Acute hospitals have seen unprecedented demographic changes, where older age, frailty and cognitive impairment now characterise the majority of health service users. Delirium is very common in this setting, and adverse outcomes are well described. However, studies investigating cognitive outcomes after delirium in unselected samples have been lacking. This thesis had four objectives: (1) To estimate the prevalence of delirium in the general population (2) To assess the association of delirium with cognitive outcomes (3) To investigate how these associations relate to underlying dementia pathology (4) To develop novel methods for retrospectively ascertaining delirium. Methods: Data from three population-based neuropathology cohort studies were used: Vantaa 85+; Cambridge City over-75s Cohort (CC75C); MRC Cognitive Function and Ageing Study (CFAS). (1) To ascertain the prevalence of delirium in the general population, a measure of delirium was developed using data recorded in standardised interview schedules, with criterion validity evaluated through the association with mortality and dementia risk. (2) The association with cognitive outcomes was tested in a series of logistic regression models, where delirium was the exposure and dementia (or worsening dementia severity) was the outcome. In addition, the association with change in Mini-Mental Status Examination (MMSE) score was assessed using random-effects linear regression. (3) In brain donors from all three cohorts, the independent effects of delirium, dementia pathology, and their interaction, were investigated using the same approach. (4) A chart-based method for deriving a retrospective diagnosis for delirium was developed, validated against bedside psychiatrist diagnosis. Vignettes from the medical record were abstracted and delirium status decided by expert consensus panel. Results: (1) Age-specific prevalence in CFAS increased with age from 1.8% in the 65-69 year age group to 13.5% in the ≥90 age group (p<0.01 for trend). (2) Delirium was consistently associated with adverse cognitive outcomes: new dementia (OR 8.7, 95% CI 2.1 to 35); worsening dementia severity (OR 3.1, 95% CI 1.5 to 6.3); faster change in Mini-Mental Status Examination (MMSE) score (1.0 additional points/year, p<0.01) (3) In the neuropathology analyses, decline attributable to delirium was -0.37 MMSE points/year (p<0.01). Decline attributable to dementia pathology was -0.39 MMSE points/year (p<0.01). However, the combination of delirium and dementia pathology resulted in the greatest decline, where the interaction contributed a further -0.16 MMSE points/year (p=0.01), suggesting that delirium worsened cognitive trajectories in dementia, but through distinct pathophysiological pathways not accounted for by Alzheimer’s, vascular or Lewy body pathology. (4) The chart abstraction method yielded a sensitivity of 0.88 and specificity 0.75 for ‘possible delirium’, with lower sensitivity (0.58) and higher specificity (0.93) for ‘probable delirium’ (AUC 0.86, 95% CI 0.82 to 0.89). This thesis adds to the small body of work on delirium in prospective studies, with the first ever analyses conducted in whole populations. The findings suggest new possibilities regarding the pathology of cognitive impairment, positioning delirium and/or its precipitants as a critically inter-related mechanism.

Orientador: Norma Sueli Pinheiro Módolo / Resumo: Introdução: A última atualização demográfica do Instituto Brasileiro de Geografia e Estatística realizada em 2017 mostrou que a população acima de 60 anos representava 14,6% dos 207,1 milhões de habitantes do Brasil, o que corresponde a aproximadamente 30 milhões de idosos, com expectativa de vida de 75,8 anos. Entre 2007 e 2011, o número acumulado de internações por fraturas de fêmur em pacientes acima de 60 anos, nos hospitais do Sistema Único de Saúde, foi de 175.781 O delirium pós-operatório é uma complicação comum nos pacientes idosos, e está associado a hospitalizações prolongadas, maiores taxas de institucionalização após a alta, deterioração cognitiva prolongada, diminuição da capacidade funcional, além de ser fator independente de mortalidade em 6-12 meses. Estudo disponível na literatura mostra que 14 a 24% dos pacientes idosos com fratura de quadril apresentam delirium já na admissão hospitalar, sendo que a prevalência durante a internação chega a 56%. Os mecanismos fisiopatológicos do desenvolvimento do delirium pós-operatório (DPO) e do déficit cognitivo pós-operatório têm sido estudados em nível molecular, porém ainda com pouco ganho. Maiores esforços de pesquisa são colocados na identificação de biomarcadores diagnósticos e prognósticos que estejam relacionados com mecanismos moleculares que levam ao DPO. Objetivos: Primariamente, relacionar os níveis séricos de dois biomarcadores de neuroinflamação (S100B e enolase neurônio-específica) com a ocorrência de deli... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Background: According to the latest census from IBGE (Instituto Brasileiro de Geografia e Estatística), population over 60 years-old accounted for 14,3% of a total 204,9 million habitants in Brazil. From 2007 to 2011, 175.781 elder patients were admitted after a hip fracture in brazilian public hospitals. Post-operative delirium (POD) is an usual complication in the elderly and is associated to longer hospital stay, cognitive impairment, functional decline and increased 6-12 months mortality rate. Delirium rates between the elder population can be as high as 14 to 24% already at admission, being the prevalence as high as 56% during hospital stay. Pathophysiologic mechanisms of delirium have been studied at molecular level, but research efforts are still needed in order to develop sensitive and specific early markers for this condition, so that diagnosis and effective treatment would be readily given. Objectives: This research project aims to correlate two neuroinflamation biomarkers serum levels (S100B protein and Neuron Specific Enolase - NSE) and the incidence of pre and postoperative delirium in elderly patients undergoing hip fracture repair. Also, we intent to evaluate how gender, ASA Physical Status classification and perioperative hypotension may contribute to changes in the levels of these biomarkers. Methods: An observational prospective study was proposed envolving patients aged 60 or more who were admitted at Clinics Hospital of Botucatu Medical School (Botucatu, S... (Complete abstract click electronic access below) / Doutor

