Delirium in older COVID-19 patients: Evaluating risk factors and outcomes.

OBJECTIVES: A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients. METHODS: This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality. RESULTS: A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3-33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1-22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40-1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71-4.72] p < 0.001), but not in multivariable analyses. CONCLUSIONS: A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty.

Was it worth it? Benefits of transcatheter aortic valve implantation from a patient's perspective.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is an important treatment option for patients with severe aortic stenosis. To improve patient selection, shared decision-making is recommended to elicit patients' treatment expectations and goals. We assessed patients' expectations and goals before TAVI treatment and whether these were met after treatment. Additionally, we evaluated how meeting these goals aligned with quality of life and functional recovery. DESIGN: A mixed method study. SETTING: An academic medical center. PARTICIPANTS: Seventy-four patients undergoing TAVI between 2015 and 2017. MEASUREMENTS: Patients' expectations and goals were assessed qualitatively before treatment. Six to twelve months post procedure, quality of life was measured with the EuroQuol-5D and any change in the number of dependencies in (instrumental) activities of daily living was assessed. RESULTS: Mean age of patients was 81.5 years, and 37.8% were male. Regaining the ability to engage in a specific hobby or activity was the most important treatment goal (33 patients, 54.1%), followed by reducing symptoms (19 patients 31.1%). 66.2% of patients stated that their treatment goal was met. Quality of life was higher in this group, as compared with patients who had not met their treatment goal. Twenty-three patients (31.1%) showed functional improvement. CONCLUSION: TAVI patients were quite capable of eliciting treatment goals and a majority stated, after treatment, that these had been met patients' experience of treatment benefits regarding these goals had poor alignment with functional outcomes. This raises questions regarding relevant outcome measurements in this population, and could aid in improving shared decision-making and patient selection for TAVI.

Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study.

AIM: Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI. METHODS: This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up. RESULTS: The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome. CONCLUSION: In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.

Melatonin, temazepam and placebo in hospitalised older patients with sleeping problems (MATCH): a study protocol of randomised controlled trial.

INTRODUCTION: Hospitalised older patients frequently suffer from inadequate sleep, which can lead to patient distress and delayed recovery from acute illness or surgical procedure. Currently, no evidence-based treatments exist for sleeping problems in hospitalised older patients. Benzodiazepines, such as temazepam, are regularly prescribed by physicians, although they have serious side effects; for older patients in particular. Melatonin is proposed as a safe alternative for sleeping problems in hospitalised older patients, but the efficacy of melatonin is unclear in this population. Therefore, the aim of this study is to investigate the effects of melatonin and temazepam compared with placebo on sleep quality among hospitalised older patients with sleeping problems. METHODS AND ANALYSIS: This study is a multicentre, randomised, placebo-controlled trial. A total of 663 patients will be randomised in a 1:1:1 fashion to receive either melatonin (n=221), temazepam (n=221) or placebo (n=221). The study population consists of hospitalised patients aged 60 years and older, with new or aggravated sleeping problems for which an intervention is needed. The primary outcome is sleep quality measured with the Leeds Sleep Evaluation Questionnaire (LSEQ). Secondary outcomes include sleep parameters measured with actigraphy and medication-related adverse effects. ETHICS AND DISSEMINATION: This study was approved by the Medical Ethics Committee of the Academic Medical Centre Amsterdam, (No 2015_302). Study findings will be disseminated through presentations at professional and scientific conferences and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NTR6908; Pre-results.

Distinct Cognitive Trajectories in the First Year After Hip Fracture.

