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Introduction:
Clinical motor subtypes have been long recognised in delirium and, despite a growing body of research, a lack of clarity exists regarding the importance of these motor subtypes. The aims of this review are to (1) examine how the concept of motor subtypes has evolved, (2) explore their relationship to the clinical context, (3) discuss...
Contexts in source publication
Context 1
... the third 'data-extraction phase', the studies were studied in detail and relevant pieces of evidence extracted for this review. in the fourth' synthesis phase', the selected studies were restructured into a comprehensive nar- rative to tackle the aims of the review set out at the beginning (Figure 1). ...
Context 2
... hundred and twenty-seven were excluded as they were not focused on delirium. The remainder of the articles (n = 87) were screened using the exclusion and including criteria and, following this process, 61 articles were iden- tified for review (Figure 1). The relevant pieces of evi- dence were extracted from these papers and the findings were organised into themes to address the aims of the review. ...
Citations
... Lindroth et al., 2020;Meagher et al., 2012b;Shim et al., 2020;Trzepacz et al., 2018. Motor subtype Hyperactive increased activity levels, increased speed of actions or speech, restlessness, wandering, abnormal content of verbal output, hyper alertness, irritability, agitation, and combativeness Albrecht et al., 2015;FitzGerald, 2018;Hayhurst et al., 2020;NICE, 2021). Hypoactive reduced activity, apathy, decreased amount or speed of speech, decreased alertness, unawareness, or hypersomnolence. ...
... Hypoactive reduced activity, apathy, decreased amount or speed of speech, decreased alertness, unawareness, or hypersomnolence. Albrecht et al., 2015;FitzGerald, 2018;Hayhurst et al., 2020;NICE, 2021. Mixed alternate between intensities of activity levels within a short time frame Albrecht et al., 2015;FitzGerald, 2018;NICE, 2021. ...
... Albrecht et al., 2015;FitzGerald, 2018;Hayhurst et al., 2020;NICE, 2021. Mixed alternate between intensities of activity levels within a short time frame Albrecht et al., 2015;FitzGerald, 2018;NICE, 2021. Normal normal psychomotor features Albrecht et al., 2015. ...
Background
The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder. However, the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses’ viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge.
Objective
The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.
Design
The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.
Settings
Surgical wards, surgical intensive care units, and post-anaesthesia care units
Data sources
A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.
Participants
Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.
Methods
In the theoretical phase, the concepts’ working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses’ descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.
Results
The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients’ compliance with care may be decreased with the continuum of delirium, which might challenge both patients’ recovery from surgery and the quality of nursing care.
Conclusions
In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
... Delirium is classified into different motor subtypes, including hypoactive, hyperactive, and mixed [2••, 13]. Hypoactive delirium involves symptoms such as lethargy, decreased awareness, apathy, and hypersomnolence [13,14]. Hyperactive delirium involves symptoms such as restlessness, increased alertness, distractibility, combativeness, and irritability [13,14]. ...
... Hypoactive delirium involves symptoms such as lethargy, decreased awareness, apathy, and hypersomnolence [13,14]. Hyperactive delirium involves symptoms such as restlessness, increased alertness, distractibility, combativeness, and irritability [13,14]. Mixed delirium includes elements of both hypoactive and hyperactive delirium and may involve fluctuations between the subtypes [13,14]. ...
... Hyperactive delirium involves symptoms such as restlessness, increased alertness, distractibility, combativeness, and irritability [13,14]. Mixed delirium includes elements of both hypoactive and hyperactive delirium and may involve fluctuations between the subtypes [13,14]. ...
Purpose
Our review aims to provide evidence-based information about diagnosis, evaluation, and management of delirium in the dementia population. In this review, we will define delirium and assess its impact on those individuals with dementia. We will summarize measures used to evaluate the underlying causes of delirium. Finally, we will discuss treatment and management options, including non-pharmacologic and pharmacologic therapies.
Recent Findings
New research into delirium has been sparse; however, there have been a couple of trials involving supplements such as melatonin. Other approaches, such as music therapy, have also been used. These have not yielded statistically significant results and may require larger trials for confirmation. Observational studies have shown an increased risk of dementia and cognitive decline in geriatric patients with delirium, meaning that prevention may be helpful for future quality of life.
Summary
Delirium in the setting of dementia can lead to significant morbidity and mortality. Timely evaluation and treatment can be effective in helping with quality and quantity of life. The overall strategy needs to be focused on prompt identification of delirium, finding possible causes, and applying safe and effective management for the patient, with expeditious discharge from an inpatient setting.