Introduktion/Bakgrund: Postoperativt delirium är en vanligt förekommande komplikation hos äldre patienter efter höftfraktur som kan få flertal negativa följder både för patienten och hälso- och sjukvården. Syfte: Syftet med litteraturstudien var att belysa riskfaktorer sjuksköterskan kan identifiera för postoperativt delirium hos äldre patienter med höftfraktur. Metod: Studiens metod var utformad enligt Polit och Becks (2017) nio steg för att utföra en litteraturstudie. Litteratursökning i databaserna CINAHL och PubMed och relevans- samt kvalitetsgranskning resulterade i tio kvantitativa artiklar som resultatet baserats på. Artiklarnas data bearbetades och analyserades induktivt och två huvudkategorier framkom som sedan delades in i sju underkategorier. Resultat: Huvudkategorierna som framkom fokuserade på sjuksköterskans identifiering av preoperativa och postoperativa riskfaktorer för postoperativt delirium efter en höftfraktur. Resultatet visade de främsta riskfaktorerna för att utveckla postoperativt delirium. Slutsats: Det framkom att det fanns flertal riskfaktorer för att utveckla postoperativt delirium efter en höftfraktur. Detta belyste sjuksköterskans viktiga roll i arbetet att identifiera dessa riskfaktorer hos patienter för att upptäcka postoperativt delirium i tid

Previous research has shown increased saccade latencies in patients with Alzheimer’s disease and mild cognitive impairment; however, this is not well-understood in patients with delirium. The present study investigates eye-tracking metrics to evaluate the feasibility of using eye-tracking to discern delirious patients from disease control patients. We recruited 24 participants from the inpatient and intensive care units (ICU) at Massachusetts General Hospital (MGH) and assessed for delirium via CAM-S, a screening tool for delirium. Participants were instructed to follow a dot stimulus as it moves across the laptop screen as their eye movements were simultaneously tracked by a Tobii Pro Fusion eye-tracker. Our experimental paradigm involved gap saccades (central fixation extinguishes before the centrifugal target appears), overlap saccades (central fixation remains after centrifugal target onset), horizontal smooth pursuit, and circular smooth pursuit tasks. The eye-tracking metrics discussed in this study are the calibration and validation accuracies, saccade latencies and total target gaze duration. Our eye-tracking method was able to capture subjects’ gaze direction and path, but further research is needed to draw strong conclusions about the feasibility to detect oculomotor abnormalities in patients with delirium.

This thesis explores the topic of narrative in the context of musical composition. Narrative based music will be presented in relation to three ethical questions of Criticism, Commonality and Metaphor, communicated to the listener through the medium of narrative. This thesis will demonstrate how I have used these three questions in relation to my own compositional methodology and propose a world-building approach to musical composition, specifically in relation to Delirium; the magic, imagined world in which all my music is connected through a central narrative.

