Delirium is a frequent syndrome among hospitalized patients, with a prevalence of 10-30% on general wards, up to 50% on palliative care units and 30-80% on intensive care units (ICU). Defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) as an acute, reversible disturbance of attention, cognition and consciousness, delirium is associated with infections, surgery, trauma and other disease conditions. Risk factors include advanced age, pre-existing neurocognitive disorders and substance abuse. Delirium is associated with increased mortality, longer hospitalization and the occurrence of post-hospital discharge complications, including post-intensive care syndrome (PICS) and posttraumatic stress disorder (PTSD). A structured post-inpatient management is limited, highlighting the need for specialized aftercare clinics. On the ICU early detection through tools, such as confusion assessment method for the ICU (CAM-ICU) and preventive measures, including the ABCDEF bundle, are essential. Family involvement and patient education can mitigate long-term effects. A greater awareness of the impact of delirium and the long-term sequelae is crucial to improve patient recovery and to address both physical and psychological needs.

Several methods are used to measure delirium severity in the postoperative period. Here, we compare severity scores from two common assessment methods: the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) and the Delirium Rating Scale-Revised-98 (DRS).

Data were collected as part of an ongoing observational cohort study of perioperative delirium in patients >65 yr old undergoing major elective surgery with an anticipated hospital stay of at least 2 days. Patients were excluded if they had a documented history of dementia, resided in a nursing home, underwent neurosurgery, or could not complete neurocognitive testing. Patients underwent paired 3D-CAM and DRS assessments before and after operation along with EEG, cognitive testing, and plasma biomarker analysis.

Of 226 subjects enrolled, 204 completed both the 3D-CAM and DRS assessments. Peak 3D-CAM severity (3D-CAM-S) scores correlated with peak DRS severity scores, for both the raw (ρ=0.74, P<0.001) and short form method (ρ=0.66, P<0.001). Peak 3D-CAM-S raw scores also correlated with delirium duration and severity duration area under the curve measures (ρ=0.71, P<0.001 and ρ=0.91, P<0.001, respectively). Similar to prior reports with the DRS, 3D-CAM-S raw scores correlated with worse performance on the Trail Making Test B (ρ=0.37, P<0.001, n=177), slow-wave electroencephalogram power (ρ=0.3, P=0.001, n=73), and plasma neurofilament light (ρ=0.26, P<0.05, n=61) and tau (ρ=0.41, P<0.001, n=63).

The 3D-CAM-S severity scores correlated with DRS, delirium duration, and biomarkers of delirium. The 3D-CAM, which is easier to implement than the DRS in postoperative patients, may provide a comparable assessment of delirium severity in this population.

NCT03124303.

Effective treatment and prevention of delirium remain challenging, largely due to the limited efficiency in identifying and validating drug targets. To address this gap, we performed a systematic Mendelian Randomization (MR) study of the druggable genome to identify potential therapeutic targets for delirium.

To identify therapeutic targets for delirium, we conducted MR and colocalization analyses using cis-eQTL data (31,684 blood samples and 1387 brain samples) and genome-wide association study (GWAS) data for delirium (discovery cohort N = 431,880; validation cohort N = 403,037). This approach enabled us to identify annotated druggable gene targets with significant associations with delirium. Additional analyses included phenome-wide association studies (PheWAS), enrichment analyses, protein network construction, drug prediction, molecular docking, and mediation analyses to assess the therapeutic and clinical relevance of these targets.

Five genes were identified as significant therapeutic targets for delirium: C4BPA, A2M, GRIK4, and C1R from blood samples, and SUMF1 from both blood and brain tissues. These genes are biologically significant for their strong association with immune function. At the gene level, PheWAS identified associations between C4BPA and other traits. Molecular docking demonstrated strong binding between drugs and proteins with available structural data. Mediation analysis revealed that C4BPA explained 16.7 % of the aging-related risk for delirium.

Our MR analysis identifies 5 potential druggable targets for the treatment of delirium. Drugs targeting these genes are more likely to succeed in clinical trials and are expected to prioritize the development of delirium treatments while reducing drug development costs.

Delirium is a severe condition, often underreported and linked to adverse outcomes such as increased mortality and prolonged hospitalization. Despite its significance, delirium prediction is often hindered by underreporting and inconsistent labeling, highlighting the need for models trained on reliably labeled data (ground truth). This review examines (i) practices for determining labels in delirium prediction models and (ii) how study designs affect label quality, aiming to identify key considerations for improving model reliability.

A search of Cochrane, PubMed, and IEEE identified 120 studies that met the inclusion criteria.

To establish the ground truth, 40.8% of studies used routine data, while 42.5% used primary data. The Confusion Assessment Method (CAM) was the most widely used assessment tool (60. 0%). Label and data leakage occurred in 35.0% of studies. High Risk of Bias (RoB) was a recurring issue, with 31.7% of studies lacking sufficient reporting and 36.7% showing inadequate outcome determination. Studies using primary data had lower RoB, whereas those with unclear label sources displayed higher RoB.

Our findings underscore the importance of careful planning in determining the ground truth frequently neglected in existing studies. To address these challenges, we provide a decision support flowchart to guide the development of more accurate and reliable prediction models.

This review uncovers significant variability in labeling methods and discusses how this may affect delirium prediction model reliability. Highlighting the importance of addressing underreporting bias and providing guidance for developing more robust models.

Delirium is commonly observed in older patients who are admitted to the emergency department (ED). Previous systematic reviews have identified poor outcomes associated with delirium in surgical, intensive care and other hospital settings, yet none have specifically considered the ED. This systematic review aims to examine associations between older patients who present or develop delirium in the ED and adverse outcomes within the hospital and after discharge.

Searches will be conducted in MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. There will be no date or language restrictions. Key terms will include concepts related to delirium, the ED and older adults. Observational studies or non-intervention clinical studies will be included that compare outcomes in older patients (ie, ≥65 years) with and without delirium. Outcomes of interest will include length of hospital stay, non-home discharge (eg, nursing home/residential aged care facility), cognitive impairment, decreased physical function, mortality, readmission to hospital and quality of life measures. Two reviewers will independently screen the studies. Data extraction and quality assessment will be extracted by one reviewer and checked by a second reviewer, with any disagreements resolved by discussion or by a third reviewer. Where appropriate, data will be combined in a meta-analysis and a GRADE assessment will be made for each outcome. All methods will be guided by the Cochrane Handbook and the Centre for Reviews and Dissemination and reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis statement as well as the recommendations set out by the Meta-analysis Of Observational Studies in Epidemiology group.

As this systematic review will use published data, ethical approval is not required. The results will be disseminated through a peer-reviewed publication and conference presentations.

CRD42024594975.

The current study aimed to investigate which one or certain combinations of preoperative comorbidities were associated with higher risk of postoperative delirium.

This propensity-score-matched cohort study analyzed a retrospective dataset of elderly patients undergoing surgery at the First Medical Center of the Chinese PLA General Hospital from January 2014 to April 2019. Univariate risk factors were selected by logistic regression, and then the combinations of these univariate factors were compared.