... Firstly, the mixed delirium uctuates between the hyperactive and hypoactive [19,30], making it challenging to identify. Secondly, due to the endogenous (severity of the condition, age, sex) and exogenous (surgery, drugs, anesthesia, intubation) and other factors of the patients [29], it is more likely to occur the mixed delirium, leading to prolonged mechanical ventilation time, hospital stay, ICU stay time and duration of delirium, In terms of the risk factors of postoperative delirium subtypes, our ndings suggested that mixed delirium was associated with ASA score, intraoperative blood loss, duration of anesthesia, duration of surgery, and the level of the in ammatory factor IL-6; hyperactive delirium had a relation with pain score and type of surgery; and hypoactive delirium was signi cantly related to preoperative treatment with β-blockers. Regarding other risk factors, a systematic review by Krewulak, K. D has analyzed the risk factors of delirium subtypes in adult ICU: age, gender, APACHE-disease severity score [27]. ...
Objective: Systematic review and meta-analysis methodology was used to estimate the pooled incidence, outcome, risk factors of postoperative delirium, including three delirium subtypes: hyperactive delirium, hypoactive delirium, mixed delirium.
Methonds: This systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses(PRISMA) guideline. MEDLINE、EMBASE、CENTRAL were searched for relevant studies. Thirty-two studies from 2714 searched results with 9049 patients were enrolled in this systematic review and meta-analysis. Inclusion criteria were:1) elective surgery population;2) the incidence of delirium subtypes was recorded ;3) cohort studies.;4) language restricted to English. In addition, studies that were randomized control trials (RCT), case reports, or uncertainty in the incidence of delirium subtypes were excluded. The related information was extracted by two reviewers independently.All the analyses were conducted by the STATA (Version 16.0; Stata Corporation, College Station, TX).
Result: The study we have performed showed that the highest incidence of postoperative delirium was hypoactive (14%[95%CI,12-16%]), followed by hyperactive (12%[95%CI,10-14%]), and the lowest was mixed delirium(9%[95%CI,7-11%]).
Conclusion : The highest incidence of postoperative delirium was hypoactive (14%[95%CI,12-16%]), followed by hyperactive (12%[95%CI,10-14%]), and the lowest was mixed delirium(9%[95%CI,7-11%]). Therefore, it is definitely necessary to update and unify the diagnosis of delirium subtypes based on current tremendous clinical research, thus controlling and adjusting the risk factors of subtypes to reduce the incidence of postoperative delirium and improve patients' prognoses.
... According to the level of motor-activity disturbances, delirium is usually classified into four categories-hypoactive, hyperactive, mixed, or "no subtype". Hypoactive delirium is found to have worse outcomes, as it is often missed and misinterpreted as fatigue, depression, or dementia, due to its less characteristic psychomotor presentation [2,3]. ...
Background:
Previous research confirmed association between delirium and subsequent dementia in different clinical settings, but the impact of post-stroke delirium on cognitive functioning is still under-investigated. Therefore, we aimed to assess the risk of dementia among patients with stroke and in-hospital delirium.
Methods:
A total of 750 consecutive patients admitted to the stroke unit with acute stroke or transient ischemic attacks were screened for delirium, during the first seven days after admission. At the three- and twelve-month follow-up, patients underwent cognitive evaluation. The DSM-5 definition for dementia was used. Cases with pre-stroke dementia were excluded from the analysis.
Results:
Out of 691 included cases, 423 (61.22%) and 451 (65.27%) underwent cognitive evaluation, three and twelve months after stroke; 121 (28.61%) and 151 (33.48%) patients were diagnosed with dementia, respectively. Six (4.96%) patients with dementia, three months post-stroke did not meet the diagnostic criteria for dementia nine months later. After twelve months, 37 (24.50%) patients were diagnosed with dementia, first time after stroke. Delirium in hospital was an independent risk factor for dementia after three months (OR = 7.267, 95%CI 2.182-24.207, p = 0.001) but not twelve months after the stroke.
Conclusions:
Patients with stroke complicated by in-hospital delirium are at a higher risk for dementia at three but not twelve months post-stroke.
... Thus, the fact that early diagnosis could improve prognosis and mortality rates in hypoactive subtypes should be noted (20,21). However, there are studies which reported that there was no difference between the subtypes based on delirium prognosis (22). There are also studies reporting that it is not effective in preventing antipsychotics treatment for delirium. ...
... There are also studies reporting that it is not effective in preventing antipsychotics treatment for delirium. (22,23). ...
... It manifests as four forms: hyperactive (acute agitation, hallucinations and restlessness); hypoactive (decreased psychomotor activity, 'difficult to identify'); mixed (manifesting both hyperactive and hypoactive symptoms); 7 and 'no sub-type' (neither hyperactive or hypoactive delirium are present). 8 Delirium is associated with prolonged hospital stays, re-admissions, institutionalisation and long-term morbidity. 9 There is some evidence that octogenarian patients remember their delirium experience up to 12 months later, and emotional distress seems to influence the way patients cope with the experience in the long-term. ...
Background::
Delirium affects nearly half of octogenarian patients after aortic valve replacement, resulting in impaired cognition, reduced awareness and hallucinations. Although healthcare professionals and relatives are often present during episodes, the nature of interactions with them is scarcely studied, and little is known about their long-term experiences.
Purpose::
The purpose of this study was to explore and describe how octogenarian patients with post-aortic valve replacement delirium experience interactions with healthcare professionals and relatives within the first year and four years later.
