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Delirium after cardiac surgery: A critical review

Numerous articles have been published investigating the incidence of and risk factors for delirium after cardiac surgery. Smith and Dimsdale reviewed the literature on postcardiotomy delirium in 1987 using a meta-analysis of 44 research studies. However, doubts about their methods and results caused the authors to re-examine the literature using these 44 references as well as computerized literature searches to gather research and review papers from medical journals. Delirium after cardiac surgery appeared to be ill-defined in most of these studies. The methods and instruments used to assess delirium proved to be very different, and the patient samples were rather heterogeneous. Therefore, in most cases, the results are not comparable. Only a small number of the studies that were examined fit the criteria for statistical meta-analysis. On the basis of our analysis, a tentative conclusion may be drawn that the incidence of postcardiotomy delirium has declined slightly and that no strong risk factors have yet been identified

Delirium after cardiac surgery : a prospective study

Delirium was one of the first mental disorders described by the ancient medical writers some 2500 years ago [1]. In his extensive and excellent monograph "Delirium: Acute Confusional States", Lipowski describes the historical development of the concept of this disorder in detail, from the time of Hippocrates till the twentieth century [IJ. His most important and remarkable finding in tracing the history of delirium is the accuracy and consistency of the clinical description, despite the confusing variety of terms applied over the centuries to the same set of symptoms. Hereafter, the most important facts from his historical outline on delirium will be summarized [1]. At first, in antiquity, what nowadays is called delirium was referred to as 'phrenitis'. It was regarded as an acute mental disorder usually associated with fever and characterized by cognitive and behavioural disturbances as well as disruption of sleep. Phrenitis was described as marked by restless and excited behaviour, while 'lethargus', considered as the opposite of phrenitis, featured listlessness, sleepiness, inertia, memory loss and dulling of the senses. Lethargus could change into phrenitis and vice versa. Only in the late eighteenth century the word delirium gradually came to replace both of the earlier terms. Celsus was the first medical 'Writer known to use the term 'delirium'. He, as the other ancient medical 'Writers, recognized delirium or phrenitis as one of the most important mental disorders at that time

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Excess mortality in general hospital patients with delirium: A 5-year follow-up of 519 patients seen in psychiatric consultation

Mortality was determined in 519 patients with delirium who were seen in psychiatric consultation in two general hospitals. Among 419 patients with simple delirium (DSM-III: 293.00) in-hospital mortality was 26%. As compared to average hospital patients the age adjusted in-hospital excess mortality ratio varied from 6.2 for patients with malignancies to 2.1 for patients with motor system disease. After hospital discharge the 5-yr cumulative mortality was 51%. As compared to the general population excess mortality was noted in most, but not in all diagnostic subgroups. The age and sex adjusted excess mortality ratio varied from 14.1 for malignancies to 1.3 for motor system disease. The figures underline a general notion that delirium may be an indicator of disorders of grave prognosis, but mortality appears to depend more on the medical condition than on the presence of delirium

A double blind, fixed blood-level study comparing mirtazapine with imipramine in depressed in-patients

Antidepressant effects of mirtazapine and imipramine were compared in a randomized, double blind, fixed blood-level study with in-patients in a single centre. Patients with a DSM-III-R diagnosis of major depression and a Hamilton (17-item) score of ≤ 18 were selected. After a drug-free and a placebo-washout period of 7 days in total, 107 patients still fulfilling the HRSD criterion of ≤ 18, started on active treatment. The dose was adjusted to a predefined fixed blood level to avoid suboptimal dosing of imipramine. Concomitant psychotropic medication was administered only in a few cases because of intolerable anxiety or intolerable psychotic symptoms. Eight patients dropped out and two were excluded from analyses because of non-compliance; 97 completed the study. According to the main response criterion (50% or more reduction on the HRSD score) 11/51 (21.6%) patients responded on mirtazapine and 23/46 (50%) on imipramine after 4 weeks' treatment on the predefined blood level. Such a dramatic difference in efficacy between antidepressants has not often been reported before. The selection of (severely ill) in-patients, including those with suicidal or psychotic features, may have significance in this respect. Optimization of treatment with the reference drug imipramine through blood level control, exclusion of non-compliance for both drugs, exclusion of most concomitant medication and a low drop-out rate may also have contributed. It is concluded that imipramine is superior to mirtazapine in the patient population studied

