The Impact of Non-Pharmacological Interventions on Delirium in Neurological Intensive Care Unit Patients: A Single-Center Interrupted Time Series Trial.

Background: Delirium is a pathobiological brain process that is frequently observed in Intensive Care Unit (ICU) patients, and is associated with longer hospitalization as well as long-term cognitive impairment. In neurological ICU patients, delirium may be more treatment-resistant due to the initial brain injury. This study examined the effects of a multicomponent non-pharmacological nursing intervention program on delirium in neurological ICU patients. Methods: A single-center interrupted time series trial was conducted in adult neurological ICU patients at high risk for developing delirium who were non-delirious at admission. A multicomponent nursing intervention program focusing on modifiable risk factors for delirium, including the optimalization of vision, hearing, orientation and cognition, sleep and mobilization, was implemented as the standard of care, and its effects were studied. The primary outcome was the number of delirium-free and coma-free days alive at 28 days after ICU admission. The secondary outcomes included delirium incidence and duration, ICU and hospital length-of-stay and duration of mechanical ventilation. Results: Of 289 eligible patients admitted to the ICU, 130 patients were included, with a mean age of 68 ± 11 years, a mean APACHE-IV score of 79 ± 25 and a median predicted delirium risk (E-PRE-DELIRIC) score of 42 [IQR 38-50]). Of these, 73 were included in the intervention period and 57 in the control period. The median delirium- and coma-free days alive were 15 days [IQR 0-26] in the intervention group and 10 days [IQR 0-24] in the control group (level change -0.48 days, 95% confidence interval (95%CI) -7 to 6 days, p = 0.87; slope change -0.95 days, 95%CI -2.41 to 0.52 days, p = 0.18). Conclusions: In neurological ICU patients, our multicomponent non-pharmacological nursing intervention program did not change the number of delirium-free and coma-free days alive after 28 days.

Post-Intensive Care Syndrome in Patients Suffering From Acute Subarachnoid Hemorrhage: Results From an Outpatient Post-ICU Aftercare Clinic.

Introduction Survivors of an acute subarachnoid hemorrhage (aSAH) may suffer from a long-term neurological disability, cognitive impairment, anxiety, and depression, which can also be related to post-intensive care syndrome (PICS). The aim of this study was to examine the prevalence of PICS symptoms in post-intensive care (ICU) aftercare aSAH patients. Methods We conducted an observational cohort study in aSAH patients from a post-ICU aftercare clinic (ICU-AC). PICS symptoms were evaluated using the Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS), and a medical questionnaire for physical and cognitive functioning. Results A total of 110 patients were included. The prevalence of anxiety and depressive symptoms was 23.6% and 19.1%, respectively. Post-traumatic stress disorder (PTSD) was seen in 26.4%. Cognitive complaints were lack of concentration (63.6%), short-term memory loss (45.8%), and reduced speed of thinking (60.9%). The most reported physical complaints were fatigue (73.6%), limitations in daily activity (72.7%), muscle weakness (41.8%), pain (36.4%), and weight loss (30.9%). PICS symptoms related to all three domains were present in 30% of patients. Conclusion The prevalence of PICS in patients after aSAH is high. Even in patients without aSAH-related neurological impairment who were discharged home, a high prevalence of PICS symptoms was reported. Early screening for PICS should comprise all three domains and is important to facilitate a better tailored rehabilitation of these patients.

Poor outcome in frail elderly patient after severe TBI.

OBJECTIVE: To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome. METHOD: 126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma. RESULTS: High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months. CONCLUSION: Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Comparison Between Deltascan Single Channel Electroencephalography (EEG), Confusion Assessment Method-Intensive Care Unit (CAM-ICU) Score and Clinical Assessment in Diagnosing Delirium in Intubated Patients in the Intensive Care Unit.

