Considering Causes for Hypoactive Delirium

Psychiatric management of Patients in intensive care units.

IntroductionDelirium is a common problem encountered amongst the elderly patients in the ICU. Development of delirium is associated with increased severity of illness, length of stay1,2 and 6-month mortality3. Delirium is classified as hyperactive, hypoactive, and mixed of which mixed delirium has been shown to be most common. Patients with hypoactive delirium are usually older4. The incidence of delirium ranges between 45% and 83% in various studies with higher incidence in patients receiving mechanical ventilation1,2. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a validated instrument for assessment of delirium in ICU3 and delirium diagnosis may be missed when assessment tools are not employed.5ObjectivesPrimaryTo study the incidence and prevalence of delirium in critically ill patients in the first week following admission to the medical ICU of a tertiary care hospitalSecondaryTo assess the incidence of delirium in patients less than 65 years and more than 65 yearsTo study the association between delirium and occurrence of organ dysfunction, need for mechanical ventilation, ICU mortalityMaterials and methodsFollowing approval from the IEC, a prospective observational study was conducted in the medical ICU. As per the incidence from a reference study5 a sample size of 357 was obtained. All patients admitted in the ICU for > 48 h were included. All patients were assessed once daily for delirium using the CAM-ICU score during the first seven days of ICU stay and type of delirium was determined from daily RAAS score. APACHE and SOFA scores were documented on admission and patients were followed for the development of organ dysfunction, need for mechanical ventilation and outcomes.Result358 patients were included in the study of whom 39 patients in coma were excluded. Of the remaining 319 patients, 40.8% (n=130) developed delirium during the first week of ICU stay. The prevalence and incidence of delirium in our study was 83.1% (n=108) and (n=22)16.9%respectively. The most common motoric subtype was hypoactive delirium n=70 53.8% patients. Patients >65 years had a higher incidence of delirium at 49.6%when compared with patients less than 65 years 34.3% (p value 0.006). Inotrope requirement (n= 41) need for mechanical ventilation (n = 39) were associated with a higher incidence of delirium (p value 0.001). Patients with delirium had a significantly higher mortality 17.8% (p value 0.001). Chi-square test was applied to find the association of development of delirium and ICU mortality, organ dysfunction and analyze the association between age and the subtypes of delirium independent sample t-test was used to compare the scores (APACHE). Statistical analyses were conducted using SPSS Version 20.0 for Windows (IBM Corporation ARMONK, NY, USA).ConclusionThe prevalence and incidence of delirium at our centre was 83.1% and 16.9%. Hypoactive delirium was the most common motoric subtype of delirium. Patients above the age of 65 years, requiring inotropes and mechanical ventilation had a higher incidence of delirium and this was associated with higher mortality.