We identified 1034 older patients developed postoperative delirium (POD) within seven days after surgery, and 3102 patients without POD were matched by propensity score matching analysis at a ratio of 1:3 for those with POD. Eight preoperative comorbidities, including hypertension, diabetes, atrial fibrillation, cerebrovascular disease, Parkinson's disease, epilepsy, depression, and chronic obstructive pulmonary disease (COPD) were more common in patients diagnosed with POD after surgery than those without POD. Patients with POD were more likely to concurrently suffer from the combinations of hypertension and cerebrovascular disease, or hypertension and COPD.

Several preoperative comorbidities are associated with a higher risk of POD in older surgical patient. Those suffering from combinations of preoperative comorbidities were more likely to develop POD, and hypertension plays a central role in these combinations.

Delirium often goes unrecognized in the hospital, leading to missed opportunities for management. The objective of this study was to test a multicomponent program for delirium screening and reporting for older, hospitalized adults.

We implemented a multicomponent delirium screening and alerting program within two university hospital units for all patients ≥ 70 years of age. The initiative compared performance of the 4 'A's Test, Nursing Delirium Screening Scale, and Confusion Assessment Method. Additionally, the study team provided recurrent educational sessions with nurses and implemented pager and electronic health record alerts for patients who screened positive for delirium. Nurses were then surveyed about their perspectives, and clinical outcomes were abstracted from the medical record.

Compared to the Confusion Assessment Method, the proportion of positive screens was significantly higher (positive screens/admissions) with the 4 'A's Test (49/448, 11% vs. 12/399, 3%, p < 0.001) and the Nursing Delirium Screening Scale (83/539, 15% vs. 12/399, 3%, p < 0.001). Among surveyed nurses, 32/41 (78%) expressed that the alerting system provided at least "moderate" motivation to screen for delirium, and 35/41 (85%) voiced that it provided at least "moderate" motivation to record positive screens. Most respondents (23/42, 55%) reported recurrent educational sessions as "very helpful." Positive screens were associated with higher mortality (6.6% vs. 1.9%, p = 0.003), longer hospitalizations (13 [± 11] days vs. 7 [± 11], p < 0.001), and higher likelihood of discharge to care facilities (45% vs. 23%, p < 0.001).

Positive delirium screening rates were higher with the 4AT and NuDesc compared to the CAM. Additionally, alerting systems and educational initiatives served as motivating factors for delirium screening and charting.

Previous observational studies have suggested a possible association between dementia and delirium. However, these findings might be influenced by confounding variables. Thus, our study aimed to investigate the causal relationship between dementia and delirium using a bidirectional Mendelian randomization (MR) analysis.

In our investigation, bidirectional MR analysis was conducted by summary statistics from genome-wide association studies (GWAS). This enabled us to evaluate the causal impact of delirium and different types of dementia, such as Alzheimer's dementia (AD), vascular dementia (VaD) and Lewy body dementia (LD).

According to MR analysis, there was a significant positive correlation between delirium risk and AD (odds ratio [OR] = 1.363; 95 % confidence interval [CI], 1.223-1.519; p = 2.140E-08) and LD (OR = 1.403; 95 % CI, 1.151-1.711; p = 8.226E-04). However, the analysis also revealed that there was no causal relationship between VaD (OR = 1.044; 95 % CI = 1.136-1.027; p = 0.316) and the risk of delirium. Additionally, our study does not provide evidence to support a causal correlation between delirium and the risk of developing any form of dementia.

The results of the MR analysis suggest a potential causal link between dementia and an increased risk of delirium. Nevertheless, it should be emphasized that the existing evidence does not provide support for a causal connection in the reverse direction, implying that delirium may not play a causative role in the onset of dementia.

Delirium is an acute shift in attention and arousal, usually triggered by acute illness or surgery in older dementia patients. Prognosis is poor, and pharmacological options are limited; non-pharmacological interventions and music show promise.

This randomised pilot and feasibility trial tested feasibility, acceptability, fidelity, and safety of music interventions (MIs) for delirium patients and assessed preliminary effectiveness and suitability of the selected effect outcomes. Participants from an acute geriatric ward were randomised to Preferred Recorded Music (PRM) and Preferred Live Music (PLM), delivered for 30 min over three consecutive days. Feasibility outcomes included recruitment rate, retention, adherence, deviations, and treatment fidelity. Clinical outcomes were trajectory of delirium symptoms (arousal, attention, cognition), delirium duration, hospital stay length, and medication intake. Post-intervention and between groups changes in delirium symptoms were compared using mixed linear regression models for the repeated measurements. Mann-Whitney test and Fishers exact test were used for length of stay and medication use, respectively.

26 participants (PLM = 14; PRM = 12), median age 87, most with hypoactive delirium were recruited at a rate of three participants per month. Retention rates for PLM and PRM were 64% and 33% respectively and adherence to PLM and PRM intervention protocols were 83% and 58%, respectively. Total adherence to the assessment protocols was 44%. PLM was delivered as intended, (treatment fidelity 93%), and PRM did not satisfy treatment fidelity (83%). All delirium symptoms except arousal improved on day 3 compared to baseline, with statistically significant improvement in attention. No conclusive pre-post or between-group differences were detected for any outcomes; confidence intervals were wide.

Feasibility of recruitment, interventions and assessments was indicated, and greater acceptability, safety and fidelity of the PLM intervention compared with the PRM. Adoption of external assessors is warranted in future trials, to mitigate slow recruitment and low adherence. Wide confidence intervals for most measures and comparisons indicate that the possible effect of the MIs on delirium cannot be excluded. The trial was registered at Clinical Trials, ID: NCT05398211, on 31/05/2022.

To evaluate the safety of propofol and sevoflurane for general anesthesia in elderly.

All studies on sevoflurane, propofol, and hyperamylasemia from the establishment of Embase, Ovid, Cochrane Library, and Google Scholar from database establishment to December 2024 were searched. Literatures were screened, and data were extracted on the grounds of inclusion and exclusion criteria. Review Manager (RevMan) (Version 5.4. The Cochrane Collaboration.) was used for statistical analysis. Outcomes assessed included time to spontaneous eye opening, extubation time, incidence rate of postoperative cognitive dysfunction (POCD), postoperative delirium, agitation, nausea and vomiting.

Fourteen trials were identified and included in this meta-analysis. The results showed no significant difference in time to spontaneous eye opening (P = 0.54), the incidence of POCD (P = 0.07), postoperative delirium (P = 0.37), and postoperative nausea and vomiting (P = 0.8) between the sevoflurane and propofol groups. Compared with propofol groups, extubation time (P < 0.0001) was significantly shortened by sevoflurane groups. Conversely, compared with sevoflurane, the incidence of postoperative agitation in the propofol group was significantly reduced (P = 0.04).

There was no difference in time to spontaneous eye-opening, the incidence of POCD, postoperative delirium, postoperative nausea, and vomiting between the sevoflurane and propofol groups. However, compared with propofol, sevoflurane can significantly shorten intubation time. The incidence of postoperative agitation (P = 0.04) was significantly lower in the propofol group compared with sevoflurane.

The purpose of this study is to examine the validity, reliability and methodological quality of delirium scales that have been translated and adapted in China using quality assessment tools.

