificity between patient subgroups according
to age, suspected dementia, or severity of illness showed no significant differences.
The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard
diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5%
of all observations, respectively. Delirium occurred in 80 (83.3%) patients
during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even
present in 39.5% of alert or easily aroused patient observations by the reference
standard and persisted in 10.4% of patients at hospital discharge.ConclusionsDelirium, a complication not currently monitored in the ICU setting,
is extremely common in mechanically ventilated patients. The CAM-ICU appears
to be rapid, valid, and reliable for diagnosing delirium in the ICU setting
and may be a useful instrument for both clinical and research purposes.

/pdf/delirium-in-mechanically-ventilated-patients-validity-and-3er9o5ci52.pdf

Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU).

Context Delirium is a common and serious complication in elderly patients Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease Objective To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders Data Sources A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL Study Selection Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language Titles, abstracts, and articles were reviewed independently by 2 of the authors Of 2939 references in the original search, 51 relevant articles were identified Data Extraction Information on study design, characteristics of the study population, and outcome were extracted Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies Data Synthesis The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia Pooled-effect estimates were calculated with random-effects models The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 227 months (7 studies; 271/714 patients [380%] with delirium, 616/2243 controls [275%]; HR, 195 [95% confidence interval {CI}, 151-252]; I2, 440%) Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 146 months; 176/527 patients [334%] with delirium and 219/2052 controls [107%]; odds ratio [OR], 241 [95% CI, 177-329]; I2, 0%) and dementia (2 studies; average follow-up, 41 years; 35/56 patients [625%] with delirium and 15/185 controls [81%]; OR, 1252 [95% CI, 186-8421]; I2, 524%) The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results Conclusion This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia

https://jamanetwork.com/journals/jama/articlepdf/186304/jrv05005_443_451.pdf

Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-analysis

This article and its accompanying editorial have been selected for the ANESTHESIOLOGYCME Program. After reading both articles, go to http://www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue. Background: The authors designed a prospective longitudinal study to investigate the hypothesis that advancing age is a risk factor for postoperative cognitive dysfunction (POCD) after major noncardiac surgery and the impact of POCD on mortality in the first year after surgery. Methods: One thousand sixty-four patients aged 18 yr or older completed neuropsychological tests before surgery, at hospital discharge, and 3 months after surgery. Patients were categorized as young (18‐39 yr), middle-aged (40‐59 yr), or elderly (60 yr or older). At 1 yr after surgery, patients were contacted to determine their survival status. Results: At hospital discharge, POCD was present in 117 (36.6%) young, 112 (30.4%) middle-aged, and 138 (41.4%) elderly patients. There was a significant difference between all age groups and the age-matched control subjects (P < 0.001). At 3 months after surgery, POCD was present in 16 (5.7%) young, 19 (5.6%) middle-aged, and 39 (12.7%) elderly patients. At this time point, the prevalence of cognitive dysfunction was similar between age-matched controls and young and middle-aged patients but significantly higher in elderly patients compared to elderly control subjects (P < 0.001). The independent risk factors for POCD at 3 months after surgery were increasing age, lower educational level, a history of previous cerebral vascular accident with no residual impairment, and POCD at hospital discharge. Patients with POCD at hospital discharge were more likely to die in the first 3 months after surgery (P 0.02). Likewise, patients who had POCD at both hospital discharge and 3 months after surgery were more likely to die in the first year after surgery (P 0.02). Conclusions: Cognitive dysfunction is common in adult patients of all ages at hospital discharge after major noncardiac surgery, but only the elderly (aged 60 yr or older) are at significant risk for long-term cognitive problems. Patients with POCD are at an increased risk of death in the first year after surgery. POSTOPERATIVE cognitive dysfunction (POCD) is often associated with cardiac surgery, but less is known about the prevalence of this problem after other types of surgery. 1,2 In 1998, the International Study of Postoperative Cognitive Dysfunction (ISPOCD1) evaluated cognitive decline in 1,218 elderly patients, aged 60 yr or older, who had undergone major noncardiac surgery, and found that cognitive dysfunction was present in 26% of older patients 1 week after surgery and in 10% 3 months after surgery. 3 However, this study had significant differences in the incidence of early POCD at the 13 participating hospitals, placing this finding in question. Research evaluating cognitive decline after cardiac and noncardiac surgery has primarily focused on older patients, who might have an increased vulnerability to neurologic deterioration. 1,3,4 However, the cognitive effects of surgery and anesthesia in younger adults are poorly understood, making it difficult to determine whether advancing age is the primary risk factor for this complication. Studies on normal aging have shown that abrupt declines in cognitive function in older adults are associated with early death. 5,6 The relation between POCD and mortality has not been reported. To investigate the hypothesis that advancing age is a risk factor for POCD, we designed a prospective cohort study evaluating the incidence of early (hospital discharge) and late (3 months after surgery) cognitive dysfunction in adults of all ages undergoing elective, major noncardiac surgery. This study used the same neuropsychological methodology as the ISPOCD1 study in an attempt to replicate its results at a single institution. 3 Patients were also followed to determine the impact of POCD on survival in the first year after major surgery. A companion article analyzes the type and severity of cognitive impairment in the elderly patients in this study. 7

