Delirium is associated with high mortality in older adult ...

Delirium is associated with high mortality after cardiac surgery. However, evidence on the epidemiology of delirium in patients with acute ... Skiptomaincontent Advertisement SearchallBMCarticles Search DownloadPDF Researcharticle OpenAccess Published:03December2020 Deliriumisassociatedwithhighmortalityinolderadultpatientswithacutedecompensatedheartfailure MisunPak1,MasahikoHara2,3,ShokoMiura4,MotohideFuruya4,MasatakeTamaki3,5,TaijiOkada1,NobuhideWatanabe1,AkihiroEndo1&KazuakiTanabe1  BMCGeriatrics volume 20,Article number: 524(2020) Citethisarticle 1724Accesses 2Citations 1Altmetric Metricsdetails AbstractBackgroundDeliriumisassociatedwithhighmortalityaftercardiacsurgery.However,evidenceontheepidemiologyofdeliriuminpatientswithacutedecompensatedheartfailure(ADHF)islimited.ThisstudyaimedtoassesstheincidenceandprognosticimpactofdeliriuminpatientswithADHF.MethodsThissingle-centerprospectiveobservationalstudyenrolled132consecutivepatientswithADHF.WeutilizedtheDiagnosticandStatisticalManualofMentalDisorders,fiftheditionandclassifiedthepatientsintotwogroupsaccordingtothepresenceorabsenceofdelirium.Theprimaryendpointwas90-dayall-causemortality.TheprognosticimpactandriskfactorsofdeliriumwereevaluatedusingmultivariableCoxandlogisticregressionanalyses,respectively.ResultsThemedianpatientagewas83(interquartilerange,75–87)years.Approximately51.5%weremen.Deliriumoccurredin36(27.3%)patients,andhyperactivedeliriumwasthemostfrequenttype(86.1%).The90-dayall-causemortalitywashigherinthepatientswithdeliriumthaninthosewithout(21.6%versus3.9%,log-rankp = 0.002).Deliriumwasassociatedwithhighermortalitywithanadjustedhazardratioof6.8(95%confidenceinterval,1.1–42.6,p = 0.042).Theriskfactorsassociatedwithdeliriumincludedadvancedage,malesex,higherclinicalfrailtyscalescore,anddementia.ConclusionsDeliriumwasassociatedwithahigher90-dayall-causemortalityintheolderadultpatientswithADHF.Hyperactivedeliriumwasthemostcommonsubtype. PeerReviewreports BackgroundDeliriumisoneofthemostcommonmentaldisordersandischaracterizedbyadisturbanceinconsciousness,whichdevelopsinashortperiodoftime[1].Itiscommonlyencounteredinavarietyofclinicalsettingsandconditions,includingheartdiseases,andadvancedageisoneofitsmostknownriskfactors[2].Thenumberofpatientswithacutedecompensatedheartfailure(ADHF)hasrecentlybeenincreasingworldwideowingtotheincreasedprevalenceofischemicandnon-ischemicheartdiseaseswithaging.Itisimportantforcardiologistsandcardiacsurgeonstoinvestigatetheepidemiologyofdeliriumandfurtherdetermineappropriatewaystomanageitbecausethisconditionisassociatedwithapoorprognosis[3,4].Postoperativedeliriuminthecontextofcardiacsurgery,isassociatedwithprolongedhospitalstayaswellashighershort-andlong-termmortalityrates[5,6,7].However,onlyafewstudieshaveinvestigatedtherelationshipbetweendeliriumandprognosisinpatientswithADHF,withmajorityofthereportedevidencederivedfromretrospectivestudies[4,5,6,7].Theprognosisofpatientswithdeliriumdependsonitssubtype,whichisdividedinto3categories:hyperactive,hypoactive,andmixed[1,8].Hypoactivedeliriumismostcommonlyobservedinpatientsaftercardiacsurgery,andtheprognosisofthesepatientsisworsethanthatofpatientswithhyperactivedelirium[5,9].Inaddition,theincidenceofeachsubtypeofdeliriumdiffersamongunderlyingclinicalconditions,andevidenceontheprognosisofeachsubtypehasnotbeenfullyestablishedinpatientswithADHF[10].Inthiscontext,theobjectiveofthissingle-centerprospectiveobservationalstudywastoinvestigatetheepidemiologyofdeliriuminpatientswithADHF,i.e.,incidence,prognosticimpactofdeliriumonmortality,andriskfactorsfordelirium.MethodsStudypopulationThissingle-centerprospectiveobservationalstudyenrolled132consecutiveadultpatients(age,> 18 years)admittedwithADHFatShimaneUniversityHospitalbetweenJanuary1toOctober31in2018.Herein,wedefinedADHFasrapidworseningofheartfailuresymptomswithaneedforhospitalizationtomanageperfusionfailureorseveredyspnea.Thepatientsreceivedstandardtreatmentforheartfailurebasedontheirclinicalprofiles,accordingtothepresenceorabsenceofcongestion(describedas“wet”vs.