A world-wide study on delirium assessments and presence of protocols.

BACKGROUND: Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE: To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN: Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING: Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS: Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS: Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION: Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

Delirium prevalence and delirium literacy across Italian hospital wards: a secondary analysis of data from the World Delirium Awareness Day 2023.

PURPOSE: Delirium, a common medical emergency among hospitalized patients, requires effective detection and management protocols. This study aims to evaluate the delirium point prevalence and its management across Italian hospitals, categorized by delirium literacy levels. Additionally, it seeks to identify prevailing barriers and future priorities in delirium practice and research. METHODS: We analyzed data from World Delirium Awareness Day (WDAD) on March 15th, 2023, collected by participating clinicians in Italian hospitals. High delirium literacy (HL) was determined based on the use of validated delirium assessment tools and the presence of a written protocol for delirium management. Conversely, low delirium literacy (LL) was determined by meeting only one or neither of these criteria. RESULTS: Fifty-eight hospital wards participated in the survey, with 25 (43.1%) classified as HL. The overall reported point prevalence of delirium was found to be approximately 10%. Notably, the reported prevalence was twice as high in the HL group compared to the LL group. Despite minimal differences compared to the other group, the HL group demonstrated greater adherence to appropriate delirium management strategies, encompassing both non-pharmacological and pharmacological strategies. Critical gaps in delirium care emerged, including suboptimal management practices, barriers to implementing evidence-based strategies, and insufficient awareness and training among professionals. CONCLUSION: The study highlights the suboptimal identification and management of delirium among Italian hospitals, emphasizing the necessity of enhancing awareness and implementing evidence-based strategies. Addressing these shortcomings is crucial for optimizing delirium care, improving patient outcomes, and mitigating the burden of delirium in hospital settings.

Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study.

Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.

Impairment of Renal and Hematopoietic Stem/Progenitor Cell Compartments in Frailty Syndrome: Link with Oxidative Stress, Plasma Cytokine Profiles and Nuclear DNA Damage.

Frailty is an age-related syndrome that drives multiple physiological system impairments in some older adults, and its pathophysiological mechanisms remain unclear. We evaluated whether frailty-related biological processes could impair stem cell compartments, specifically the renal stem compartment, given that kidney dysfunctions are frequent in frailty. A well-characterized in vitro nephrosphere model of human adult renal stem/progenitor cells has been instrumental to and was appropriate for verifying this hypothesis in our current research. Evaluating the effects of plasma from older individuals with frailty (frail plasma) on allogeneic renal stem/progenitor cells, we showed significant functional impairment and nuclear DNA damage in the treated cells of the renal stem compartment. The analysis of the frail plasma revealed mitochondrial functional impairment associated with the activation of oxidative stress and a unique inflammatory mediator profile in frail individuals. In addition, the plasma of frail subjects also contained the highest percentage of DNA-damaged autologous circulating hematopoietic progenitor/stem cells. The integration of both molecular and functional data obtained allowed us to discern patterns associated with frailty status, irrespective of the comorbidities present in the frail individuals. The data obtained converged toward biological conditions that in frailty caused renal and hematopoietic impairment of stem cells, highlighting the possibility of concomitant exhaustion of several stem compartments.

Atrial fibrillation accelerates functional decline in older adults: a 15-year follow-up population-based study.

AIMS: Atrial fibrillation (AF) has been associated with functional impairment. However, the role exerted by AF on the long-term trajectories of functional mobility remains to be elucidated. This study aimed to evaluate the impact of AF on functional mobility by tracing walking speed (WS) trajectories over 15 years of follow-up in a population-based cohort of individuals aged 60+ years. METHODS AND RESULTS: This population-based cohort study included 3141 community-dwelling participants (mean age 73.7 years; 63.6% women) from the Swedish National Study on Aging and Care in Kungsholmen, who were regularly examined from 2001-2004 to 2016-2019. Functional mobility was assessed by measuring WS in a standardized way. The association between AF and WS trajectories was assessed by multivariable joint models accounting for the longitudinal dropouts due to death. Stratified analyses by demographic and clinical factors were performed. The effect-modifying role of oral anticoagulant therapy (OAC), incident heart failure (HF), and incident stroke was finally investigated. At baseline, 285 (9.1%) participants were ascertained to have AF. A faster annual WS decline was observed in persons with AF than in non-AF peers (adjusted ß coefficient per year = -0.011, 95% confidence interval: -0.016 to -0.005). Incident HF and stroke were associated with greater WS decline in participants with AF. OAC use was not associated with a slower functional decline. CONCLUSION: Atrial fibrillation is associated with a faster physical function decline in older individuals. Incident HF and stroke possibly accelerate WS decline over time in AF participants.

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy.

BACKGROUND: The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older. METHODS: An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care. RESULTS: In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training. CONCLUSIONS: Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

Interventions to prevent and treat delirium: An umbrella review of randomized controlled trials.

Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.

A pandemic of delirium: an updated systematic review and meta-analysis of occurrence of delirium in older adults with COVID-19.