A comprehensive search was conducted in PubMed, Embase, Web of Science, China Knowledge Network (CNKI), VIP database, Wanfang database, and China Biomedical Literature Database. The search covered the period from the establishment of the database until September 1, 2023. Two researchers independently screened the literature and extracted data. Studies were included if they focused on the translation of a delirium scale from English into simplified or traditional Chinese, with a study population aged ≥ 18 years and full text available. The risk of bias was assessed through the QUADAS-2 instrument. Level of evidence recommendation is completed with the GRADE and performed with GRADE GPT. Due to high heterogeneity across studies, a random-effects model was applied to calculate diagnostic accuracy indicators (sensitivity, specificity, and area under the curve index). This study has registered in the prospero.

Thirteen studies were included, of which 2 were case-control studies and 11 were cross-sectional studies. These studies involved 13 adult delirium assessment tools, and were all translated following the Brislin or ISPOR principle. The results of the methodological quality assessment showed that 3D-CAM, 4AT, CAM-ICU, CAM-ICU-7, and S-PTD had higher quality ratings, with 4AT being the highest quality. 4AT, CAM, 3D-CAM, CAM-CR, CAM-ICU, CAM-ICU-7, and Nu-DESC were recommended at a level B. The Cronbach's coefficient of most studies is over 0.8, and the inter-rater reliability of most studies is near or over 0.9, indicating good internal consistency and stability. Besides, a significant inverse correlation was found between these 13 Chinese-adapted delirium scales and their reference tests, with most studies were over 0.7, and especially 3 studies offered S-CVI and I-CVI value that were all larger than 0.9, indicating a good discriminate validity and content validity, though different cut-off points were recommended by different scales. Moreover, the sensitivity and specificity of these studies were mainly larger than 0.9, which proved the good diagnostic accuracy of these included scales. The pooled sensitivity of 7 Chinese delirium adaption scales that provided statistical data is 0.93 (95% CI: 0.89-0.96), and the pooled specificity is 0.94 (95% CI: 0.94-0.96), and the AUC is 0.98 (95% CI: 0.96-0.99).

The research on the Chinese adaptation of the delirium scale in China is relatively abundant and of acceptable quality. Taking into account factors of methodological quality and diagnostic accuracy, Chinese-adapted delirium assessment scales such as 3D-CAM, 4AT, CAM, CAM-ICU, CAM-ICU-7, and NuDESC appear to be suitable alternatives to the original English delirium scales and are recommended for use in primary care settings in China. Future research and continuous optimization are needed to improve the scientific rigor and accuracy of these tools, which will help advance the field. No Patient or Public Contribution is considered.

Causes of delirium are often multiple in older people and a significant number of them are missed at the initial assessment. We wanted to develop a checklist to help clinicians to systematically screen for the most frequent and important causes of delirium in this population.

Three investigators, based on previous studies, drafted three possible checklist base models, comprising 18-29 items. A panel of 12 experts voted to choose one of the models, and then followed a modified Delphi consensus method to review each item and further develop the checklist. The consensus checklist was then tested in a small group of patients. The target population was older patients with delirium arriving to the emergency department or to a medical hospital ward.

The longest of the three drafts was unanimously chosen by the panel. After three rounds, a consensus was reached and a final checklist agreed. It is composed by 27 items organized in five groups of causes: infections, hydro-electrolytic disturbances, drugs, acute neurological conditions, and other acute diseases. A pilot study conducted by 15 physicians in 21 consecutive patients showed that the checklist was easy to complete, quick (mean 4 min) and most clinicians, though it helped them through the initial diagnostic work.

We have developed and pilot tested a checklist for screening for acute precipitants of delirium in older patients, aimed to facilitate early recognition and treatment of the multiple causes that often coexists in this population.

In recent years, many pharmacological agents for the prevention of delirium have emerged; however, the efficacy of these agents in preventing delirium remains unclear.

To compare and rank the efficacy of different pharmacological interventions for the prevention of delirium.

A systematic review and network meta-analysis.

Relevant randomized controlled trials on drug prevention of delirium were extracted from three electronic databases. A network meta-analysis was then conducted to assess the relative efficacy of drug interventions in preventing delirium. The quality of the data was evaluated using the Cochrane Risk of Bias tool.

A total of 80 randomized controlled trials on drug interventions were included in the final analysis. Treatment with dexmedetomidine can prevent delirium.

Dexmedetomidine treatment can prevent delirium and reduce patient suffering. Healthcare professionals should be encouraged to use dexmedetomidine for delirium prevention.

Delirium frequently occurs in individuals with acute kidney injury (AKI), leading to serious adverse outcomes. However, there are currently no predictors of early intervention for delirium in clinical practice. This study aims to investigate whether a correlation exists between TyG indices and the clinical symptoms of delirium in patients with AKI.

Eligible participants diagnosed with AKI from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database were categorised based on their TyG index. The primary outcome of this study was the incidence of delirium. The TyG indices were quartile and Kaplan-Meier (K-M) cumulative curve was conducted to compare the consequence of each group. Cox proportional hazards and restricted cubic spline (RCS) analyses were employed to explore the associations between TyG indices and outcomes. To mitigate potential biases, a no-replacement propensity score matching (PSM) approach was employed. Subgroup analyses were conducted to explore differences across various demographic and clinical categories.

A positive correlation between the quartile groupings of TyG-AVG and an increased cumulative incidence of delirium in individuals with severe AKI, as demonstrated through K-M cumulative curves and Cox regression analysis. Regarding the TyG index, patients in the 4th group displayed the highest hazard of delirium in both of the methods mentioned above. Furthermore, RCS analysis indicated that the interaction between the two variables is approximately linear. Subgroup analyses revealed that the effects of both metrics remained consistent across most examined subgroups.

Higher TyG indices were clearly associated with the incidence of delirium in patients with severe AKI. These indices could serve as valuable tools for identifying delirium-prone individuals with AKI.

Health care professionals (HCPs) in nursing homes, such as nurses and general practitioners (GPs), indicate a need for delirium-specific education. However, establishing educational interventions in the nursing home setting is challenging. e-learning is one method of compensating for these difficulties. Therefore, this study aims to develop a curriculum for interdisciplinary e-learning to improve delirium-specific knowledge in HCPs in nursing homes.

Delirium-specific competencies were formulated on the basis of exploratory setting-independent literature. The competencies were assessed for relevance (very relevant, relevant, less relevant and not relevant) by an expert panel through a two-stage Delphi study that included an integrated workshop. A consensus was assumed if 80% of the experts rated a competence as very relevant or relevant in the first round. Competencies with approval ratings between 75% and 80% after the first round and/or that were critically commented upon were discussed in the subsequent workshop and assessed again in the second round. The competencies that received approval ratings below 75% in the first Delphi round were removed. In the second Delphi round, competencies that did not achieve at least 80% approval were ultimately excluded.

A total of 120 competencies were formulated, including 108 that addressed both disciplines, 4 addressed nurses, and 8 addressed GPs. Nineteen experts participated in the first Delphi round, after which n=92 (76.7%) of the competences were approved and n=18 (15%) were deleted. A total of 10 (8.3%) of the competencies were critically discussed by 10 experts in the subsequent workshop, of which 6 were deleted. Four competencies (3 addressed nurses and 1 GP) were evaluated by 11 experts in the second Delphi, 3 of which were confirmed (the competence addressing GPs was deleted). Overall, n=97 (81.2%) competencies were included in the final curriculum. Of these, n=64 (66%) addressed both disciplines, n=16 (16.5%) addressed nurses, and n=17 (17.5%) addressed GPs.