“dry”ifpresentvs.absent)andhypoperfusion(describedas”cold”vs.“warm”ifpresentvs.absent)asdeterminedintheinternationalguidelinesforthemanagementofADHF[11].Briefly,bedsidephysicalexaminationidentifiesthecombinationoftheseoptions,whichincludesfourclinicalphenotypes:warmandwet(wellperfusedandcongested);coldandwet(hypoperfusedandcongested);coldanddry(hypoperfusedwithoutcongestion);andwarmanddry(compensated,wellperfusedwithoutcongestion)[11].Thedecisionforhospitalizationortreatmentstrategieswasmadeattheattendingphysician’sdiscretion.ThestudyprotocolcompliedwiththeHelsinkiDeclarationstandardsandwasapprovedbytheinstitutionalreviewboardofShimaneUniversityHospital.Therequirementforwritteninformedconsentwaswaivedinthisstudy.Theethicalcommitteereachedthisrecommendationbecausethisstudyemployedanobservationaldesignwithoutanypre-specifiedinterventionsforthestudypatients.However,therighttorejecttheenrolmentwasguaranteedbytheopt-outoptioninthestudyprotocol,whichwasrelayedtothepatients,theirfamilymembers,orproxy.ThisstudywasregisteredwiththeUniversityHospitalMedicalInformationNetworkClinicalTrialsRegistry,asacceptedbytheInternationalCommitteeofMedicalJournalEditors(UMIN000032646).DiagnosisandtreatmentofdeliriumThepresenceofdeliriumwasassessedeverydaybyadoctorornursefor14 daysafterthehospitalizationusingtheDiagnosticandStatisticalManualofMentalDisorders,fifthedition(DSM–5)[1].ThesubtypesofdeliriumwerealsoevaluatedusingtheDSM–5.Hyperactivedeliriumisdescribedasadisruptiveandcombativebehavior,particularlycharacterizedbyagitation,suchasrestlessness;hypoactivedeliriumisdescribedasadecreasedamountofactivity,suchaslistlessness;andmixeddeliriumhasbothfeatures[1,9].Consultationtoapsychiatristwasmadeasnecessary.Somepatientstookoralsedative–hypnoticdrugs,suchasramelteonandbenzodiazepines.Theprescriptionwascompletelyatthediscretionoftheattendingphysician.Ramelteonwasusedforregulatingcircadiansleep-wakerhythm,andbenzodiazepineswereusedforthemanagementofanxietyandinsomniaassociatedwithADHFsymptoms,butnotforthemanagementofdelirium.Intravenoussedativemedications,suchasdexmedetomidineandpropofol,wereadministeredforrespiratorymanagementtopatientswhoreceivednon-invasivepositivepressureventilation(NIPPV)andthosewhowereintubated.Whenthepatientsbecamedelirious,wemanageddeliriumasfollows.First,non-pharmacologicaltreatmentsfordeliriumwereprovidedtoallpatients.Theyincludedreorientationandenvironmentalinterventions,suchasproperpatientcaresettingswithlow-levellightingandminimalnoisetoavoidsleepinterruptionatnight[12].Whennon-pharmacologicaltreatmentswereinsufficient,pharmacologicaltreatments,suchasoralantipsychoticdrugs,includingrisperidone,wereadditionallyconsideredandprovided.Whenagitationwassevere,temporalphysicalrestraintswereintroducedfollowingclinicalpracticeguidelinesbytheAmericanCollegeofCriticalCareMedicineTaskForce,butheldtoaminimum[13].Forexample,weintroducedrestraintsonlyifpatientswerestillinterferingwiththetreatment,suchasself-removaloftheinfusionrouteortrachealtube,evenafterremovalofasmuchenvironmentalriskscausingdeliriumaspossible.Regardlessofstudyenrolment,ethicalapprovalandwritteninformedconsentbypatients,theirfamilymembersorproxyweremandatoryforrestraintsandtakenatthetimeofadmissionasaroutineclinicalpracticeatourinstitution.Everykindofrestraintshouldbediscussedbytheattendingmedicalstaff,includingdoctorsandnurses,beforeintroductiontothepatients.Restraintsusuallystartedfromabed-fence,withthedegreeofsuppressiongraduallyincreasing,suchasusingmittens,asappropriate.StatisticalanalysisTheprimaryendpointwassetasthe90-dayall-causemortalityandthesecondaryendpointasthecumulativeincidenceofdeliriumfromthedayofadmission.Theincidenceofeachsubtypeofdeliriumwasalsorecorded.Continuousvariableswereexpressedasmedians(interquartilerange[IQR,25thto75thpercentiles])andcategoricalvariablesasabsolutenumbers(percentages).Thestudypopulationwasclassifiedintotwogroupsaccordingtothepresenceorabsenceofdeliriumduringhospitalizationtoassesstheprognosticimpactofdelirium.ComparisonofdatabetweenthetwogroupswasperformedusingtheWilcoxonranksumtestforcontinuousvariablesandchi–squaretestforcategoricalvariables.Kaplan–Meieranalysiswasemployedtoestimatethe90-dayall-causemortalityandcumulativeincidenceofdeliriumwiththecorresponding95%confidenceinterval(CI).Thedifferenceinthe90-dayall-causemortalitybetweenthetwogroupswasevaluatedusingalog–ranktest.TheprognosticimpactofdeliriumandriskfactorsassociatedwithdeliriumwereevaluatedusingunivariableandmultivariableCoxregressionandlogisticregressionanalyses,respectively.Explanatoryvariableswereselectedclinicallyconsideringpreviousreports.AllstatisticalanalyseswereconductedusingMicrosoftROpenversion3.3.2,andp-valuesof65yearsofagewithacutedecompensatedheartfailure.AmJCardiol.2011;108:402–8.Article  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DownloadreferencesAcknowledgementsWeexpressourheartfeltgratitudetotheJapanSocietyofClinicalResearchforitsdedicatedsupport.FundingNone.AuthorinformationAffiliationsDepartmentofCardiology,ShimaneUniversityFacultyofMedicine,89–1Enya–cho,Izumo,Shimane,693–8501,JapanMisunPak, TaijiOkada, NobuhideWatanabe, AkihiroEndo & KazuakiTanabeCenterforCommunity-BasedHealthcareResearchandEducation,ShimaneUniversity,Izumo,JapanMasahikoHaraDepartmentofClinicalInvestigation,JapanSocietyofClinicalResearch,Osaka,JapanMasahikoHara & MasatakeTamakiDepartmentofPsychiatry,ShimaneUniversityFacultyofMedicine,Izumo,JapanShokoMiura & MotohideFuruyaDepartmentofMinimallyInvasiveSurgicalandMedicalOncology,FukushimaMedicalUniversity,Fukushima,JapanMasatakeTamakiAuthorsMisunPakViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMasahikoHaraViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarShokoMiuraViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMotohideFuruyaViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMasatakeTamakiViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarTaijiOkadaViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarNobuhideWatanabeViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarAkihiroEndoViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarKazuakiTanabeViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarContributionsMP,MHandMTcontributedtotheconceptionanddesignofthework.MP,SM,MF,MT,TO,NW,AE,andKTcollectedtheclinicaldata.DataanalysesweremainlyperformedbyMPandMH,andMP,MH,SM,MF,MT,TO,NW,AE,andKTinterpretedthesedata.MP,MHandMTcontributedtothefirstdraftingandMP,MH,SM,MF,MT,TO,NW,AE,andKTrevisingthemanuscriptcriticallyforimportantintellectualcontent.Allauthorshavereadandagreedtothecontentsofthemanuscript.CorrespondingauthorCorrespondenceto MisunPak.Ethicsdeclarations Ethicsapprovalandconsenttoparticipate ThestudyprotocolcompliedwiththeHelsinkiDeclarationstandardsandwasapprovedbytheinstitutionalreviewboardofShimaneUniversityHospital.Writteninformedconsentwassubstitutedbyanopt-outfashionaccordingtotherecommendationoftheethicalcommitteebecausethisstudyemployedanobservationaldesign,whichprovidedpatientswithnointerventions,andpatientswithdeliriumcouldnotvoluntarilyconsentbythemselves.ThisstudywasregisteredwiththeUniversityHospitalMedicalInformationNetworkClinicalTrialsRegistry,asacceptedbytheInternationalCommitteeofMedicalJournalEditors(UMIN000032646). Consentforpublication Notapplicable. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. 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ReprintsandPermissionsAboutthisarticleCitethisarticlePak,M.,Hara,M.,Miura,S.etal.Deliriumisassociatedwithhighmortalityinolderadultpatientswithacutedecompensatedheartfailure. BMCGeriatr20,524(2020).https://doi.org/10.1186/s12877-020-01928-7DownloadcitationReceived:02August2020Accepted:23November2020Published:03December2020DOI:https://doi.org/10.1186/s12877-020-01928-7SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsAcutedecompensatedheartfailureHyperactivedeliriumClinicalfrailtyscaleDementia DownloadPDF AssociatedContent Section Neurology,strokeandcognition Advertisement BMCGeriatrics ISSN:1471-2318 Contactus Submissionenquiries:[email protected] Generalenquiries:[email protected]