IntroductionAfter general anaesthesia, children sometimes have changes in their behaviour. These alterations in behaviour can occur immediately upon emerging from anaesthesia in the recovery ward or later in the subsequent days and weeks whilst at home. There may even be a permanent impact on learning and behaviour.Our knowledge in this area has improved substantially in recent years; however, there are still major gaps in our understanding. The classification, aetiology and measurement of behaviour change still needs to be properly delineated, and treatment options and prevention strategies need to be tested.MethodsAn observational study of 4424 children who had a general anaesthetic was performed to explore the incidence of hypoactive delirium in the recovery setting. A novel measurement tool, the Cornell Assessment of Pediatric Delirium, was used to detect this type of behaviour change in the immediate postoperative period. The incidence of hypoactive delirium was compared with that of hyperactive delirium and associated risk factors were analysed.A randomised controlled trial of 249 children was conducted to determine if dexmedetomidine, an alpha-2 agonist with anxiolytic, analgesic and anti-inflammatory properties, would reduce the incidence of behaviour change in the first month after general anaesthesia. Children were randomised to receive the drug preoperatively, intraoperatively or not at all. The incidence of behaviour change was measured using two different instruments: the Post Hospitalization Behaviour Questionnaire for Ambulatory Surgery and the Strength and Difficulties Questionnaire. Differences in the incidence of behaviour change between the groups at three time points were examined. In addition, correlation of the outcomes using each of the measurement tools was explored.A review of long-term neurobehavioural outcomes was conducted to summarise the existing knowledge base and describe the current international collaboration to address this issue.Results and discussionI found that hypoactive delirium does occur in children in the immediate postoperative period and in my study, 23% of all cases of delirium in recovery were hypoactive in nature. Hypoactive delirium has been well documented in critically ill children but has not been described in this population previously. It is known that children with delirium or changes in behaviour immediately after general anaesthesia are at greater risk of problem behaviours at home and may exhibit reduced compliance with future episodes of healthcare. The Cornell Assessment of Pediatric Delirium is easy to use and can detect both hyperactive and hypoactive delirium. It is therefore a suitable metric for use in the recovery setting.Dexmedetomidine, whether given before or during general anaesthesia, had little effect on the incidence of behaviour change on postoperative days 3 and 14. However, by day 28 there were fewer problem behaviours in the group of children who received an intraoperative dose. Dexmedetomidine was also associated with less pain and less emergence delirium, but it did prolong the hospital stay by approximately 40 minutes on average. Dexmedetomidine is a useful adjunct for general anaesthesia and may have particular benefit for children at risk of anxiety and problem behaviours.There was weak to moderate correlation between the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and the Strength and Difficulties Questionnaire. Neither instrument is ideal for measuring this outcome, and for research in this area to progress, a new, validated measurement tool is urgently needed.Conclusion and future directionsIn the immediate postoperative period, children can experience a form of delirium that is hypoactive in nature; therefore, the tools used to measure delirium during this time need to be capable of detecting these types of behaviours. Dexmedetomidine may be a useful adjunct in reducing the incidence of behaviour changes in the first month after anaesthesia and is also a promising agent for mitigating long-term neurobehavioural issues.There is a need for a new, well-validated tool to facilitate future research in the area of post-hospitalisation behaviour change. In addition to a questionnaire, which relies on subjective recall from the patient or parent, wearable technology should be explored and utilised to better inform clinicians and researchers about children’s behaviour after anaesthesia.The effect of anaesthesia on long-term neurobehavioural outcomes is currently being investigated, but results will take many years to be available. Dexmedetomidine is one of the medications being investigated in this area of research. It is a promising adjunct for general anaesthesia in children because, in addition to its analgesic and anti-inflammatory effects, it also has neuroprotective properties.

Postoperative Delirium

Background: Delirium is a common, preventable complication of intensive care unit treatment. It is often under-diagnosed and is an independent predictor of mortality and morbidity. Delirium screening is not a routine practice currently at surgical ICU-NHSL. Methodology: Patients requiring mechanical ventilation for more than 24 hours at surgical ICU- NHSL were screened for delirium using CAM–ICU score. The potential risk factors contributing to delirium were also studied. Data was analysed using SPSS 17. Results: Delirium was present in 66.6% patients. Importantly, the commonest subtype was hypoactive delirium (50%) while hyperactive and mixed delirium accounted for 30% and 20% respectively. Significantly higher proportion of patients who developed delirium were males (p= 0.02). There was no association between patients’ age and development of delirium. Patients with delirium had a significantly higher incidence of acute liver impairment (p=0.03), acute malnutrition (p=0.05) and impaired glycaemic control (p= 0.05). There was a statistically significant association between presence of invasive lines (p=0.004), use of propofol (p= 0.006) and use of opioids (0.03) and development of delirium. Conclusion: The study revealed high incidence of delirium in patients who are mechanically ventilated for more than 24 hours. Majority of them were having hypoactive delirium. The need for early identification using routine delirium screening tools and assessment of risk factors contributing to delirium is highlighted.