PURPOSE: Delirium has been recognized as an atypical presenting feature of COVID-19 in older adults and is independently associated with mortality. We aimed to perform an updated systematic review of the literature and proportional meta-analysis to assess prevalence and incidence of delirium in older adults with COVID-19, addressing differences according to sex, frailty status, and settings. METHODS: We searched databases for English-language articles on prevalence and incidence of delirium in older adults with COVID-19, published between March 2020 and January 2023. RESULTS: Of the 1171 articles identified, 66 met selection criteria and were included in the meta-analysis (n = 35,035 participants, age-range 66-90 years old, 46.6% females). We observed similar pooled prevalence (20.6% [95% Confidence Interval (CI) 17.8-23.8%]) and incidence (21.3% [95% CI 14.7-30%]) of delirium. Pooled occurrence (both prevalence and incidence) of delirium was similar according to sex (females 21.3% [95% CI 16-27.5%] vs. males 23.8%% [95% CI 18.2-30.4%], p-value = 0.55) and study setting (nursing homes 22.5% [95% CI 14.2-33.6%] vs. hospital 20.3% [95% CI 17-24%], p = 0.68), but it was significantly higher in frail versus non-frail patients (37% [95% CI 26.6-48.8%] vs. 12.5% [95% CI 7.8-19.6%], p-value < 0.01). Delirium definitions and assessment tools largely varied across studies. CONCLUSION: This review delineates delirium as a common feature of COVID-19, particularly in frail older adults, and supports its formal inclusion among COVID-19 symptoms. The considerable heterogeneity in delirium assessment highlights the need for an operational strategy to standardize definitions and tools utilization in the management of frail older adults.

Estudio transversal multicéntrico sobre la prevalencia de delirium en unidades de ortogeriatría: protocolo de «Estudio DELFRA 24» / Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol

Introducción El delirium es la complicación perioperatoria más frecuente en el adulto mayor con fractura de cadera (FC) conllevando un impacto catastrófico en su recuperación funcional y su estado cognitivo. Actualmente se desconoce la prevalencia real de este síndrome ya que no está protocolizada su detección y abordaje en la práctica clínica habitual. Métodos Se realizará un estudio observacional multicéntrico de tipo transversal a nivel nacional en el que participarán distintas unidades de ortogeriatría de España. Se evaluará la prevalencia de delirium con la escala 4AT, así como las características de este y su relación con otros síndromes geriátricos, variables sociodemográficas, características de la cirugía y parámetros analíticos. Resultados La recogida de datos se llevará a cabo el próximo día mundial del delirium (miércoles 13 de marzo de 2024), por lo que los resultados se esperan durante el segundo o tercer trimestre del año 2024. Conclusiones Conocer la prevalencia real y las características del delirium en mayores con FC podría contribuir a sensibilizar en la detección sistemática, la prevención y el abordaje protocolizado del delirium en servicios quirúrgicos, disminuyendo el impacto de sus consecuencias. (AU)

Introduction Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. Methods A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. Results Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. Conclusions Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences. (AU)

Estudio transversal multicéntrico sobre la prevalencia de delirium en unidades de ortogeriatría: protocolo de «Estudio DELFRA 24» / Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol

Introducción El delirium es la complicación perioperatoria más frecuente en el adulto mayor con fractura de cadera (FC) conllevando un impacto catastrófico en su recuperación funcional y su estado cognitivo. Actualmente se desconoce la prevalencia real de este síndrome ya que no está protocolizada su detección y abordaje en la práctica clínica habitual. Métodos Se realizará un estudio observacional multicéntrico de tipo transversal a nivel nacional en el que participarán distintas unidades de ortogeriatría de España. Se evaluará la prevalencia de delirium con la escala 4AT, así como las características de este y su relación con otros síndromes geriátricos, variables sociodemográficas, características de la cirugía y parámetros analíticos. Resultados La recogida de datos se llevará a cabo el próximo día mundial del delirium (miércoles 13 de marzo de 2024), por lo que los resultados se esperan durante el segundo o tercer trimestre del año 2024. Conclusiones Conocer la prevalencia real y las características del delirium en mayores con FC podría contribuir a sensibilizar en la detección sistemática, la prevención y el abordaje protocolizado del delirium en servicios quirúrgicos, disminuyendo el impacto de sus consecuencias. (AU)

Introduction Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. Methods A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. Results Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. Conclusions Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences. (AU)

Shifting the Paradigm of Nursing Home Care for People with Dementia: The Italian Experience of Il Paese Ritrovato and the Impact of SARS-CoV-2.

BACKGROUND: Il Paese Ritrovato is an Italian nursing home founded in 2018, it is based on the Alzheimer village model and admits people with mild-to-moderate dementia. OBJECTIVE: Describe the impact of the SARS-CoV-2 pandemic on people living at Il Paese Ritrovato through a Comprehensive Geriatric Assessment (CGA) regularly administered prior to and during the pandemic. METHODS: We explored the effects of a person-centered approach. We assessed 64 subjects (enrolled and followed between June 2018 and December 2020), who underwent at least 18 months of observation prior to the pandemic. Each subject was evaluated using a CGA on admission time (T0) and at defined time-points: T6, T12, T18. One last CGA evaluation was performed during the SARS-CoV-2 pandemic (TCovid-19). Temporal trends during T0-T18, and differences between T18 and TCovid-19 were calculated. RESULTS: The mean age was 82 years with a prevalence for females (77.0%) and Alzheimer's disease diagnosis (60%). Psychiatric and behavioral disorders were the most common conditions (80%). We utilized a nonpharmacological approach aimed at promoting the residents' overall wellbeing and observed satisfactory performance during the first 18 months. In comparison with the pre-pandemic period, TCovid-19 enlightened +11.7% use of antidepressants and a decline of Mini-Mental State Examination mean values (not statistically significant), while engagement in activities dropped. CONCLUSIONS: The pandemic may have disrupted the existing model of care, but at the same time, it confirmed that the Il Paese Ritrovato approach, which encompasses symptoms improvement and multicomponent support, is in fact beneficial.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives.

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.