Background The aim of this article is to assess the feasibility of using single-channel electroencephalography (EEG) measurement for detecting delirium in intubated Intensive care (ICU) patients and to assess the level of agreement between the EEG measurements, the CAM-ICU score and the clinical diagnosis of delirium. Materials and methods This study was an exploratory pilot between May 2021 and September 2021 including intubated patients in the ICU. For this study the Prolira® (Arnhem, The Netherlands) Deltascan single-channel EEG was used and compared with the Confusion Assessment Method (CAM)-ICU and the clinical diagnosis of delirium by ICU physicians. Results In total 23 patients were found eligible for this study, of which 20 were included in the final analysis. The patients mean age was 63.0 ± 8.8 years, and the majority (thirteen) was male (65%). In total 17 of the 20 patients (85%) received the diagnosis delirium by the medical team. There were no statistically significant differences between the Deltascan and CAM-ICU measurements in diagnosing delirium per time point (p values respectively 0.21; 0.90; 0.34; 0.11; 0.056 and 0.091). AUCs for the agreement between the CAM-ICU and the Deltascan measurements were respectively: 0.676 ± 0.205; 0.333 ± 0.224; 0.402 ± 0.146; 0.488 ± 0.202; 0.06 ± 0.077 and 0.06 ± 0.109 (all p>0.05). AUCs for the level of agreement between the clinical diagnosis delirium and Deltascan were: 0.676 ± 0.152; 0.686 ± 0.146; 0.711 ± 0.132; 0.688 ± 0.136; 0.500 ± 0.158 and 0.700 ± 0.211 (all p>0.05). Conclusion In this exploratory study, we showed that there is no statistical agreement between CAM-ICU and Delta scan measurements. Secondly, there is a higher agreement, although not statistically significant between the clinical diagnoses of a delirium (by a clinician) with the Deltascan measurements. Despite this small study we think that the Deltascan can be of additional value in intubated ICU patients and therefore larger studies are needed to substantiate our findings.

C-Terminal Proarginine Vasopressin is Associated with Disease Outcome and Mortality, but not with Delayed Cerebral Ischemia in Critically Ill Patients with an Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is an important indication for intensive care unit admission and may lead to significant morbidity and mortality. We assessed the ability of C-terminal proarginine vasopressin (CT-proAVP) to predict disease outcome, mortality, and delayed cerebral ischemia (DCI) in critically ill patients with aSAH compared with the World Federation of Neurological Surgeons (WFNS) score and Acute Physiological and Chronic Health Evaluation IV (APACHE IV) model. METHODS: C-terminal proarginine vasopressin was collected on admission in this single-center, prospective, observational cohort study. The primary aim was to investigate the relationship between CT-proAVP and poor functional outcome at 1 year (Glasgow Outcome Scale score 1-3) in a multivariable logistic regression model adjusted for WFNS and APACHE IV scores. Secondary aims were mortality and DCI. The multivariable logistic regression model for DCI was also adjusted for the modified Fisher scale. RESULTS: In 100 patients, the median CT-proAVP level was 24.9 pmol/L (interquartile range 11.5-53.8); 45 patients had a poor 1-year functional outcome, 19 patients died within 30 days, 25 patients died within 1 year, and DCI occurred in 28 patients. Receiver operating characteristics curves revealed high accuracy for CT-proAVP to identify patients with poor 1-year functional outcome (area under the curve [AUC] 0.84, 95% confidence interval [CI] 0.77-0.92, p < 0.001), 30-day mortality (AUC 0.84, 95% CI 0.76-0.93, p < 0.001), and 1-year mortality (AUC 0.79, 95% CI 0.69-0.89, p < 0.001). CT-proAVP had a low AUC for identifying patients with DCI (AUC 0.67, 95% CI 0.55-0.79, p 0.008). CT-proAVP ≥ 24.9 pmo/L proved to be a significant predictor for poor 1-year functional outcome (odds ratio [OR] 8.04, 95% CI 2.97-21.75, p < 0.001), and CT-proAVP ≥ 29.1 pmol/L and ≥ 27.7 pmol/L were significant predictors for 30-day and 1-year mortality (OR 9.31, 95% CI 1.55-56.07, p 0.015 and OR 5.15, 95% CI 1.48-17.93, p 0.010) in multivariable models with WFNS and APACHE IV scores. CT-proAVP ≥ 29.5 pmol/L was not a significant predictor for DCI in a multivariable model adjusted for the modified Fisher scale (p = 0.061). CONCLUSIONS: C-terminal proarginine vasopressin was able to predict poor functional outcome and mortality in critically ill patients with aSAH. Its prognostic ability to predict DCI was low. TRIAL REGISTRATION: Nederlands Trial Register: NTR4118.

Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies.

INTRODUCTION: Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery. AREAS COVERED: First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families. EXPERT OPINION: PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.

The Impact of Nursing Delirium Preventive Interventions in the ICU: A Multicenter Cluster-randomized Controlled Clinical Trial.

Rationale: Delirium is common in critically ill patients and is associated with deleterious outcomes. Nonpharmacological interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objectives: To determine the effects of a multicomponent nursing intervention program on delirium in the ICU. Methods: A stepped-wedge cluster-randomized controlled trial was conducted in ICUs of 10 centers. Adult critically ill surgical, medical, or trauma patients at high risk of developing delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. The primary outcome was the number of delirium-free and coma-free days alive in 28 days after ICU admission. Measurements and Main Results: A total of 1,749 patients were included. Time spent on interventions per 8-hour shift was median (interquartile range) 38 (14-116) minutes in the intervention period and median 32 (13-73) minutes in the control period (P = 0.44). Patients in the intervention period had a median of 23 (4-27) delirium-free and coma-free days alive compared with a median of 23 (5-27) days for patients in the control group (mean difference, -1.21 days; 95% confidence interval, -2.84 to 0.42 d; P = 0.15). In addition, the number of delirium days was similar: median 2 (1-4) days (ratio of medians, 0.90; 95% confidence interval, 0.75 to 1.09; P = 0.27). Conclusions: In this large randomized controlled trial in adult ICU patients, a limited increase in the use of nursing interventions was achieved, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registered with www.clinicaltrials.gov (NCT03002701).

Accuracy in prediction of long-term functional outcome in patients with traumatic axonal injury: a comparison of MRI scales.

Purpose: Functional outcome prediction for patients with traumatic axonal injury (TAI) is not highly related to the MRI classifications. The aim of this study was to assess the accuracy in predicting functional outcome in patients with TAI with several MRI scoring methods and to define the most accurate method.Methods: Patients with TAI (2008-2014) confirmed on MRI <6 months after injury were included in this retrospective study. Long-term functional outcome was prospectively assessed using the Glasgow Outcome Score Extended. The Gentry classification is most used in clinical practice. This method was compared to methods that score lesion load, lesion locations, and to modified Gentry classifications. The area under the curve (AUC) was calculated for the scoring methods.Results: A total of 124 patients with TAI were included, medium follow-up 52 months. The AUC for the Gentry classification was 0.64. All tested methods were poor predictors for functional outcome, except for the 6-location score (area under the curve: 0.71). No method was significantly better than the Gentry classification.Conclusion: The Gentry classification for TAI correlates with functional outcome, but is a poor predictor for the long-term functional outcome. None of the other tested methods was significantly better.

High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction.

BACKGROUND: Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT). METHODS: We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2). RESULTS: Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable. CONCLUSION: High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.

The use of the PSH-AM in patients with diffuse axonal injury and autonomic dysregulation: A cohort study and review.

PURPOSE: 1) To determine the clinical expression and consequences of autonomic dysregulation in patients with diffuse axonal injury (DAI), and 2) to study the use of the "paroxysmal sympathetic hyperactivity assessment measure" (PSH-AM). METHODS: Patients clinically diagnosed with autonomic dysregulation were selected from a cohort involving 116 patients with DAI. We studied the incidence of autonomic features, treatment, and outcome. In addition a systematic review was performed. RESULTS: Autonomic dysregulation was diagnosed in 19 of 116 (16.4%). Lower age (OR 0.95) and higher DAI grade (OR 7.2) were risk factors for autonomic dysregulation. Autonomic dysregulation was associated with an unfavourable outcome (OR 5.6) and a longer ICU and hospital stay. On the PSH-AM 57.9% (n = 11) scored a probable paroxysmal sympathetic hyperactivity (PSH), 36.8% (n = 7) scored possible, and 5.2% (n = 1) scored unlikely. The review yielded 30 articles. The incidence of autonomic dysregulation after TBI varied from 7.7-32.6% (mean 13.5%). TBI patients with autonomic dysregulation had a longer ICU stay and poorer outcome. CONCLUSION: Patients with DAI and autonomic dysregulation had a longer ICU stay and a poorer outcome compared to patients without autonomic dysregulation. The PSH-AM is a potential valuable tool to determine the likelihood of autonomic dysregulation.