Yield and costs of direct and stepped screening for depressive symptoms in subjects aged 75 years and over in general practice

OBJECTIVE To examine yield and costs of two screening methods for depressive symptoms in subjects ≥75 years in general practice. METHODS In 73 general practices of 12.144 registered subjects ≥75 years 10.681 could be invited for screening. In the first 31 practices we invited 3797 subjects for direct screening which implied an invitation by letter followed by a home visit to administer the 15-item Geriatric Depression Scale (GDS-15). In the remaining 42 practices 6884 subjects were invited for stepped screening which implied that the GDS-15 was sent by post, followed by a home visit only if the self-administered GDS-15-score was ≥ 4 points. Being screen-positive for depressive symptoms was defined as an interviewer-administered GDS-15-score ≥5 points. Screening costs were estimated based on results in this study. RESULTS Of all registered subjects 707 (5.8%) were already being treated for depression. The yield of direct screening was higher than of stepped screening (2.6% versus 1.9%, p = 0.009), with similar yields for subjects aged 75-79 years and for subjects aged ≥80 years. In a standard GP-practice with 160 subjects ≥75 years estimated total screening costs are about twice as high for direct screening than for stepped screening. Estimated costs per screen positive subject are €350 for direct screening and €250 for stepped screening. CONCLUSION Direct screening has a higher yield, but is also more time consuming and more expensive. Whether the extra yield is clinically relevant and worth the extra costs, will depend on the subsequent treatment effect. Trial registration: www.controlled-trials.com/ISRCTN 71142851 Copyright © 2010 John Wiley & Sons, Ltd.Medical Decision Makin

Optimal screening for increased risk for adverse outcomes in hospitalised older adults

Background: screening for frailty might help to prevent adverse outcomes in hospitalised older adults. Objective: to identify the most predictive and efficient screening tool for frailty. Design and setting: two consecutive observational prospective cohorts in four hospitals in the Netherlands. Subjects: patients aged ≥70 years, electively or acutely hospitalised for ≥2 days. Methods: screening instruments included in the Dutch Safety Management Programme [VeiligheidsManagementSysteem (VMS)] on four geriatric domains (ADL, falls, undernutrition and delirium) were used and the Identification of Seniors At Risk, the 6-item Cognitive Impairment Test and the Mini-Mental State Examination were assessed. Three months later, adverse outcomes including functional decline, high-healthcare demand or death were determined. Correlation and regression tree analyses were performed and predictive capacities were assessed. Results: follow-up data were available of 883 patients. All screening instruments were similarly predictive for adverse outcome ( predictive power 0.58–0.66), but the percentage of positively screened patients (13–72%), sensitivity (24–89%) and specificity (35–91%) highly differed. The strongest predictive model for frailty was scoring positive on ≥3 VMS domains if aged 70–80 years; or being aged ≥80 years and scoring positive on ≥1 VMS domains. This tool classified 34% of the patients as frail with a sensitivity of 68% and a specificity of 74%. Comparable results were found in the validation cohort. Conclusions: the VMS-tool plus age (VMS+ ) offers an efficient instrument to identify frail hospitalised older adults at risk for adverse outcome. In clinical practice, it is important to weigh costs and benefits of screening given the rather low-predictive power of screening instruments

The Meta VCI Map consortium for meta-analyses on strategic lesion locations for vascular cognitive impairment using lesion-symptom mapping: design and multicenter pilot study

Introduction: The Meta VCI Map consortium performs meta-analyses on strategic lesion locations for vascular cognitive impairment using lesion-symptom mapping. Integration of data from different cohorts will increase sample sizes, to improve brain lesion coverage and support comprehensive lesion-symptom mapping studies. Methods: Cohorts with available imaging on white matter hyperintensities or infarcts and cognitive testing were invited. We performed a pilot study to test the feasibility of multicenter data processing and analysis and determine the benefits to lesion coverage. Results: Forty-seven groups have joined Meta VCI Map (stroke n = 7800 patients; memory clinic n = 4900; population-based n = 14,400). The pilot study (six ischemic stroke cohorts, n = 878) demonstrated feasibility of multicenter data integration (computed tomography/magnetic resonance imaging) and achieved marked improvement of lesion coverage. Discussion: Meta VCI Map will provide new insights into the relevance of vascular lesion location for cognitive dysfunction. After the successful pilot study, further projects are being prepared. Other investigators are welcome to join