Delirium is an interdisciplinary challenge. Hence, the majority of our newly developed competencies address both disciplines. However, discipline-specific competencies must be addressed in the development of e-learning. A competence-based curriculum is a necessary basis for providing interdisciplinary e-learning for HCPs in nursing homes.

Delirium in intensive care unit (ICU) patients poses a significant challenge, affecting patient outcomes and health care efficiency. Developing an accurate, real-time prediction model for delirium represents an advancement in critical care, addressing needs for timely intervention and resource optimization in ICUs.

We aimed to create a novel machine learning model for delirium prediction in ICU patients using only continuous physiological data.

We developed models integrating routinely available clinical data, such as age, sex, and patient monitoring device outputs, to ensure practicality and adaptability in diverse clinical settings. To confirm the reliability of delirium determination records, we prospectively collected results of Confusion Assessment Method for the ICU (CAM-ICU) evaluations performed by qualified investigators from May 17, 2021, to December 23, 2022, determining Cohen κ coefficients. Participants were included in the study if they were aged ≥18 years at ICU admission, had delirium evaluations using the CAM-ICU, and had data collected for at least 4 hours before delirium diagnosis or nondiagnosis. The development cohort from Yongin Severance Hospital (March 1, 2020, to January 12, 2022) comprised 5478 records: 5129 (93.62%) records from 651 patients for training and 349 (6.37%) records from 163 patients for internal validation. For temporal validation, we used 4438 records from the same hospital (January 28, 2022, to December 31, 2022) to reflect potential seasonal variations. External validation was performed using data from 670 patients at Ajou University Hospital (March 2022 to September 2022). We evaluated machine learning algorithms (random forest [RF], extra-trees classifier, and light gradient boosting machine) and selected the RF model as the final model based on its performance. To confirm clinical utility, a decision curve analysis and temporal pattern for model prediction during the ICU stay were performed.

The κ coefficient between labels generated by ICU nurses and prospectively verified by qualified researchers was 0.81, indicating reliable CAM-ICU results. Our final model showed robust performance in internal validation (area under the receiver operating characteristic curve [AUROC]: 0.82; area under the precision-recall curve [AUPRC]: 0.62) and maintained its accuracy in temporal validation (AUROC: 0.73; AUPRC: 0.85). External validation supported its effectiveness (AUROC: 0.84; AUPRC: 0.77). Decision curve analysis showed a positive net benefit at all thresholds, and the temporal pattern analysis showed a gradual increase in the model scores as the actual delirium diagnosis time approached.

We developed a machine learning model for delirium prediction in ICU patients using routinely measured variables, including physiological waveforms. Our study demonstrates the potential of the RF model in predicting delirium, with consistent performance across various validation scenarios. The model uses noninvasive variables, making it applicable to a wide range of ICU patients, with minimal additional risk.

Postoperative delirium (POD) is a severe complication following cardiac surgery and is associated with increased morbidity and mortality. The impact of intra- and early postoperative factors on the occurrence of POD following cardiac surgery remains controversial. To close this gap, we investigated intra- and early postoperative factors and their predictive values for POD.

We performed a prospective observational study that aimed to FIND DElirium RIsk factors (FINDERI) for patients undergoing elective cardiac surgery. POD was assessed using the Confusion Assessment Method algorithm. Intra- and early postoperative factors were extracted from electronic medical records and reviewed by cardiac surgeons. To identify potential predictors of POD, we used univariate and multivariate logistic regression along with machine learning (ML) with ten-fold cross-validation.

In our study cohort of 490 patients, 106 screened positive for POD (21.6%). In the multivariate analysis, we found a positive association between POD occurrence and age ( P < 0.001), duration of surgery ( P = 0.027), combined (versus isolated) surgical procedures ( P = 0.024), opening of the cardiac chambers ( P = 0.046), and ventilation time ( P < 0.001). The ML-based decision tree identified a two level-algorithm including ventilation time and aortic cross-clamping time, with an AUC of 0.7116 ( P = 0.0002) in the validation set. In the ML-based LASSO regression analysis, we identified ventilation time, administration of erythrocyte concentrates (EC), and usage of cardiopulmonary bypass (CPB) as predictors of POD, with an AUC of 0.7407 ( P < 0.0001) in the validation set.

The results of this analysis highlight the associations between ventilation time, aortic cross-clamping time, administration of EC, and usage of CPB and POD. Additionally, they suggest that the optimization of surgical protocols has the potential to reduce POD risk in individuals undergoing cardiac surgery.

We explored how adult surgical patients perceived their risk of major postoperative complications, including neurological complications, and how much information they wanted to receive about such risks.

We undertook a mixed-methods study including a 13-item survey and thematic analysis of semi-structured interviews with patients undergoing noncardiac, non-neurologic surgery.

Of 557 distributed surveys, 547 were returned completed. Of these, 88% of respondents had previously undergone surgery. Respondents were most likely to indicate an extreme level of concern for major stroke (64%), followed by heart attack (56%), minor stroke (46%), and cognitive decline (43%). Women were more likely to indicate a higher level of concern for cognitive decline than men (odds ratio 1.6, 95% confidence interval 1.1-2.4, P=0.015). Seventeen people participated in interviews. Six themes were identified: (1) trust in healthcare professionals; (2) surgery to achieve hopes and ambitions; (3) previous experiences govern expectations and perception of risk; (4) positive outlook and spirituality as protective factors; (5) support matters; and (6) a personalised approach to risk discussion.

Many participants did not know the risks of major perioperative complications but based their risk perception on previous experiences and trust in health professionals. Participants focused on hope more than their concerns. Information provision should be personalised as patients expressed differences in the desired amount of information on risks.

No established blood markers can preoperatively predict postoperative delirium. Blood concentrations of amino acid catabolites and dipeptides, including those secreted extracellularly during T-lymphocyte activation, were investigated as predictors of postoperative delirium using metabolomic analyses to ascertain whether preoperative blood metabolites could predict postoperative delirium. Eighteen and 24 participants were included in the delirium and non-delirium groups, respectively. Higher preoperative levels of amino acid (tryptophan) catabolites, via the indoleamine 2,3-dioxygenase pathway, were observed in the delirium group and identified as potential predictors of postoperative delirium in this study. The delirium group had preoperatively elevated levels of tryptophan catabolites and only a limited increase postoperatively, suggesting that the tryptophan catabolic pathway may be activated preoperatively in patients at high risk of delirium. Non-targeted metabolomic analysis found a set of preoperatively elevated γ-glutamyl dipeptides as potential predictors of postoperative delirium. In vitro experiments showed that T-cell-receptor stimulation increases tryptophan metabolism and specific γ-glutamyl dipeptide secretion, offering a possible explanation for the increased levels of metabolites in postoperative delirium. This study showed that levels of amino acid metabolites associated with blood immune activity may have the potential to predict postoperative delirium.