OBJECTIVES: Change in cognitive functioning is often observed after hip fracture. Different patterns, with both improvement and decline, are expected, depending on premorbid cognitive functioning and events that occur during hospitalization. These patterns are unknown and important for older hip fracture patients with different levels of premorbid cognitive functioning. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: We conducted a secondary analysis of a multi-center randomized controlled trial. 302 consecutive patients aged 65-102 years old, admitted for hip fracture surgery, were enrolled. The Mini Mental State Examination (MMSE) was obtained at hospital admission, at discharge, and at 3 and 12 months after discharge. Cognitive trajectories were identified with Group Based Trajectory Modelling, using the repeated MMSE measurements as outcome variable. To illustrate the specific characteristics of this relative novel methodological approach, it was contrasted with results obtained from linear mixed effects modeling. RESULTS: 146 (48.3%) patients had premorbid cognitive impairment and 85 patients (28.1%) experienced delirium during admission. Three distinct cognitive trajectories were identified and labeled based on different MMSE course over time: improvement (57.9%), stable (28.1%), and rapid decline (13.9%), with an annual MMSE change of 1.7, 0.8, and -3.5 points respectively. With mixed effects modeling an overall annual increase of 0.7 MMSE points was estimated for the group as a whole. CONCLUSION: Three distinct cognitive trajectories were identified in a population of older hip fracture patients. These trajectory groups can be used as a starting point to inform patients and caregivers on the possible prognosis after hip fracture. Group based trajectory modelling is a useful technique when the purpose is to describe patterns of change within a population and a variety of trajectories are expected to exist.

The Effect of Treatment of Anemia with Blood Transfusion on Delirium: A Systematic Review.

OBJECTIVES: Treating the precipitating factors of delirium is the mainstay of the prevention and treatment of delirium. We aim to investigate the role of anemia and blood transfusion within the multicomponent prevention and treatment strategy of delirium. DESIGN: Systematic review. SETTING: We included cohort studies or Randomized Controlled Trials (RCTs) that considered blood transfusion as treatment for delirium or risk factor, and had delirium as outcome. PARTICIPANTS: Hospitalized patients above 55 years old. MEASUREMENTS: We searched MEDLINE from 1946 through November 2014. Quality assessment and data extraction were performed systematically. RESULTS: We included 23 studies (n = 29,471). The majority of the studies (n = 22) had a limited quality and for one study quality was uncertain. Two studies evaluated the association between transfusion strategy and postoperative delirium and found no association. Twenty-one studies investigated blood transfusion as a risk factor for delirium. In four of the 21 studies it could be assumed that delirium occurred after transfusion. One of these studies stated that transfusion was a significant risk factor for subsequent delirium (odds ratio (OR) = 3.68, 95% confidence interval (CI) = 1.32-10.94). The other three studies found no association between transfusion and delirium. In the remaining 17 studies, it was not clear whether delirium occurred before or after transfusion, so no conclusion could be drawn on the role of transfusion in delirium development. CONCLUSION: The majority of the included studies was not suited to answer the research question properly as the time course of the beginning of delirium as to transfusion was lacking. Our review shows that there is no good quality evidence available for blood transfusion to be a risk factor for delirium or to be a preventive or treatment option.

Unraveling the Relationship Between Delirium, Brain Damage, and Subsequent Cognitive Decline in a Cohort of Individuals Undergoing Surgery for Hip Fracture.

OBJECTIVES: To assess the association between serum S100B levels (a marker of brain damage), delirium, and subsequent cognitive decline. DESIGN: Substudy of a multicenter randomized controlled trial. SETTING: Surgical, orthopedic, and trauma surgery wards of two teaching hospitals. PARTICIPANTS: Individuals aged 65 and older (range 65-102) admitted for hip fracture surgery (N = 385). MEASUREMENTS: During hospitalization, presence of delirium was assessed daily. S100B was assayed in repeated serum samples. Twelve months after discharge, cognitive decline and mortality were evaluated. Cognitive decline was defined as an increase in Informant Questionnaire on Cognitive Decline Short Form score of 1 standard deviation or more or a decrease in Mini Mental State Examination score of 3 points or more between admission and 12 months after discharge. RESULTS: Premorbid cognitive impairment was present in 226 (58.7%) participants, and 127 (33.0%) experienced perioperative delirium. Multivariable analysis showed that older age and presence of infection, but not of delirium, were associated with higher S100B levels. Levels were also higher after surgery than before. Of participants with perioperative delirium, 58.6% experienced cognitive decline or death, and only age was a risk factor; 36.5% of participants without perioperative delirium experienced cognitive decline or death in the following year, and higher S100B, premorbid cognitive impairment, and older age were risk factors. CONCLUSION: In a cohort of older adults with hip fracture, no association was found between serum S100B levels and occurrence of delirium. S100B was associated with cognitive decline or death in the first year after hip fracture only in participants without perioperative delirium. S100B seems to be of limited value as a biomarker of brain damage associated with delirium.