Patients with Diffuse Axonal Injury Can Recover to a Favorable Long-Term Functional and Quality of Life Outcome.

Functional outcome and quality of life are difficult to predict in patients with diffuse axonal injury (DAI) after traumatic brain injury (TBI). The primary aim of this cross-sectional cohort study was to assess the long-term functional outcome in patients with DAI and to identify prognostic factors. Second, health-related quality of life (HRQL) at long-term follow-up was assessed. Patients ≥16 years of age with TBI and DAI (admitted 2008-2014) were included. Clinical and imaging data were collected. The primary outcome parameter was the Glasgow Outcome Scale Extended (GOSE) at long-term follow-up. Second, the HRQL was assessed with the Quality Of Life after Brain Injury (QOLIBRI) questionnaire. DAI was diagnosed in 185 patients. Long-term functional outcome was obtained in 134 patients (72%), median follow-up was 54 months (range 14-100); and 51% had a favorable outcome (GOSE 6-8). Independent prognostic factors were age, pupillary reaction, Hb, DAI grading, and return of consciousness ≤7 days. Sixty-two percent had a good HRQL, after a median follow-up of 57 months (range 14-100) with age as an independent prognostic factor. More than half of patients with DAI had a favorable functional outcome and a good HRQL at long-term follow-up. Also in patients with a DAI grade 3, a favorable outcome was seen. HRQL is a clinically relevant outcome measure because it reflects perceived outcome by patients. Independent prognostic variables for functional outcome were factors obtained in the acute phase after injury, whereas age was an independent prognostic factor for HRQL.

Induced Hypertension for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.

BACKGROUND AND PURPOSE: Induced hypertension is widely used to treat delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but a literature review shows that its presumed effectiveness is based on uncontrolled case-series only. We here report clinical outcome of aneurysmal subarachnoid hemorrhage patients with DCI included in a randomized trial on the effectiveness of induced hypertension. METHODS: Aneurysmal subarachnoid hemorrhage patients with clinical symptoms of DCI were randomized to induced hypertension or no induced hypertension. Risk ratios for poor outcome (modified Rankin Scale score >3) at 3 months, with 95% confidence intervals, were calculated and adjusted for age, clinical condition at admission and at time of DCI, and amount of blood on initial computed tomographic scan with Poisson regression analysis. RESULTS: The trial aiming to include 240 patients was ended, based on lack of effect on cerebral perfusion and slow recruitment, when 21 patients had been randomized to induced hypertension, and 20 patients to no hypertension. With induced hypertension, the adjusted risk ratio for poor outcome was 1.0 (95% confidence interval, 0.6-1.8) and the risk ratio for serious adverse events 2.1 (95% confidence interval, 0.9-5.0). CONCLUSIONS: Before this trial, the effectiveness of induced hypertension for DCI in aneurysmal subarachnoid hemorrhage patients was unknown because current literature consists only of uncontrolled case series. The results from our premature halted trial do not add any evidence to support induced hypertension and show that this treatment can lead to serious adverse events. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01613235.

Prospective Evaluation of Noninvasive HeadSense Intracranial Pressure Monitor in Traumatic Brain Injury Patients Undergoing Invasive Intracranial Pressure Monitoring.