Perioperative neurocognitive disorder (PND) is a severe postoperative complication in older patients. Epigenetic changes are hallmarks of senescence and are closely associated with cognitive impairment. However, the effects of anesthesia and surgery on the aging brain's epigenetic regulatory mechanisms and its impact on cognitive impairment remain unclear. Using a laparotomy PND model, we report significant reduction in DNA methyltransferase 3a (DNMT3a) in hippocampal neurons of aged mice, which causes global DNA methylation decrease. Knockdown of DNMT3a leads to synaptic disorder and memory impairment in aged mice. Mechanistically, bisulfite sequencing revealed that DNMT3a deficiency reduces methylation in the LRG1 promoter region and promotes its transcription. We also show that activation of TGF-β signaling by the increase in LRG1 level, ultimately impacts the synaptic function. In contrast, both overexpressing DNMT3a or knockdown LRG1 in hippocampus can attenuate the synaptic disorders and rescue postoperative cognitive deficits in aged mice. Our results reveal that DNMT3a is a previously undefined mediator in the pathogenesis of PND, which couples epigenetic regulations with anesthesia/surgery-induced synaptic dysfunction and represents a therapeutic target to tackle PND.

To explore the existing literature on delirium within the acute care setting from the family members' perspective and summarise key findings.

A scoping review guided by Arksey and O'Malley's methodological framework and refined by the Joanna Briggs Institute.

The Population, Concept, and Context framework recommended by the Joanna Briggs Institute's scoping review protocol identified the main concepts in the primary review question. The inclusion criteria focused on primary research studies from any chronological date that explored the family members' experience of delirium within the acute care setting. Following screening by two independent reviewers, data extraction was conducted and presented in tabular form, detailing the study aim, sample, setting, methods, key findings and recommendations for future research and clinical practice.

A comprehensive search was conducted in January 2025 using CINAHL+, MEDLINE, JBI, Cochrane Library, Web of Science, Scopus and Google Scholar. Citation searching and reference lists supplemented this review to identify relevant studies.

Seventeen studies met the inclusion criteria. Families' experiences of delirium were categorised into (1) lack of awareness and understanding of delirium; (2) communication and informational needs of family members regarding delirium; (3) the emotional impact delirium has on family members, and (4) family desire to participate in their loved one's care.

This review highlighted a paucity of literature addressing the experiences of family members who witness delirium in the acute care setting. The existing research underscored the need for clear communication and information regarding delirium to mitigate the negative emotional impact that delirium places on families.

This scoping review provides insights into the challenges facing families witnessing delirium in the acute care setting. A better understanding of family members' experiences can guide the development of a supported family-centred approach to delirium care.

No patient/public contribution.

Postoperative delirium occurs in up to 40% of older surgical patients and has been associated with prolonged hospital stays, long-term cognitive impairment and increased 1-year postoperative mortality. Postoperative sleep disturbances may increase the risk of delirium, but studies investigating pharmacotherapies to improve postoperative sleep to prevent delirium remain limited. Suvorexant is a selective antagonist of orexin 1 and 2 receptors and is approved for insomnia pharmacotherapy by the Food and Drug Administration. It has the potential to improve postoperative sleep and reduce postoperative delirium rates, but randomised controlled trials (RCTs) are needed to determine the efficacy of postoperative suvorexant administration. The REPOSE study (reducing delirium by enhancing postoperative sleep with suvorexant) is a single-centre, randomised, double-blinded RCT that aims to evaluate the efficacy of suvorexant in increasing total sleep time (TST) and decreasing delirium severity in older patients undergoing non-cardiac surgery.

REPOSE will enroll 130 patients (aged ≥65 years) undergoing non-cardiac surgery with a planned postoperative inpatient stay. Participants will be randomised to receive 20 mg oral suvorexant or placebo nightly on postoperative nights 0, 1 and 2. The primary endpoint is TST on the first postoperative night, as measured using an electroencephalography headband. The secondary endpoint is peak postoperative delirium severity as measured by the 3-minute diagnostic interview for the confusion assessment method severity scores. Primary endpoint data will be analysed with a two-sample t-test using an intent-to-treat approach to compare TST on the first night that a patient received a study drug dose. Secondary and exploratory endpoint data will be analysed using two-sample t-tests between groups.

Ethical approval was obtained from the Duke Institutional Review Board (protocol #00111869). Results of the REPOSE study will be published in a peer-reviewed journal and presented at academic conferences. Trial data will be deposited in ClinicalTrials.gov.

NCT05733286.

Nonagenarians and centenarians are a growing and vulnerable groups of patients admitted to ICU. There is limited information on their characteristics, outcomes, and complications.

We performed a scoping review of studies focused on nonagenarians and centenarians admitted to ICU. We assessed their characteristics, the presence of frailty, the presence of comorbidities, their complications, their ICU and hospital length of stay and mortality and their long-term outcomes.

We assessed 36 studies, mostly retrospective, with one classified as a National Quality Registry study and another as a prospective analysis of two large multinational cohorts. The studies involved 16,859 patients with a mean age of 92.4 years and a male prevalence of 39.3%. Multiple comorbidities were present in the majority of patients. Overall, 40.7% of patients received mechanical ventilation, with a median of 36% (range: 0%-100%; IQR: 23.8%-50%). Mean duration of mechanical ventilation was 90.4 h, with a median of 84 h (range: 10-221 h; IQR: 12.25-146.5 h). Cardiovascular and renal complications were common. Mean ICU stay across studies was 5.4 days, with a median of 5 days (range: 0.9-13 days; IQR: 2.55-7.03 days). The median length of hospital stay was 12.4 days (range: 5.7-31 days; IQR: 11-17.6 days). The median hospital mortality was 25.55% (range: 0%-62.5%; IQR: 15%-35.5%). The mean six-month and 1-year mortality rates were 38.6% and 45.6%, respectively.

Nonagenarians and centenarians admitted to ICU are a highly comorbid and vulnerable population who experience prolonged hospital stays and complications. However four out of five survive to hospital discharge and half are alive at one year after admission. Therefore, through judicious patient selection, ICU care can be both meaningful and beneficial. Our findings underscore the need for a standardized reporting structure for nonagenarians and centenarians admitted to the ICU to allow comparability across studies, enhanced data quality and reliability, greater research efficiency, and better identification of the unique health needs in this vulnerable patient cohort.

This study investigated whether cognitive training (CT) ameliorates postoperative delirium (POD) in older patients undergoing total hip and knee arthroplasty.

This clinical trial was conducted from 18 February to 10 July 2023 and included individuals aged 60-79 who underwent elective total hip and knee arthroplasties with surgery durations ≤3 hours under general anaesthesia. Patients with preoperative cognitive dysfunction and dementia were excluded. The incidence of POD was compared between the CT and routine care (RC) groups as the primary outcome. Secondary outcomes included adverse events, postoperative pain within 48 hours, and POD characteristics.

In this study, 122 individuals were divided into two groups. The overall incidence of POD was 8.2% (10 out of 122), with no significant difference between the two groups (9.8% for CT group vs. 6.6% for RC group; P = .509). Secondary outcomes also showed no significant difference between the two groups. The training time was less, and the compliance rate was poor in the CT group (4.0%). Nonetheless, the results revealed a significant difference in POD rates among CT subgroups, and a robust correlation was identified between CT sessions lasting less than the median duration of 12 minutes and the incidence of POD (P = .043).