Method::
An explorative design with qualitative content analysis was used. Delirium was assessed for five consecutive days after aortic valve replacement using the Confusion Assessment Method. Delirious patients ( n=10) were interviewed 6-12 months post-discharge and four years later ( n=5). We used an inductive approach to identify themes in transcribed interviews.
Findings::
An overarching theme emerged: ' Healthcare professionals' and relatives' responses made a considerable impact on the delirium experience postoperatively and in a long-term'. Three sub-themes described the patients' experiences: ' the need for close supportive care', ' disrespectful behaviour created a barrier' and ' insensitive comments made lasting impressions'. Having healthcare professionals and relatives nearby made the patients feel secure, while lack of attention elevated patients' emotional distress. Four years later, patients clearly recalled negative comments and unsupportive actions in their delirious state.
Conclusions::
Healthcare professionals and relatives have an essential role in the aortic valve replacement recovery process. Inconsiderate behaviour directed at older patients in delirium elevates distress and has long-term implications. Supportive care focused on maintaining the patients' dignity and integrity is vital.
... inconsistent. According to a recent review, 5 there are only 9 studies that have specifically assessed the occurrence of delirium psychomotor subtypes in hip-fractured patients. Of these, only 3 focused on the association between the different subtypes and mortality, ultimately reaching contrasting conclusions. ...
... We acknowledge that classifications may be misleading in some cases. However, various methods have been used in previous studies to classify delirium psychomotor activity 5,22,[26][27][28] with no clear superiority of one method to the others. 22,28 Another limitation is that delirium psychomotor subtypes may have changed during the course of hospital admission, limiting our ability to classify delirium into stable psychomotor subtypes. ...
Objective
Studies exploring the incidence and impact of the psychomotor subtypes of postoperative delirium (POD) on the survival of hip fracture patients are few, and results are inconsistent. We sought to assess the incidence of POD subtypes and their impact, in addition to delirium duration, on 6‐month mortality in older patients after hip‐fracture surgery.
Methods
This is a prospective study involving 571 individuals admitted to an Orthogeriatric Unit within a 5‐year period with a diagnosis of hip fracture. Survival status was assessed 6 months after posthip fracture surgery. Postoperative delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Postoperative delirium subtypes were classified according to Lipowski's criteria. Cox regressions were used to evaluate the associations between POD subtypes, POD duration, and 6‐month mortality, adjusting for covariates.
Results
The incidence of psychomotor POD subtypes was hypoactive 57 (10.0%), hyperactive 84 (14.7%), and mixed 79 (13.8%). Six‐month mortality rates were 8.3%, 10.7%, 36.8%, and 29.1% in the no‐delirium, hyperactive, hypoactive, and mixed‐delirium subgroups, respectively. In adjusted models, the hypoactive subgroup (Hazard Ratio, HR = 3.14, 95% Confidence Intervals, CI, 1.63‐6.04) and mixed subgroup (HR = 2.89, 95% CI, 1.49‐5.62) showed high mortality rates and a significantly increased risk of mortality associated with POD duration as well.
Conclusions
Hyperactive delirium was the most common POD psychomotor subtype, but hypoactive and mixed POD were associated with 6‐month mortality risk. Moreover, the risk of death 6 months after surgery increased for both subgroups (hypoactive and mixed) with increasing duration of POD.
Introduction
Delirium is frequently multifactorial, and causes are often missed in clinical practice. The Aetiology in Delirium - Diagnostic Support Tool (AiD-DST) was developed to improve recognition of the causes. We undertook an evaluation of an electronic version of AiD-DST.
Methods
A development and evaluation life cycle of improvement was used. In phase 1, alpha testing among the development group evaluated technical performance of AiD-DST. In phase 2, we performed a cycle of beta testing among junior doctors to assess impressions of AiD-DST using Think Aloud methodology. We grouped responses into themes and made changes to AiD-DST by the development group accordingly. In phase 3, usability and acceptance of AiD-DST was assessed using the mHealth App Usability Questionnaire (MAUQ).
Results
In phase 1, software issues were identified, and modifications made. In phase 2, feedback was obtained from 29 junior doctors. Three cycles of feedback were obtained. The number of items identified after each cycle were 20, 12 and 7, respectively. Content was grouped into themes of; ‘style and grammar’, ‘formatting’, ‘IT’, ‘missed diagnosis’ and ‘other concerns.’ In phase 3, 20 participants completed MAUQ questionnaire. Overall, the average score was 6.36 (SD=0.8) with 7 as the highest attainable score. This translates to agreement up to strong agreement concerning usability of AiD-DST.
Conclusion
After a process of optimisation, AiD-DST has been shown to be a usable and potentially useful diagnostic support tool to help junior doctors identify cause(s) of delirium. An implementation study is planned.
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.
Importance:
Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.
Objective:
To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.
Evidence review:
A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.
Findings:
A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.
Conclusions and relevance:
In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
