Delirium in older adults / Delirium em idosos

This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.

Esta revisão narrativa examina de maneira abrangente os conceitos mais atuais sobre etiopatogenia, diagnóstico, prevenção e tratamento do delirium, uma síndrome neuropsiquiátrica aguda caracterizada por mudanças flutuantes na cognição e na consciência. Com a interação entre a vulnerabilidade subjacente e a gravidade dos insultos agudos, delirium pode ocorrer em qualquer idade, mas afeta com notória frequência idosos hospitalizados. Delirium também está associado a diversos desfechos adversos, incluindo prejuízo funcional, declínio cognitivo, aumento dos custos de saúde e morte. O diagnóstico é baseado em avaliações clínicas e cognitivas, com preferência para o uso de instrumentos de detecção sistematizados, como o Confusion Assessment Method (CAM). Delirium e suas consequências são combatidos de forma mais eficaz por meio de intervenções preventivas com múltiplos componentes, como as propostas pelo Hospital Elder Life Program (HELP). Quando há falha na prevenção, o manejo do delirium se baseia principalmente na identificação e na reversão dos fatores precipitantes e no controle não farmacológico dos sintomas do delirium. As intervenções farmacológicas no delirium devem ser restritas aos casos de agitação perigosa ou sintomas psicóticos graves.

Intervenciones multicomponente en la prevención del delirium entre adultos mayores hospitalizados: un análisis crítico de la literatura / Multicomponent interventions in preventing incident delirium in elderly inpatients: a critical appraisal of literature

Introducción: el delirium es un síndrome neuropsiquiátrico común entre adultos mayores. Se asocia a mayor mortalidad, deterioro cognitivo y aumentos en costos en salud. Las intervenciones multicomponentes parecen ser eficaces en prevenir el delirium. Objetivo: evaluar la evidencia disponible respecto del uso de intervenciones multicomponentes para prevenir delirium entre adultos mayores hospitalizados. Metodología: se realizó una revisión de la literatura en cinco bases de datos, en búsqueda de revisiones sistemáticas que informaran la utilidad de las intervenciones multicomponentes para reducir el delirium incidente. Las revisiones fueron evaluadas en cuanto a su calidad sobre la base de los criterios de la Colaboración Cochrane. Resultados: se detectaron tres revisiones sistemáticas. La estrategia de búsqueda fue adecuada en todas, aunque dos de ellas incluyeron ensayos no aleatorizados en el análisis. Los programas evaluados fueron heterogéneos, por lo que no se realizó metaanálisis en ninguna de ellas. Sin embargo, fueron descritos resultados benéficos en todas ellas. Discusión: existe evidencia de moderada calidad que sugiere que las intervenciones multicomponentes son eficaces para reducir el delirium incidente. Es necesario realizar nuevas revisiones sistemáticas restringidas a ensayos aleatorizados para obtener una respuesta definitiva sobre su utilidad.

Introduction. Delirium is a common neuropsychiatric syndrome arising among elderly inpatients. It has been associated with increased mortality, cognitive decline and increased healthcare costs. Multicomponent interventions might be useful in preventing incident delirium. Objectives. To assess the available evidence regarding multicomponent interventions in preventing incident delirium among elderly inpatients. Methods. A literature review was conducted in 5 databases in search for systematic reviews evaluating multicomponent interventions in preventing incident delirium. Included reviews were assessed by using the criteria recommended by the Cochrane Collaboration. Results. Three systematic reviews were found. All described adequate searching methods, but two considered non-randomized designs for analyses. Important heterogeneity was seen among studies, precluding meta-analyses. However, beneficial effects were described regarding incident delirium prevention. Discussion. Moderate-quality evidence suggests that multicomponent interventions are useful in preventing delirium. New systematic reviews should restrict their methods to randomized trials in order to allow a definitive conclusion to be made.

Delirium en el hospital, una revisión narrativa / Delirium in the hospital, a narrative review

El delirium es una complicación frecuente entre pacientes hospitalizados, particularmente entre adultos mayores y aquellos con deterioro cognitivo. Se ha asociado a mayor mortalidad, estadías hospitalarias prolongadas, deterioro cognitivo, mayores tasas de institucionalización al alta y mayores costos para los sistemas de salud. Su fisiopatología es escasamente comprendida, planteándose en los últimos años un origen inflamatorio predominante. Ello explicaría su transversalidad y relación con la gravedad de cuadros subyacentes. Clínicamente se caracteriza por su inicio agudo con curso fluctuante, inatención, pensamiento desorganizado y un nivel de conciencia alterado. El enfrentamiento diagnóstico exige la búsqueda sistemática de desencadenantes en forma adicional a las manifestaciones del síndrome. Su tratamiento sintomático está basado en los neurolépticos como primera línea y el lorazepam en caso de que los primeros no puedan utilizarse o exista un escenario de indicación especial. Existe evidencia de que el cuadro puede prevenirse mediante la instauración de estrategias multicomponentes.