The incidence of POD in older patients undergoing total hip or knee arthroplasty may not be mitigated by CT. As POD was exclusively observed in patients with fewer CT sessions, it suggests that the compliance-recommended CT sessions may contribute to the POD.

Emerging evidence suggests coronavirus disease 2019 (COVID-19) infection may increase the risk of developing dementia, although studies have reported conflicting findings. This meta-analysis aimed to synthesise the literature on the association between COVID-19 and the risk of new-onset dementia.

PubMed, Embase and Web of Science were searched for cohort studies or case-control studies that investigated new-onset dementia development among adult COVID-19 survivors compared to individuals without COVID-19 infection from inception to 9 November 2023. Studies that exclusively involved populations younger than 18 years, with known dementia or lacked adequate data about the risk of dementia were excluded. Two authors independently conducted the screening of eligible studies, data extraction and risk of bias assessment. The primary outcome was new-onset dementia following COVID-19 infection. Data were pooled using random-effects models, with hazard ratios (HRs) and 95% confidence intervals (CIs) calculated.

A total of 15 retrospective cohort studies encompassing 26 408 378 participants were included. Pooled analysis indicated COVID-19 was associated with an increased risk of new-onset dementia (HR = 1.49, 95% CI: 1.33-1.68). This risk remained elevated when compared with non-COVID cohorts (HR = 1.65, 95% CI: 1.39-1.95), and respiratory tract infection cohorts (HR = 1.29, 95% CI: 1.12-1.49), but not influenza or sepsis cohorts. Increased dementia risk was observed in both males and females, as well as in individuals older than 65 years (HR = 1.68, 95% CI: 1.48-1.90), with the risk remaining elevated for up to 24 months.

This meta-analysis demonstrates a significant association between COVID-19 infection and increased risk of developing new-onset dementia, which underscores the need for cognitive monitoring and early intervention for COVID-19 survivors to address potential long-term neurological impacts.

We aimed to evaluate the understanding of delirium among multidisciplinary medical staff and assess whether a brief e-learning course improved their knowledge on the topic.

A total of 611 medical staff members participated in the study, including 32 physicians, 393 nurses, 33 nursing assistants, 21 pharmacists, and 132 other multidisciplinary staff, which included non-clinical personnel. A 20-question delirium knowledge test was administered both before and after a 40-min, on-demand e-learning course.

At baseline, there was limited understanding that delirium involves a disturbance of consciousness, can be triggered by physical illness or medications, and that few medications are recommended for its treatment. Furthermore, visual hallucinations were not widely recognized as a common type of hallucination in delirium. However, care strategies and non-pharmacological interventions for delirium were well understood even before the course. After the brief e-learning course, knowledge scores significantly increased, demonstrating a large effect size of 0.53. Physicians and pharmacists achieved higher overall knowledge scores after the course compared to other occupational groups.

Education and targeted dissemination efforts regarding the causes, diagnosis, and pharmacological treatment of delirium are essential for enhancing delirium knowledge among multidisciplinary staff. The leadership role of a "liaison" psychiatrist is pivotal for ensuring effective delirium care and fostering a team-based approach in clinical practice.

Assessing recovery after general anesthesia is complicated because patients must be sufficiently arousable to pay attention to the verbal instructions probing cognitive function. All delirium screens that have been used in the postanesthesia care unit (PACU) rely heavily on a patient's ability to process language information and respond appropriately. However, postanesthesia effects on speech-language functions have not been specifically evaluated. Here we present a novel, qualitative PACU evaluation for cognitive domains critical for speech-language functions, and we compare this assessment against a multidomain neurocognitive examination: Telephonic Montreal Cognitive Assessment (t-MoCA). This may be used to identify trajectories of neurocognitive recovery after surgery with general anesthesia and provide neuroanatomic correlates for specific deficits.

We investigated 48 patients undergoing general anesthesia for noncardiac and nonneurologic elective surgeries. Preoperatively, participants were administered our PACU speech-language assessment (PACU-SLA) and t-MoCA. Both assessments were again administered postoperatively in the PACU. Different versions of PACU-SLA were administered pre- versus postoperatively. Twenty-three participants randomly received the same t-MoCA versions (group AA), and 25 participants received different versions (group AB), pre- versus postoperatively. Assessments were administered ≥30 minutes after PACU arrival, and before PACU discharge. Statistical analysis was performed using Wilcoxon-signed-rank tests for nonnormally distributed paired data, analysis of covariance for assessing the impact of group (AA versus AB) and preoperative scores on postoperative scores, and χ2 tests for unpaired categorical data (P < .05 indicating significance).

After adjusting for preoperative scores, the postoperative t-MoCA scores of group AB were significantly lower than group AA (F[1-46] = 21.7, P < .001). Similarly, the t-MoCA scores of episodic-memory (delayed-recall) decreased in group AB (F[1-46] = 48.6, P < .001). For PACU-SLA, there were no postoperative changes in auditory-comprehension and object-naming scores, but a decrease was observed in (1) scores of a 9-point narrative-production task of expressive-fluency (n = 48; median [25th-75th]; preoperative: 9[9-9], postoperative: 7[7-8], P < .001), and (2) total words generated in 2 30-second tasks of verbal-fluency (n = 48; median[25th-75th]: preoperative: 23[12.5-33.5], postoperative: 16.5[9.5-26.5], P < .001). Scores on a 4-point sentence-repetition task were also noted to decrease postoperatively (n = 48; median[25th-75th]; preoperative: 4[3-4], postoperative: 4[3-4], P = .04). When grouping participants by preoperative cognitive status (pMCI, n = 9; preoperative normal, n = 39), both groups showed postoperative changes in verbal-fluency (F[1-46] = 6.97, P = .01) and narrative-production scores (F[1-46] = 5.51, P = .02).

The PACU-SLA revealed lower fluency (hypophonia) with relatively intact comprehension, naming, and repetition, during recovery from general anesthesia. These deficits share features with transcortical motor aphasia.

Postoperative delirium (POD) in older adults is associated with high risk of morbidity and mortality. With limited treatment options, prevention is essential. Melatonin has been suggested to prevent delirium through regulating the sleep-wake cycle and serotonin metabolism, which has been shown to be disrupted in patients with POD. However, the evidence regarding the use of melatonin for POD prevention is limited and inconclusive.

Our multicenter, 2-arm, parallel-group, feasibility randomized controlled trial evaluated the effect of melatonin on POD incidence after noncardiac surgery in patients >65 years (n = 120). Patients were randomized to 3 mg oral melatonin or placebo once preoperatively and for 7 days postoperatively. Patients were assessed twice daily for delirium and followed at 3 months postoperatively. Feasibility outcomes were recruitment rate, medication adherence, and proportion completing 3-month follow-up. Clinical outcomes were delirium incidence, sleep quality, institutional discharge, and cognitive status at 3 months.

