"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Il principio dell'appropriatezza clinica quale criterio di erogazione della prestazione medica

Nell\u2019ambito di una ricerca multidisciplinare volta a sviscerare ed affinare il concetto di appropriatezza in medicina, assurto a pilastro di riferimento della buona pratica clinica negli ultimi decenni, si ravvede la necessit\ue0 di declinare l\u2019operato del medico nelle molteplici dimensioni clinica, organizzativa, etica e deontologica in cui tale agire si trova strutturato, al fine di esplicitare le varie istanze che concorrono, possibilmente in accordo tra loro, a definire la prescrizione medica in relazione alle richieste ed alle necessit\ue0 del paziente-persona affidatogli. Il progressivo superamento della concezione paternalistica dell\u2019operato medico, il passaggio dalla figura del medico-condotto, attore solitario di un monologo privo di dialogo, alla logica dell\u2019equipe multidisciplinare, e la ricerca di un confronto e di una compartecipazione diretta medico-paziente ha richiesto una revisione dei pilastri fondanti l\u2019appropriatezza della pratica clinica e l\u2019approdo ad una dimensione scientifica letteraria globalmente condivisa che costituisce terreno di incontro e scontro tra professionisti e riveste una valenza clinica e giuridica non trascurabile. Lo spread ubiquitario delle Medicine Complementari e Alternative (CAM), in risposta alle criticit\ue0 sollevate dai pazienti nei confronti della Medicina Occidentale Convenzionale, richiede una attenta analisi degli strumenti di critical appraisal della metodologia intrinseca delle CAM ed una definizione a tutto tondo della situazione sociale e storica in cui le CAM trovano terreno fertile e soddisfano le richieste in primo luogo di ascolto ed approccio empatico cui la Medicina Convenzionale iperspecialistica e tecnocentrica talora non d\ue0 giusto spessore . Inoltre detta presentazione si propone di evidenziare le problematiche connesse al sovrautilizzo di prestazioni sanitarie inappropriate per paziente e setting assistenziale, con ricadute significative in termini di violazione dell\u2019identit\ue0 etico-fisica del paziente ed economicit\ue0, con dispendio improprio di risorse sanitarie. Infine ci siamo proposti di analizzare le ragioni molteplici che sostengono e alimentano le conflittualit\ue0 tra medico e paziente e tra colleghi medici di diversa estrazione specialistica. Si sottolinea, inoltre, la necessit\ue0 imprescindibile di \u201cempowerment\u201d dei professionisti sanitari e dei pazienti stessi, ossia di potenziamento delle conoscenze di quest\u2019ultimi in termini di risorse sanitarie disponibili, appropriatezza clinica ed organizzativa al fine di consentire loro di richiedere prestazioni appropriate nel setting appropriato, contrastando messaggi talvolta fuorvianti sostenuti dalla consultazione priva di filtri dei mass media e della rete informatica, vagliati dal paziente senza competenze specifiche in ambito medico-giuridico. Stilare obbiettivi terapeutici realistici e titolati sul potenziale recupero del paziente in esame e prescindere da una medicina difensivistica si propongono nella trattazione come strumenti per favorire anche una maggior integrazione tra colleghi professionisti e indubbiamente favorire un miglior utilizzo razionalizzato delle risorse disponibili. Si esplicita sin d\u2019ora che rimandi ad aspetti prettamente giuridici di diritto sanitario e analisi delle ripercussioni giuridiche del concetto di appropriatezza in sanit\ue0 sono oggetto di trattazione in altri capitoli di questo volume, nei confronti dei quali questo capitolo si pone come complementare, quale osservatore privilegiato del punto di vista del clinico che si trova ad operare nella realt\ue0 odierna

Post-operaqtive residual curarization (PORC): a big issue for patients' safety

Post-operaqtive residual curarization (PORC): a big issue for patients' safet

Peri-operative risk management in patients with Alzheimer disease

The aim of this review is to identify an evidence-based perioperative management for patients affected by Alzheimer's disease (AD) that are scheduled to undergo surgery. This will minimize the negative effects of anesthesia and postoperative sedation and correct those perioperative variables possibly responsible for a decline in cognitive status and a worsening of AD. We here gather evidence on the importance of correct preoperative assessment regarding cognitive and functional status and the presence of preoperative delirium. The potential role of anesthesia, surgery, and postoperative analgosedation as risk factors for development of delirium are herein outlined. Finally, pain assessment instruments, as well as principles of management strategies for postoperative delirium in subjects with AD, are suggested

Psychometric properties and validation of the Italian version of the Mainz pain staging system as a tool for pain-patients referral selection.

Rationale, aims and objectivesIndications are lacking on which patient to refer to pain facilities. Pain-chronicity stage and outcome prognosis may be used for such aims. The Mainz pain-staging system (MPSS) classifies pain patients in three chronicity stages that respectively require more extensive management. We explored the psychometric and validation properties of its Italian version towards its application as screening/referral tool. MethodsI-MPSS was administered to n=120 mixed non-cancer-pain outpatients. Psychometric analyses and formal validation included: content validity, by assessing the hypothesis of an existing relationship between the I-MPSS classes and criteria derived from an operational case definition of chronic pain; construct validity, by principle component analysis (PCA); the autonomous construct of the I-MPSS was assessed by the strength of the Spearman correlation between its classes and the brief pain inventory (BPI) items; and reliability, by applying Cronbach's alpha statistics. Associations between psychosocial moderators and the I-MPSS were assessed applying (2) analyses. ResultsQuantitative and qualitative analyses showed significant differences between I-MPSS classes for health care and drug utilization; BPI item scores significantly differed between the classes; Spearman correlation between I-MPSS classes and BPI items was mostly moderate or mild. PCA and scree test identified four components accounting for 63.7% of the variance. Cronbach's alpha was 0.842. ConclusionsThe I-MPSS showed satisfactory psychometric and validation properties. With adequate feasibility, it enabled the screening of mixed non-cancer-pain outpatients in three chronicity/prognostic stages. Results are sufficient to warrant its use for a subsequent impact study as a prognostic model and screening tool for referring pain patients