Bakgrund: På intensivvårdsavdelningen vårdas kritiskt sjuka eller skadade patienter. Upp till 80 % av patienterna som intensivvårdas drabbas under vårdtiden av intensivvårdsdelirium. Intensivvårdsdelirium är ett akut förvirringstillstånd som kännetecknas av ändrad medvetandenivå, avvikande beteende, nedsatt orienteringsförmåga och försämrade minnesfunktioner. Det finns tre olika tillstånd av intensivvårdsdelirium, en hyperaktiv form som innebär att patienten akut blir rastlös, motoriskt orolig och agiterad, en hypoaktiv form som innebär att patienten blir slö och sluten och en mixad form med inslag av både hyper- och hypoaktivt intensivvårdsdelirium. Intensivvårdsdelirium innebär ett stort lidande för patienten och för samhället ökade kostnader för hälso- och sjukvård. Syfte: Att beskriva intensivvårdssjuksköterskors erfarenheter av faktorer som berör intensivvårdsdelirium. Metod: En strukturerad litteraturstudie med systematisk ansats. Insamlad data analyserades enligt Bettany-Saltikov &amp; McSherrys (2016) metod. Resultat: I resultatet framkom två kategorier samt sju subkategorier. Kategorierna fick rubrikerna Faktorer som kan förebygga intensivvårdsdelirium och Faktorer som kan påverka intensivvårdsdelirium. I Faktorer som kan förebygga intensivvårdsdelirium beskriver intensivvårdssjuksköterskorna sina erfarenheter av förebyggande faktorer, bland annat hur vårdmiljön kan anpassas för att minska risken för intensivvårdsdelirium. Faktorer som kan påverka intensivvårdsdelirium handlar bland annat om viktiga faktorer som att ta sig tid att finnas vid patientens sida och samarbete med läkare och övriga kollegor. Slutsats: Resultatet visar att arbetet med intensivvårdsdelirium behöver förbättras. Framför allt behövs mer utbildning samt samsyn mellan kollegor och professioner. Vidare forskning inom området skulle kunna leda till ett minskat lidande för patienten och minskade kostnader för hälso- och sjukvård.

Purpose: The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery. Design: A retrospective, exploratory design was used. Methods: A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017. Findings: The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ2 = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ2 = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found. Conclusions: Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.

An estimated 50% of older hospitalized patients experience delirium. This has created significant complications costing an estimated $164 billion or more per year worldwide. The ability to identify patients developing delirium would allow the implementation of specific interventions to decrease or eliminate the adverse effects of delirium. The purpose of this quality improvement project was to provide high quality delirium education to determine if medical unit nursing staff could successful implement the Confusion Assessment Method (CAM) screening tool to identify patients experiencing delirium as the first phase of an overall plan. Implementation of the project followed Roger's diffusion of innovations theory. Patients were additionally screened for 5 potential risk factors of delirium from the multifactorial model of delirium to determine if delirium could be identified in the local population admitted to a single hospital. With a high quality education intervention, the staff nurses on the medical unit successfully implemented the CAM into their nursing practice and accurately identified delirium. Nurses identified delirium and subsyndromal delirium in 25% of the 208 patients in the study population. Consistent with the literature, patients who had a urinary catheter and experienced an iatrogenic event were predictors of delirium. An additional predictor of delirium, not included in the multifactorial model of delirium, included patients receiving benzodiazepines. This quality improvement project suggests that quality delirium education combined with the use of an accurate delirium detection tool could predict delirium accurately in the medical floor population. This has the potential to reduce the impact of delirium on patients, hospital staff, and reduce hospital expenditures.

Patients in hospital intensive care units are at increased risk to develop delirium, a condition which is characterized by a disturbance of consciousness and a change in cognition. Critical care nurses must have the knowledge to assess, recognize, and manage delirium. The purpose of this project was to develop an evidence-based policy for the assessment of delirium and a comprehensive nursing education plan which included an analysis and synthesis of the literature, a curriculum plan, and a pretest/posttest. The Johns Hopkins Evidence-Based Practice Model framed the project, which used a multidisciplinary team approach. Two nursing leaders, each with a doctor of philosophy degree, served as content experts for the educational curriculum plan and the pretest/posttest. The curriculum plan was evaluated using a dichotomous scale of 1 = not met and 2 = met. An average score of 2 was achieved showing the content met the objectives. The pretest/posttest items were validated using a Likert-type scale ranging from 1 = not relevant to 4 = very relevant. A content validation index score of 1.0 was computed, revealing that the items met the objectives and content of the curriculum. The pretest/posttest was administered before and after the educational program to determine the knowledge gained. A paired samples t test was conducted and found to have a statistically significant difference in the scores for the pretest (M = 81.25, SD = 11.29) and post-test (M = 94.06, SD = 7.12); t (31) = -5.92, p = 0.01, revealing that the critical care nurses gained significant knowledge with the delirium educational program. This project can promote positive social change because early recognition and management of the patient with delirium can facilitate positive outcomes for patients, families, and systems.

Figueroa-Ramosa et al. (2013) concluded that the combination of sedation withdrawal and mechanical ventilation withdrawal trial was feasible and well tolerated. The conclusion is not well supported because of the absence of a comparison to the uncombined protocol and due to evidence that the patients did not tolerate them particularly well.