Background: Delirium is a complex neuropsychiatric syndrome common in all medical settings. An acute change in cognition characterizes a disturbance of consciousness, usually resulting from an underlying medical condition or withdrawal from medications or drugs. Three different subtypes of delirium have been identified based on the motor symptoms exhibited by the patient: hyperactive, hypoactive, and mixed. This study aims to review the use of methylphenidate for treating hypoactive delirium. Methods: The review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We performed a literature search of PubMed, MEDLINE, Cochrane, and clinical trial registries from 1990 to 15 March 2023. Results: A total of 115 articles were identified. After removing duplicates, 68 abstracts were reviewed by all the authors. Then, 13 full-text articles were assessed for eligibility. Three articles were deemed eligible for the systematic review. These included one prospective clinical study, one case series, and one case report. The total number of participants was 17, with multiple comorbidities. Most studies reported using methylphenidate for hypoactive delirium in terminally ill patients. All reviewed studies reported symptomatic benefits in individuals with hypoactive delirium. Conclusions: Methylphenidate may be beneficial in treating hypoactive delirium in terminally ill patients. Clinical trials are needed to assess the safety and efficacy of methylphenidate in Hypoactive delirium.

Objective: To measure the point prevalence of delirium in the patients admitted to the cardiac ICU with acute coronary syndromes, with particular attention to the most commonly noted delirium and the impact on ICU mortality and length of ICU stay. Study Design: Prospective cohort study. Place and Study Duration: National Institute of Cardiovascular Diseases, Karachi Pakistan, from Mar and Jul 2021. Methodology: Consecutive adult patients with age >18 years admitted to the cardiac ICU after acute coronary syndromes were assessed for delirium using the confusion assessment method (CAM)-ICU tool and Richmond agitation sedation score (>-3). The types of delirium were also assessed. Results: 201 patients were enrolled, half of patients with ST-elevation MI (51.2%) and shock (45.8%). Delirium was identified in 71 (35.3%) patients, 30 (42.2%) had hypoactive delirium and 41 (57.7%) had hyperactive delirium. In multivariable regression, independent risk factors for delirium were: sepsis 3.19 (1.15-8.87), uremia 4.12 (1.18-14.46), mechanical ventilation 7.58 (1.2-47.99), and non-invasive ventilation 8.55 (2.9-25.2). Overall mortality was 35 (17.4%); 27/71 (38%) vs. 8/130 (6.2%); p 0.001 in patients with and without delirium, respectively. In multivariable regression, delirium was an independent risk factor for mortality at 7.12 (2.16-2.23). The mean ICU stay was 7.772.36 days vs. 3.91.44 days; p 0.001 for patients with and without delirium. Conclusion: The deleterious effect of delirium in terms of higher morbidity and mortality cannot be overemphasised. Hypoactive delirium is as common as the hyperactive type, with the same mortality risk. Assessment for delirium is mandatory for all patients admitted..............

