Objective To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Design Prospective validation study. Setting Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). Patients The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. Measurements and main results An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). Conclusions The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium

Objectives: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. Design: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. Studies: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. Main outcome measures: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. Results: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P Conclusions: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.

/pdf/reduction-of-postoperative-mortality-and-morbidity-with-1uuz7uqkyl.pdf

Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.

Context Delirium is a common and serious complication in elderly patients Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease Objective To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders Data Sources A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL Study Selection Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language Titles, abstracts, and articles were reviewed independently by 2 of the authors Of 2939 references in the original search, 51 relevant articles were identified Data Extraction Information on study design, characteristics of the study population, and outcome were extracted Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies Data Synthesis The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia Pooled-effect estimates were calculated with random-effects models The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 227 months (7 studies; 271/714 patients [380%] with delirium, 616/2243 controls [275%]; HR, 195 [95% confidence interval {CI}, 151-252]; I2, 440%) Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 146 months; 176/527 patients [334%] with delirium and 219/2052 controls [107%]; odds ratio [OR], 241 [95% CI, 177-329]; I2, 0%) and dementia (2 studies; average follow-up, 41 years; 35/56 patients [625%] with delirium and 15/185 controls [81%]; OR, 1252 [95% CI, 186-8421]; I2, 524%) The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results Conclusion This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia

https://jamanetwork.com/journals/jama/articlepdf/186304/jrv05005_443_451.pdf

Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-analysis

Epidural anesthesia and analgesia. Their role in postoperative outcome.

DELIRIUM IS A SYNDROME OF acutely altered mental status characterized by inattent ion and a f luctuat ing course. With occurrence rates of up to half of older patients postoperatively, and even higher in elderly patients admitted to intensive care units, delirium is the most common complication in hospitalized older people. Delirium causes distress to patients and caregivers, has been associated with increased morbidity and mortality, and is a major burden to health care services in terms of expenditures. Numerous studies have addressed the long-term prognosis of older individuals who experienced delirium during hospitalization. The evidence that these studies provide is not entirely consistent (eg, older patients with delirium experienced increased long-term mortality in one study, but not in another). Elements of study design, such as delirium and outcome ascertainment and time to follow-up, may affect conclusions. Whether delirium independently contributes to poor outcome or merely represents a marker of underlying disease is especially relevant. The long-term detrimental seAuthor Affiliations: Department of Geriatric Medicine, Medical Center Alkmaar, Alkmaar, the Netherlands (Mr Witlox and Dr de Jonghe); Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands(MsEurelingsandDrsEikelenboomandvanGool); Department of Geriatric Medicine, Kennemer Gasthuis, Haarlem,theNetherlands(DrKalisvaart);andGGZinGeest, Amsterdam, the Netherlands (Dr Eikelenboom). Corresponding Author: Willem A. van Gool, MD, PhD, Department of Neurology, Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, the Netherlands (w.a.vangool@amc.uva.nl). Context Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease.

Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia

Fifty-seven patients, all over the age of 64, with femoral neck fracture were randomized to receive epidural or halothane anesthesia to see if the anesthetic technique influenced the incidence of postoperative confusion. All patients were lucid on admission. Using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as criteria for confusion, we found that 44% of the patients developed confusion that correlated closely to a history of mental depression (P less than 0.01) and to the use of drugs with anticholinergic effect (P less than 0.005). There was no difference in the incidence of confusion between the two anesthetic groups. In patients given halothane, however, early postoperative hypoxemia was associated with confusion (P less than 0.05). Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times. It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique.

Postoperative confusion after anesthesia in elderly patients with femoral neck fractures.

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Postoperative confusion after anesthesia in elderly patients with femoral neck fractures.