https://www.medpagetoday.com/upload/2007/12/27/00000542-200801000-00007.pdf

Predictors of Cognitive Dysfunction after Major Noncardiac Surgery

DELIRIUM IS A SYNDROME OF acutely altered mental status characterized by inattent ion and a f luctuat ing course. With occurrence rates of up to half of older patients postoperatively, and even higher in elderly patients admitted to intensive care units, delirium is the most common complication in hospitalized older people. Delirium causes distress to patients and caregivers, has been associated with increased morbidity and mortality, and is a major burden to health care services in terms of expenditures. Numerous studies have addressed the long-term prognosis of older individuals who experienced delirium during hospitalization. The evidence that these studies provide is not entirely consistent (eg, older patients with delirium experienced increased long-term mortality in one study, but not in another). Elements of study design, such as delirium and outcome ascertainment and time to follow-up, may affect conclusions. Whether delirium independently contributes to poor outcome or merely represents a marker of underlying disease is especially relevant. The long-term detrimental seAuthor Affiliations: Department of Geriatric Medicine, Medical Center Alkmaar, Alkmaar, the Netherlands (Mr Witlox and Dr de Jonghe); Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands(MsEurelingsandDrsEikelenboomandvanGool); Department of Geriatric Medicine, Kennemer Gasthuis, Haarlem,theNetherlands(DrKalisvaart);andGGZinGeest, Amsterdam, the Netherlands (Dr Eikelenboom). Corresponding Author: Willem A. van Gool, MD, PhD, Department of Neurology, Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, the Netherlands (w.a.vangool@amc.uva.nl). Context Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease.

Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia

Cerebral white matter lesions (WMLs) have been associated with cognitive dysfunction. Whether periventricular or subcortical WMLs relate differently to cognitive function is still uncertain. In addition, it is unclear whether WMLs are related to specific cognitive domains such as memory or psychomotor speed. We examined the relationship between periventricular and subcortical WMLs and cognitive functioning in 1,077 elderly subjects randomly sampled from the general population. Quantification of WMLs was assessed by means of an extensive rating scale on 1.5-T magnetic resonance imaging scans. Cognitive function was assessed by using multiple neuropsychological tests from which we constructed compound scores for psychomotor speed, memory performance, and global cognitive function. When analyzed separately, both periventricular and subcortical WMLs were related to all neuropsychological measures. When periventricular WMLs were analyzed conditional on subcortical WMLs and vice versa, the relationship between periventricular WMLs and global cognitive function remained unaltered whereas the relationship with subcortical WMLs disappeared. Subjects with most severe periventricular WMLs performed nearly 1 SD below average on tasks involving psychomotor speed, and more than 0.5 SD below average for global cognitive function. Tasks that involve speed of cognitive processes appear to be more affected by WMLs than memory tasks.

JS Gravenstein

Papers

Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study