April 2021 <i>Stroke</i> Highlights

We appreciate the comments from Zhang et al.1 on our recent article “Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.”2Consistent with many others,3 our study also found that intraoperative hypotension occurred more frequently in patients given combined epidural–general anesthesia. Increasing evidence suggests that intraoperative hypotension is associated with an increased risk of postoperative delirium.4,5 According to the suggestion of Zhang et al.,1 we included intraoperative hypotension in a post hoc treatment-by-covariate interaction analysis for the primary outcome. Our results did not find significant interaction between treatment intervention and intraoperative hypotension. The effect of combined epidural–general anesthesia on delirium was similar in the subgroups with or without intraoperative hypotension (with intraoperative hypotension [systolic blood pressure &lt; 80 mmHg]: relative risk 0.68; 95% CI, 0.20 to 2.37; without intraoperative hypotension: 0.33, 0.16 to 0.67; interaction P = 0.243).In our study, delirium was assessed twice daily with the Confusion Assessment Method for the Intensive Care Unit during the first 7 postoperative days. Immediately before assessing delirium, sedation or agitation was assessed with the Richmond Agitation-Sedation Scale. Patients who developed delirium were classified into three subtypes according to the Richmond Agitation-Sedation Scale assessment results. Hyperactive delirium was defined when the Richmond Agitation-Sedation Scale score was consistently positive (from +1 to +4). Hypoactive delirium was defined when the Richmond Agitation-Sedation Scale score was consistently negative or neutral (from –3 to 0). Mixed-type delirium was defined when both hyperactive and hypoactive episodes existed.6 In accord with the results of others, hypoactive delirium was the most common subtype in our patients of the two groups.2Among our patients, 58 (3.4%) developed delirium within the first 7 postoperative days; of those who developed delirium, 21 (36%) had two episodes or more. The duration of delirium (number of days with at least one episode of delirium) was shorter in patients given combined epidural–general anesthesia (median 0 days [interquartile range, 0 to 0] with combined epidural-general anesthesia vs. 0 days [0 to 0] with general anesthesia alone; mean difference –0.04, 95% CI, –0.08 to –0.01; P &lt; 0.001). Among 58 patients who developed delirium, the duration of delirium did not differ between the two groups (median 1 day [interquartile range, 1 to 2] vs. 1 day [1 to 2]; mean difference 0.42, 95% CI, –0.26 to 1.10; P = 0.546).This work was funded by the Peking University (Beijing, China) Clinical Research Program [PUCRP201101]. The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.The authors declare no competing interests.

Neuroleptic Dose in the Management of Delirium in Patients with Advanced Cancer

Introduction Delirium is prevalent in patients with idiopathic Parkinson’s disease (iPD) who are admitted to hospital. The hypoactive subtype of delirium is associated with poorer outcomes in hospitalised patients. The aim of this study was to evaluate different outcomes across delirium subtypes in unplanned hospital admissions in patients living with iPD. Methods Data was collated prospectively on all patients with idiopathic Parkinson’s disease admitted to our hospital’s medical wards between 1st January 2019 and 30th March 2020. Electronic case-note review and in-person assessments were used to determine a diagnosis of delirium, the delirium subtype, and key outcomes including length of stay (LOS) and mortality. Data was analysed with respect to both index admissions and those readmitted during the study period. Results 123 patients with iPD (male 52.8 %, mean age 77.9 years) accounted for 189 admissions. Delirium was present in 91/189 admissions (48%). There was no difference in Hoen &amp; Yahr or Clinical Frailty Scale levels between groups with and without delirium. The prevalence of dementia was higher in the delirium group (48.3% vs 25.5%). Hypoactive delirium was the most common subtype (49.5%); hyperactive (13.2%), mixed (11%) and neutral (neither hypo- nor hyperactive) 26.4%. 12-month mortality in the index admissions was highest in the hypoactive subtype (57.1%). Median LOS (all admissions) was 11.5 days in patients with delirium vs 5.5 days in those without. A mixed delirium phenotype had longest LOS (mean 30.7 days) compared with other subtypes. Conclusions The hypoactive subtype of delirium predominates in hospitalised patients with iPD. Length of stay was longest in those experiencing a mixture of hyperactive and hypoactive subtypes, and mortality was highest in the hypoactive group. Healthcare settings need robust systems screening for delirium in Parkinson’s patients, with prevention and management processes to reduce morbidity and mortality in this complex group.