Between September 2021 and June 2023, 85 patients were randomized (~1 patient/wk); of these, 92.9% adhered to study medications and 87.1% completed the 3-month follow-up. POD occurred in 9 patients with no statistical difference between the groups (melatonin group, n = 7; placebo group, n = 2; adjusted odds ratio: 1.12; 95% confidence interval: 0.006-150.1). There were no differences in any other clinical outcomes. Pandemic-related challenges, including interruption of surgeries and restrictions on research procedures impacted feasibility and the study was terminated early due to futility.

Based on our observations, a sample size of >1000 patients is required for a definitive trial to evaluate the role of melatonin in reducing the incidence of POD. Design changes need to be considered to address feasibility challenges and ongoing post-pandemic modifications to patient care.

Patients and families who have experienced delirium may seek information about delirium online, but the quality and reliability of online delirium-related websites are unknown.

This study aimed to identify and evaluate online delirium-related websites that could be used for patient and family education.

We searched Microsoft Bing, Google, and Yahoo using the keywords "delirium" and the misspelled "delerium" to identify delirium-related websites created to inform patients, families, and members of the public about delirium. The quality of identified delirium-related website content was evaluated by 2 authors using the validated DISCERN tool and the JAMA (Journal of the American Medical Association) benchmark criteria. Readability was assessed with the Simple Measure of Gobbledygook, the Flesch Reading Ease score, and the Flesch Kincaid grade level. Each piece of website content was assessed for its delirium-related information using a checklist of items co-designed by a working group, which included patients, families, researchers, and clinicians.

We identified 106 websites targeted toward patients and families, with most hospital-affiliated (21/106, 20%) from commercial websites (20/106, 19%), government-affiliated organizations (19/106, 18%), or from a foundation or advocacy group (16/106, 15%). The median time since the last content update was 3 (IQR 2-5) years. Most websites' content (101/106, 95%) was written at a reading level higher than the recommended grade 6 level. The median DISCERN total score was 42 (IQR 33-50), with scores ranging from 20 (very poor quality) to 78 (excellent quality). The median delirium-related content score was 8 (IQR 6-9), with scores ranging from 1 to 12. Many websites lacked information on the short- and long-term outcomes of delirium as well as how common it is. The median JAMA benchmark score was 1 (IQR 1-3), indicating the quality of the websites' content had poor transparency.

We identified high-quality websites that could be used to educate patients, families, or the public about delirium. While most delirium-related website content generally meets quality standards based on DISCERN and JAMA benchmark criteria, high scores do not always ensure patient and family-friendliness. Many of the top-rated delirium content were text-heavy and complex in layout, which could be overwhelming for users seeking clear, concise information. Future efforts should prioritize the development of websites with patients and families, considering usability, accessibility, and cultural relevance to ensure they are truly effective for delirium education.

Delirium is an acute, neuropsychiatric syndrome, characterized by an altered mental state. It often affects hospital in-patients and is associated with an increased risk of mortality, dementia, and functional decline. Delirium can be detected through the use of validated assessment tools, administered by nurses, and early detection is associated with improved outcomes for patients. However, validated tools are infrequently utilised and cases of delirium are frequently missed. A greater understanding of nurses' use of validated delirium assessment tools is needed in order to reduce the number of missed cases.

The aim of this scoping review is to identify how validated assessment tools are used by nurses in general acute care settings to assess for delirium and identify the barriers and enablers for said tools' use.

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The databases CINAHL, PubMed, Web of Science, and Scopus will be searched using a search strategy. Grey literature will also be searched using Google Scholar and BASE. Results will be uploaded to Covidence where the sources will be screened for relevance. Data from relevant sources will be extracted using a data extraction tool.

The PRISMA-ScR flow diagram will present the results of the search. Results will be mapped descriptively and presented as both tabulated results and a narrative summary.

This protocol outlines the structure of a scoping review that will analyse the existing literature surrounding nurses use of validated delirium assessment tools. This review aims to map the evidence of delirium assessment tool utilisation by nurses and identify any barriers to usage. This will support future researchers and policy makers in the improvement of delirium assessment in acute care settings.

Inpatient delirium and unplanned hospital readmissions are associated with increased mortality. This study aimed to determine the effect of 28-day unplanned hospital readmissions on 12-month mortality post-discharge in patients with delirium during index hospitalisation.

Retrospective longitudinal cohort study of adults aged 65 or above with delirium during hospitalisation at a Victorian quaternary hospital was performed. Delirium was identified by the inclusion of ICD-10 (International Classification of Diseases, 10th revision) codes in the hospital medical discharge summary. Descriptive statistics was obtained for baseline characteristics. Cox proportional hazards model was developed to identify independent predictors of 12-month post-discharge mortality.

One thousand six hundred thirty-four patients with delirium during in-patient admission were included. The overall 12-month mortality rate was 35% (572 patients). Of the 1,425 patients who survived their index admission, 11.2% had an unplanned 28-day readmission. In Cox regression analysis, unplanned readmission (hazard ratio (HR) 2.3, 95% confidence internal (CI) 1.7-2.9), older age (HR 1.38, CI 1.11-1.72), Charlson Comorbidity Index (HR 1.21, CI 1.17-1.27), and discharge to nursing home (HR 1.58, CI 1.23-2.02) were independent predictors of 12-month mortality. Readmitted patients with 12-month mortality were older, with higher rates of dementia, polypharmacy, and nursing home residence compared to readmitted patients who did not reach this endpoint.

Unplanned hospital readmission within 28 days of discharge is an independent predictor of 12-month mortality post in-hospital delirium admission. Admissions complicated by delirium and readmission episodes should instigate discussions regarding prognostication and goals of care. Greater research is required to minimise hospital readmission rates following discharge in this cohort.

The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (β =  - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (β = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (β = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.

Perioperative neurocognitive disorders are common perioperative complications associated with various poor outcomes. Regional cerebral oxygen saturation (rSO2) monitoring is a noninvasive technique based on near-infrared spectroscopy detection. Due to the considerable controversy among currently published studies on the application of intraoperative rSO2 monitoring in adult patients undergoing elective noncardiac surgery, this study aims to conduct a systematic review and meta-analysis to provide more comprehensive and robust evidence to support clinical decision-making.

This study conducted a systematic literature search of databases including PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science, from their inception to May 1, 2024. The eligible randomized controlled trials included adult patients undergoing elective noncardiac surgery under general anesthesia who received optimized anesthesia management guided by rSO2 monitoring and those in the control group who received routine anesthesia management under standard monitoring or blinded rSO2 monitoring. The primary outcomes were the incidence of perioperative neurocognitive disorders, including postoperative delirium (POD) and postoperative cognitive dysfunction (POCD), and Mini-Mental State Examination (MMSE) scores. Secondary outcomes included the incidence of intraoperative cerebral desaturation and length of hospital stay (LOS).

The pooled results showed that compared to the control group, optimized anesthesia management guided by intraoperative rSO2 monitoring significantly reduced the incidence of POCD within 7 days postoperatively and may reduce the incidence of POCD at 3 months and longer periods postoperatively. However, it may not reduce the incidence of POD within 7 days or longer periods postoperatively, improve MMSE scores, reduce the incidence of intraoperative cerebral desaturation, or shorten LOS. Given the substantial heterogeneity in the pooled results for MMSE scores within 7 days postoperatively and LOS, and the limited number of studies reporting the incidence of POD, POCD, and MMSE scores after 7 days postoperatively, the related results should be interpreted with caution.