BACKGROUND: Currently, intracranial pressure (ICP) is measured by invasive methods with a significant risk of infectious and hemorrhagic complications. Because of these high risks, there is a need for a noninvasive ICP (nICP) monitor with an accuracy similar to that of an invasive ICP (iICP) monitor. OBJECTIVE: We sought to assess prospectively the accuracy and precision of an nICP monitor compared with iICP measurement in severe traumatic brain injury (TBI) patients. METHODS: Participants were ICP-monitored patients who had sustained TBI. In parallel with the standard invasive ICP measurements, nICP was measured by the HeadSense HS-1000, which is based on sound propagation. The device generated an acoustic signal using a small transmitter, placed in the patient's ear, and picked up by an acoustic sensor placed in the other ear. The signal is then analyzed using proprietary algorithms, and the ICP value is calculated in millimeter of mercury (mm Hg). RESULTS: Analysis of 2911 paired iICP and nICP measurements from 14 severe TBI patients showed a good accuracy of the nICP monitor indicated by a mean difference of 0.5 mm Hg. The precision was also good with a standard deviation of 3.9 mm Hg. The Pearson r correlation was 0.604 (P < 0.001). CONCLUSIONS: The HeadSense HS-1000 nICP monitor seems sufficiently accurate to measure the ICP in severe TBI patients, is patient friendly, and has minimal risk of complications.

Effects of Induced Hypertension on Cerebral Perfusion in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.

BACKGROUND AND PURPOSE: The presumed effectiveness of induced hypertension for treating delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage is based on uncontrolled case-series only. We assessed the effect of induced hypertension on cerebral blood flow (CBF) in aneurysmal subarachnoid hemorrhage patients with delayed cerebral ischemia in a randomized clinical trial. METHODS: Aneurysmal subarachnoid hemorrhage patients were randomized to induced or no induced hypertension (control group) at delayed cerebral ischemia onset. CBF was assessed, blinded for treatment allocation, with computed tomographic perfusion in standardized predefined regions at delayed cerebral ischemia onset and after 24 to 36 hours of study treatment. Mean arterial blood pressure was compared between groups (linear mixed model). The primary outcome measure was the difference in change in overall CBF (Mann-Whitney U test). RESULTS: Mean arterial blood pressure was, on average, 12 mm Hg (95% confidence interval, 8.6-14.5) higher in the hypertension group (n=12) than in the control group (n=13). Change in overall CBF (mL/100g per s) was -8.5 (range, -42 to 30) in the control group and 0.1 (range, -31-43) in the hypertension group (P=0.25). CONCLUSIONS: Change in overall CBF did not differ to a statistically significant extent between the groups. Based on our results, 225 to 250 patients per group are needed to find a statistically significant difference in change in overall CBF between induced hypertension and no hypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT0161323.

The influence of APACHE II score on the average noise level in an intensive care unit: an observational study.

BACKGROUND: Noise levels in hospitals, especially in intensive care units (ICUs) are known to be high, potentially affecting not only the patients' well-being but also their clinical outcomes. In an observational study, we made a long-term measurement of noise levels in an ICU, and investigated the influence of various factors on the noise level, including the acute physiology and chronic health evaluation II (APACHE II) score. METHODS: The average noise level was continuously measured for three months in all (eight) patient rooms in an ICU, while the patient data were also registered, including the APACHE II score. The 24-hour trend of the noise level was obtained for the patients of length-of-stay (LOS) ≥1 day, which was compared to the timeline of the ICU routine events. For the patients with LOS ≥4 days, the average noise levels in the first four days were analyzed, and regression models were established using the stepwise search method based on the Akaike information criterion. RESULTS: Features identified in the 24-hour trends (n = 55) agreed well with the daily routine events in the ICU, where regular check-ups raised the 10-minute average noise level by 2~3 dBA from the surrounding values at night, and the staff shift changes consistently increased the noise level by 3~5 dBA. When analyzed in alignment with the patient's admission (n=22), the daytime acoustic condition improved from Day 1 to 2, but worsened from Day 2 to 4, most likely in relation to the various phases of patient's recovery. Regression analysis showed that the APACHE II score, room location, gender, day of week and the ICU admission type could explain more than 50% of the variance in the daily average noise level, LAeq,24h. Where these factors were argued to have causal relations to LAeq,24h, the APACHE II score was found to be most strongly correlated: LAeq,24h increased by 1.3~1.5 dB when the APACHE II score increased by 10 points. CONCLUSIONS: Patient's initial health condition is one important factor that influences the acoustic environment in an ICU, which needs to be considered in observational and interventional studies where the noise in healthcare environments is the subject of investigation.