Introduction: The aging population has been rapidly growing in the United States (U.S.). In line with this trend, older adults’ mobility and transportation safety are an increasing priority. Many states have implemented driver licensure laws specific to older adults to limit driving among the elderly with driving skill decline. Evaluations of these laws have primarily focused on their safety benefits related to older drivers’ fatal crash rate or injury rate. However, very few studies investigated licensure law effects on older adults’ mobility. Objective: The objective of our study is to evaluate the association between older driver licensure laws and older adult daily traveling and passenger exposure. Methods: The 2003–2017 American Time Use Survey (ATUS) data were linked with statewide driver licensure law provisions. Adults aged 55–64 years were used as the reference group to control for the effects of non-licensure-law factors (e.g., economic trend). We used modified Poisson regressions with robust variance to estimate the relationships between licensure law provisions and the likelihoods of older men and women’s daily traveling and passenger behaviors. Results: Laws requiring a vision test at in-person renewal were associated with increased daily traveling likelihood for women aged 75 years or older, primarily as a passenger. Laws requiring a knowledge test were related to a reduced daily overall traveling likelihood for women aged 75 years or older. Conclusions: In general, licensure law provisions are not strongly related to older adults’ mobility, in particular for older male adults. Older female adults’ daily mobility may be more likely to be influenced by the change of licensure laws than older male adults. The existence of gender-based disparities in responding to licensure laws requires future studies to account for the gender difference in estimating the effects of those traffic policies on older adults’ mobility and traffic safety.

Validation of the Swedish version of the Nursing Delirium Screening Scale as a screening tool for nurses to use to detect postoperative delirium in patients 70 years and older undergoing cardiac surgery. Delirium is common among old patients after cardiac surgery. Underdiagnosis and poor documentation of postoperative delirium is problematic, and nurses often misread the signs. A prospective observational study. Patients (n = 142) scheduled for cardiac surgery were assessed three times daily by the nursing staff using the Nursing Delirium Screening Scale. Nursing Delirium Screening Scale was compared with the Mini Mental State Examination and the Organic Brains Syndrome Scale, evaluated day one and day four postoperatively. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders - DSM-IV-TR criteria. A larger proportion of patients were diagnosed with delirium according to the Mini Mental State Examination and Organic Brains Syndrome Scale compared with the Nursing Delirium Screening Scale, both on day one and day four. The Nursing Delirium Screening Scale protocol identified the majority of hyperactive and mixed delirium patients, whereas several with hypoactive delirium were unrecognised. The Swedish version of the Nursing Delirium Screening Scale was easily incorporated into clinical care and showed high sensitivity in detecting hyperactive symptoms of delirium. However, in the routine use by nurses, the Nursing Delirium Screening Scale had low sensitivity in detecting hypoactive delirium, the most prevalent form of delirium after cardiac surgery. Nursing Delirium Screening Scale probably has to be combined with cognitive testing to detect hypoactive delirium. Nurses play a key role in detecting delirium. The Nursing Delirium Screening Scale was easy incorporated instrument for clinical practice and identified the majority of hyperactive and mixed delirium, but several of the patients with hypoactive delirium were unrecognised. Training of assessment and cognitive testing seems to be necessary to detect hypoactive delirium.

Although mania is commonly associated with bipolar disorder, it can have many etiologies (1). Thus, “primary mania” results from bipolar disorder, whereas “secondary mania” results from pharmacological, metabolic, or neurologic causes (1, 2). Older adults are at risk for secondary mania because of increased medical comorbidities and neurological changes. In one retrospective study of 50 patients with mania who were older than 65 years, it was the first manic episode for 28% of the patients and 71% had a comorbid neurological disorder (3). The etiology of mania is important because although acute symptomatic treatment of both primary and secondary mania may be similar, appropriate treatment of secondary mania includes addressing the cause (1). We present here two case histories of secondary mania in older adults, discuss their presentations and differential diagnosis in turn, and discuss treatment.

Delirium (or Acute Confusional State) refers to an acute alteration of attention, consciousness, and cognitive performance. Particularly the hypoactive subtype of delirium represents a diagnostic and clinical challenge. As symptoms of hypoactive delirium may overlap with the clinical picture present in dementia and depression, correct diagnostic differentiation can be challenging. In the absence of timely diagnosis and treatment, hypoactive delirium can last for several weeks. Apart from the health consequences for the patient, such a long course can stress caregivers and the family to their very limit. In this article, we will address the particularities of hypoactive delirium in hospital practice, the neurobiological bases of this disorder, the challenges it represents at the diagnostic level as well as its recommended management according to current literature.