Despite the presence of heterogeneity and the inclusion of a limited number of studies for some outcomes, it is still recommended that clinical anesthesiologists routinely perform intraoperative rSO2 monitoring and optimize intraoperative anesthesia management based on the monitoring results to maximize rSO2 and improve cerebral perfusion, thereby improving patients' neurocognitive outcomes. Further large-scale, high-quality studies are needed to confirm the conclusions of this study.

Delirium is not a harmless transient event during ICU hospitalization; rather, it is a severe complication of critical illness associated with increased mortality, morbidity, and persistent disability. Despite being recognized for decades, it remains underdiagnosed. Employing validated tools for detection helps reduce missed cases. Early detection facilitates prompt management. Sedatives, opioids, and antipsychotics should be avoided whenever possible. Optimizing environmental triggers, minimizing iatrogenicity, and treating underlying critical illness constitute the basis of the currently recommended approach to diminish the burden of delirium in ICU patients.

Delirium is a highly prevalent neuropsychiatric syndrome characterised by acute and fluctuating impairments in attention and cognition. Mechanisms driving delirium are poorly understood but it has been suggested that blood cytokines and chemokines cross the blood brain barrier during delirium, directly impairing brain function. It is not known whether these molecules reach higher brain levels when the blood cerebrospinal fluid barrier (BCSFB) is impaired. Here, in human hip-fracture patients, we tested the influence of BCSFB integrity on CSF levels of chemokines and assessed their association with delirium. CSF levels of IP-10, eotaxin, eotaxin 3 and TARC showed weak to moderate correlations with BCSFB permeability, as measured by the Qalbumin ratio, while MCP1, IL-8, MIP1α and MIP1β showed no significant correlation. Chemokines were not associated with delirium in univariate analysis or when stratified on dementia status, but exploratory analyses showed that elevated Eotaxin (CCL11) and MIP1α (CCL3) were associated with prevalent delirium. Modelling acute systemic inflammation, we used bacterial LPS (250 μg/kg) or sterile laparotomy surgery in mice to demonstrate de novo synthesis of chemokines at the choroid plexus (CP) and microvasculature. Gene expression data showed CP-enriched expression of Il1b, Tnfa, Cxcl1 and Ccl3 in both models and immunohistochemistry showed cytokine and chemokine synthesis in CP stromal (IL-1β, CCL2/MCP1) or epithelial cells (CXCL10/IP-10) cells and at the microvasculature. Larger studies are required to confirm these human findings on chemokine associations with BCSFB permeability and prevalent delirium. Preclinical studies are warranted to determine whether chemokines might play a role in the pathophysiology of delirium.

Postoperative delirium (POD) is a common complication with a high health-related impact. The creation of a model (Siena posTopeRative dElirium in vaScular Surgery) to identify high-risk patients with consecutive prompt diagnosis and correct management.

This is an observational retrospective study to evaluate POD incidence in patients who underwent elective vascular surgery procedures between 2018 and 2020. POD was detected using CAM and defined as the onset of an acute confusional state, clinically manifesting as a disturbed state of consciousness, cognitive dysfunction, or alteration in perception and behavior. The total population was divided in the development and validation subsamples. Multivariable logistic regression analysis was performed, identifying variables related to the occurrence of POD. An additive score was created and the STRESS score was internally validated using the Validation subgroup.

A total of 1067 patients were enrolled. POD occurred in 111 cases (10.4%). Multivariable logistic regression analysis for POD occurrence revealed as significant predictors: age>75 years, CKD, dyslipidaemia, psychiatric disease, CAD, hospitalization in the previous month, preoperative NLR >3.59, preoperative Hb < 12 g/dl, preoperative Barthel score <75, major amputation, CLTI revascularization, general anesthesia, and postoperative urinary catheter. These variables were used to create the STRESS score. The model was applied to both development and validation subgroups; AUC was respectively 0.7079 (p < .0001) and 0.7270 (p < .0001).

The STRESS score has a good predictive potentiality for POD occurrence in elective vascular surgery procedures. However, implementation and external validation are needed to be correctly used in everyday clinical practice.

The only curative treatment for patients with end-stage liver disease (ESLD) is liver transplantation (LT). Patients with ESLD can develop delirium due to multiple etiologies. In this study, we aimed to assess the prevalence and impact of delirium on outcomes and resource utilization among hospitalized patients undergoing LT.

We used the National Inpatient Sample Database 2016-2020 to identify adult patients undergoing LT. Patients were stratified into two groups based on the presence of delirium. The outcomes studied were in-hospital mortality, perioperative adverse events, and resource utilization. Multivariate logistic and linear regression analysis was used to identify the relationship between delirium and outcomes.

Of 34 405 included patients, 4930 (14.3%) patients had delirium. Patients with delirium had a higher need for renal replacement therapy (31.7% vs. 17.6%, P  < 0.001), vasopressor support (16.8% vs. 11.1%, P  < 0.001), and mechanical ventilation (34.1% vs. 15.3%, P  < 0.001). They also had higher total perioperative complications (77.3% vs. 60.4%, P  < 0.001), longer length of stay (34.8 vs. 17. 7, P  < 0.001), and total hospitalization charges ($927 200 vs. $565 486 P  < 0.001). After multivariable analysis, patients with delirium had higher odds of perioperative complications (adjusted odds ratio: 1.54, 95% confidence interval: 1.24-1.92, P  < 0.001) and resource utilization.

Our finding suggests the need for physicians to identify and reverse delirium as soon as possible.

To investigate the: 1) correlation between the maintenance or cessation of selective serotonin reuptake inhibitors (SSRIs) during hospitalization and the incidence of delirium among critically ill patients; 2) evaluate the effectiveness of utilizing SSRIs as a potential intervention for managing delirium in critically ill adults; and 3) evaluate the effects of continuing SSRIs in patients who were previously prescribed these medications on incidence of delirium or withdrawal symptoms manifesting as delirium.

PubMed, Scopus, Embase, PsycInfo, and ProQuest Central, and additional studies identified from reference lists and relevant systematic reviews.

Studies included adults 18 years old and older with critical illness necessitating ICU care administered SSRIs during their hospital stay, where delirium and/or adverse effects were reported as outcomes.

Two team members extracted data from included studies into evidence tables, which were subsequently discussed to synthesize and align the extracted findings. Extraction criteria included study population and the type of control or comparison group, exposures, primary and secondary outcome measures, results, and implications. We used Study Quality Assessment Tools provided by the National Heart, Lung, and Blood Institute and National Institutes of Health public websites along with the TREND checklist to evaluate the quality of articles and analyze for bias.

Two reviewers analyzed the studies' risk for bias. Analysis followed the Grading of Recommendations Assessment, Development, and Evaluation criteria used in Cochrane systematic reviews. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist to design and report the study.

The cessation of SSRIs in patients who were previously prescribed these medications is associated with an increased incidence of delirium or withdrawal symptoms manifesting as delirium. Continuing these medications in the setting of critical illness may mitigate the risk of delirium. Further investigation is warranted into the impact of SSRIs on delirium in patients not taking these medications prior to ICU admission.