Delirium in acute stroke: a predictor of subsequent cognitive impairment? A two-year follow-up study.

OBJECTIVE: Delirium is an independent risk factor for cognitive impairment and development of dementia in medical patients. It has never been thoroughly studied whether this association is also present in the stroke population. Our aim was to evaluate the effects of delirium in the acute phase after stroke on cognitive functioning two years later. METHODS: Two years after stroke, 50 patients (22 with and 28 without delirium in the acute phase) were assessed on two screening instruments for dementia and a neuropsychological test battery. RESULTS: Delirium was an independent predictor for development of dementia as assessed by the Clinical Dementia Rating Scale (odds ratio (OR) 4.7; 95% confidence interval (CI) 1.08 to 20.42) and by the Rotterdam-CAMCOG (OR 7.2, 95% CI 1.88 to 27.89). Cognitive domains most affected in patients with previous delirium were memory, language, visual construction and executive functioning. CONCLUSIONS: Delirium in the acute phase after stroke is an independent predictor for severe cognitive impairment two years after stroke. These findings emphasize the importance of both rapid detection and treatment of delirium after stroke. Furthermore, periodic monitoring and evaluation of cognitive functioning in these vulnerable patients in the years after stroke is strongly recommended.

[Delirium on intensive care frequently missed: clinical impression alone is not enough]. / Delirium op de Intensive Care vaak gemist: klinische blik alleen is niet voldoende.

OBJECTIVE: To compare the sensitivity and specificity of a routine assessment (clinical impression) with a structured assessment which uses a validated assessment scale for the recognition of delirium on the intensive care unit (ICU). DESIGN: Observational study. METHOD: During their admission to the intensive care unit, 103 patients were assessed daily (with a maximum of 40 days) for the presence of delirium using the Confusion assessment method for the intensive care unit (CAM-ICU). Their physicians indicated whether or not they considered the patient delirious. These findings were compared. For all patients daily information was also collected about fixation and complications, such as self-extubation or self-removal of catheters. RESULTS: The patients were assessed for a period of 502 patient-days. CAM-ICU scores were positive (n = 108), negative (n = 235) or non-assessable because the patient was comatosed or deeply sedated (n = 159). The sensitivity of clinical detection by the physicians was 45% in comparison to the CAM-ICU. The specificity was high (97%). CONCLUSION: The diagnosis delirium is frequently missed on the ICU when only based on clinical impression. Routine assessment using a validated assessment scale such as the CAM-ICU might possibly improve this.

A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative.

BACKGROUND: Delirium is a common disorder in the early phase of stroke. Given the presumed cholinergic deficiency in delirium, we tested treatment with the acetylcholinesterase inhibitor rivastigmine. METHODS: This pilot study was performed within an epidemiological study. In 527 consecutive stroke patients presence of delirium was assessed during the first week with the confusion assessment method. Severity was scored with the delirium rating scale (DRS). Sixty-two patients developed a delirium in the acute phase of stroke. Only patients with a severe and persistent delirium (defined as a DRS of 12 or more for more than 24 hours) were enrolled in the present study. In total 26 fulfilled these criteria of whom 17 were treated with orally administered rivastigmine with a total dose between 3 and 12 mg a day. Eight patients could not be treated because of dysphagia and one because of early discharge. RESULTS: No major side effects were recorded. In 16 patients there was a considerable decrease in severity of delirium. The mean DRS declined from 14.8 on day one to 8.5 after therapy and 5.6 after tapering. The mean duration of delirium was 6.7 days (range; 2-17). CONCLUSION: Rivastigmine is safe in stroke patients with delirium even after rapid titration. In the majority of patients the delirium improved after treatment. A randomized controlled trial is needed to establish the usefulness of rivastigmine in delirium after stroke. TRIAL REGISTRATION: Nederlands Trial Register NTR1395.