Delirium is a common complication in hospitalized patients, particularly the elderly and those with cognitive impairment. It has been associated with higher mortality, prolonged hospitalization, cognitive impairment, higher rates of institutionalization at discharge and higher costs for healthcare systems. Its pathophysiology is poorly understood, and more recently a predominantly inflammatory origin has been proposed, which could explain its pervasiveness and association with underlying conditions. Clinically, it is characterized by acute onset with fluctuating course, inattention, disorganized thinking and altered level of consciousness. Diagnostic approach is based on the systematic search for triggering factors as well as the manifestations of the syndrome. Symptomatic treatment is based neuroleptics as first line treatment, and lorazepam when the former cannot be used or there are special indications. There is evidence that the condition can be prevented by resorting to multi-component strategies.

Delirium / Delirium

Delirium, também conhecido como estado confusional agudo é uma alteração cognitiva definida por início agudo, curso flutuante, distúrbios da consciência, atenção, orientação, memória, pensamento, percepção e comportamento. É condição cada vez mais comum entre pacientes hospitalizados e acomete, preferencialmente, pacientes idosos e debilitados. Trata-se de emergência médica, já sendo comprovadas maiores taxas de mortalidade, maior tempo de internação e maiores índices de institucionalização quando do episódio de delirium. O mecanismo fisiopatológico ainda não está bem definido, sendo a alteração na neurotransmissão o mecanismo mais provável. A abordagem do paciente deve incluir a identificação de fatores predisponentes e precipitantes, com intervenções adequadas a cada um visando à resolução do quadro. Apresenta-se por alteração do nível de consciência, déficit de atenção e outros distúrbios da cognição, podendo se apresentar na forma hiperativa, hipoativa ou mista. Apesar de já estar bem definido, por diversas vezes passa despercebido aos profissionais de saúde. A principal medida na abordagem de delirium é a prevenção, e são necessárias medidas institucionais e treinamento dos profissionais de saúde. O tratamento não-farmacológico consiste em medidas que evitem os fatores responsáveis pelo desenvolvimento do delirium, sendo a primeira opção na abordagem inicial. O tratamento farmacológico se reserva aos pacientes com agitação importante, com risco de trauma físico, e que não apresentem resposta às medidas não-farmacológicas. Por sua frequência e importância como fator prognóstico, o delirium deve ser abordado de forma sistematizada, com a elaboração de fluxogramas de atendimento e definição de medidas uniformizadas para cada instituição.

Delirium, also known as acute confusional state is a cognitive impairment defined by acute onset and fluctuating course, disturbance of consciousness, attention, orientation, memory, thought, perception and behavior. It is an increasingly common condition among hospitalized patients and more frequent in, elderly and debilitated patients. It is a medical emergency, already proven higher death rates, longer hospitalization and higher rates of institutionalization due the occurrence of delirium. The pathophysiologic mechanism is not yet well established, with the change in neurotransmission most probably involved. Management of patients should include identification of risk factors and precipitants, with appropriate interventions aimed at each resolution. It is presented by altered level of consciousness, attention deficit and other disorders of cognition, which may present as hyperactive, hypoactive, or mixed. Although well defined, several times delirium goes unrecognized by health professionals. The main measure in addressing delirium is prevention, with institutional measures required as well as training of health professionals. Non-pharmacological treatment consists of measures to prevent the factors responsible for the development of delirium, and is the first option in the initial approach. Pharmacological treatment is reserved for patients with major upheaval, with the risk of physical trauma, and presenting no response to non-pharmacological measures. For the frequency and importance as a prognostic factor, delirium should be approached systematically, with flowcharting care and defining standardized measures for each institution.

Subdiagnóstico de delirium en adultos mayores hospitalizados / Delirium in Chilean elderly inpatients: an overlooked problem

Background: Delirium is a common underdiagnosed and undertreated problem in elderly inpatients, associated to higher morbidity, mortality and health cost. Aim: To evaluate the prevalence of delirium at hospital admission in medically ill elderly patients and the attending physician's diagnosis and treatment of delirium. Patients and methods: In a prospective and descriptive study, consecutive patients aged 65 years or more, admitted to an internal medicine ward were evaluated by independent physicians, during the first 48 h of admission, to asses the presence of delirium. Diagnosis of delirium was based on the Confusion Assessment Method. Medical and nurse records were reviewed. Family was interviewed when necessary. Results: One hundred eight patients (52% women, age range 65-94 years) with an APACHE II score of 11.6±5, were evaluated. Fifty seven patients (53%) had delirium (32% hyperactive, 72% hypoactive and 5% mixed). Delirium prevalence was significantly higher in older patients (66% among those aged 75 years or older versus 30% in younger, p <0.05) and among patients with more severe conditions (88% among those with an APACHE score over 16 versus 47% below that value, p <0.05). Medical records of patients with delirium showed that this diagnosis was present only in 32% and cognitive deficit was described in 73%. Ten percent of patients with delirium received sedative medication and 38% were physically restricted. There were no environmental interventions to prevent or control delirium. Conclusions: Delirium in elderly inpatients at this unit is an extraordinarily prevalent problem, seriously under diagnosed (68%) and under treated. This study should alerts our medical community to improve the diagnosis and management of delirium in elderly inpatients.