The Effects of Blood Transfusion on Delirium Incidence.

BACKGROUND: Both anemia and blood transfusion could be precipitating factors for delirium; hence in postoperative patients with anemia at high risk for delirium, it is controversial whether transfusion is the best option. The aim of this study is to investigate the association of anemia and delirium and the role of blood transfusion within the multicomponent prevention strategy of delirium. METHODS: We conducted a substudy of a multicenter randomized controlled trial. Four hundred fifteen patients aged 65 to 102 years old admitted for hip fracture surgery were enrolled. Delirium was assessed daily using criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Data on hemoglobin values and transfusion were collected from the electronic medical records. RESULTS: One hundred fifteen (32.5%) patients experienced delirium during hospitalization, 238 (57.5%) had a hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) at any time during hospitalization, and 140 (33.7%) received a blood transfusion. Anemia (a hemoglobin level ≤ 6.0 mmol/L [9.7 g/dL]) was associated with delirium (odds ratio, 1.81; 95% confidence interval, 1.15-2.86). Blood transfusion was a protective factor for delirium in patients with the lowest measured hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) (odds ratio, 0.26; 95% confidence interval, 0.10-0.70). CONCLUSION: Low hemoglobin level is associated with delirium, and receiving a blood transfusion is associated with a lower delirium incidence. It would be interesting to investigate the effect of blood transfusion as part of the multicomponent treatment of delirium in patients with anemia.

Antimicrobial susceptibility of Streptococcus pneumoniae in adult patients with pneumococcal pneumonia in an urban hospital in Mozambique.

BACKGROUND: Streptococcus pneumoniae is the leading cause of community-acquired pneumonia in Africa. Antimicrobial resistance of S. pneumoniae to penicillin and other commonly used antibiotics has increased worldwide. However, prevalence data from the African region are sparse, especially with regard to adults. FINDINGS: In this study, adult patients presenting at an urban referral hospital in central Mozambique were screened for pneumococcal pneumonia during an 8-week period in 2010: Patients with a respiratory syndrome underwent chest radiography and a sputum sample was collected for pneumococcal culture and antimicrobial susceptibility testing. A urine sample was tested for the presence of pneumococcal antigen.177 patients with a respiratory syndrome were included. Overall, 41/177 (23%) patients fulfilled criteria for definite or probable pneumococcal pneumonia and in the group of patients with a positive chest x-ray this concerned 35/86 (41%) patients. 166 sputum cultures yielded 16 pneumococcal strains. One mg oxacillin disc testing identified potential penicillin resistance in 7/16 (44%) strains. Penicillin minimal inhibitory concentrations (MICs) were measured for 15 of these strains and ranged from <0.016-0.75 mg/L. No MICs >2 mg/L were found, but 3/15 (20%) pneumococcal strains had MICs >0.5 mg/L. All pneumococci were sensitive to erythromycin as measured by disc diffusion testing, whereas 44% was resistant to trimethoprim-sulfametoxazole. CONCLUSIONS: The proportion of pneumonia cases attributable to pneumococcus appeared to be high. Whilst none of the S. pneumoniae strains tested were penicillin resistant, standard penicillin dosing for pneumonia may be insufficient given the observed range of pneumococcal penicillin MICs.