Delirium in the acute phase after stroke: Incidence, risk factors, and outcome (original) (raw)
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The course of delirium in acute stroke
Age and Ageing, 2009
Background and purpose: several studies have assessed delirium post-stroke but conflicting results have been obtained. Also, the natural history and outcome of delirium post-stroke need to be fully elucidated. Methodology: eligible stroke patients were assessed for delirium on admission and for four consecutive weeks using the Confusion Assessment Method (CAM). Risk factors for delirium were recorded. Our outcome measures were length of stay, inpatient mortality and discharge destination. Results: of 110 eligible patients, 82 were recruited over 7 months. Delirium was detected in 23 patients (28%); 21 of these were delirious on their first assessment. Sixty-nine per cent of patients who had four weekly assessments were delirious at 4 weeks. Multivariate logistic regression analysis was performed, and two models were identified. With unsafe swallow in the analysis, delirium was associated with an unsafe swallow on admission (OR 28.4, P<0.001), Barthel score < 10 (OR 32.1, P = 0.004) and poor vision pre-stroke (OR 110.8, P = 0.01). With unsafe swallow removed from the analysis, delirium was associated with an admission C-reactive protein (CRP) > 5 mg/l (OR 10.2, P = 0.009), Barthel score < 10 (OR 46.5, P = 0.001) and poor vision pre-stroke (OR 85.2, P = 0.01). Delirious patients had a higher mortality (30.4% vs. 1.7%, P<0.001), longer length of stay (62.2 vs. 28.9 days, P<0.001) and increased risk of institutionalisation (43.7 vs. 5.2%, OR 14, P<0.001). Conclusions: delirium is common post-stroke. Most cases develop at stroke onset and remain delirious for an appreciable period. Delirium onset is associated with stroke severity (low admission Barthel), unsafe swallow on admission, poor vision pre-stroke and a raised admission CRP. Delirium is a marker of poor prognosis.
Delirium in acute stroke: a review
International Journal of Stroke, 2007
Background Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation. Summary of review Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke. Conclusion This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke.
The evaluation of delirium post-stroke
International Journal of Geriatric Psychiatry, 2009
Objective The aim of this study was to assess and compare the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS) in the detection of delirium in the acute stroke setting, when used by a non-psychiatrist doctor. Methods Consecutive participants within 4 days of an acute stroke were screened for delirium using the CAM and the DRS. Patients also had a Mini-Mental State Examination at each assessment. Patients were screened weekly for a maximum of 4 weeks. The CAM and DRS were compared against each other with respect to agreement and applicability. Results Of 110 eligible patients, 82 were recruited over a 7 month period. Delirium developed in 23 patients (28%), 21 of whom developed delirium during week 1. We found high agreement between the CAM and the DRS in the detection of stroke in the acute stroke setting (k values 0.97, 0.86, 0.79 and 1 at weeks 1, 2, 3 and 4, respectively). In addition, there was strong correlation between low MMSE scores (MMSE less that 10) and delirium (k scores 1.0, 0.82, 0.83 and 1.0 at weeks 1, 2, 3 and 4, respectively). Conclusions Delirium is a common complication post-stroke. The CAM is equivalent to the DRS in the acute stroke setting when used by a trained non-psychiatrist. A low MMSE score may have a small benefit in identifying patients that are at risk of having delirium.
Duration of delirium in the acute stage of stroke
Acta clinica Croatica
The aim of the study was to determine duration of delirium in patients with acute stroke according to sex, age, type and localization of lesion. We assessed delirium prospectively in a sample of 233 consecutive patients with an acute (< or =4 days) stroke using the Delirium Rating Scale (DRS-R-98) and Diagnostic and Statistical Manual of Mental Disorders (DSM IV). The average duration of delirium was 4 days in patients with ischemic stroke and 3 days in patients with hemorrhagic stroke. There was no statistically significant difference in delirium duration between these two patient groups. A longer duration of delirium was recorded in women and in patients older than 65. The period of delirium was longer in patients with right hemispheric lesions. Patients did not differ according to delirium duration, sex, age, type and localization of stroke. In two thirds of patients, the symptoms of delirium completely disappeared on medicamentous treatment, while in the remaining one third o...
Mortality and Functional Disability of Post-stroke Delirium
Materia socio-medica, 2018
Introduction: Small number of studies have evaluated the mortality and the degree of functional disability of post-stroke delirium, and our aim was to determine that. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glasgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Delirious patients had a significantly higher mortality (p = 0.0005). As opposed to the type of stroke mortality was higher after ischemic (p = 0.0005). The patients without delirium had significantly better cumulative survival during the first year after stroke (p = 0.0005). Delirious patients aged ≥65 years had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). In relation to the type of stroke delirious patients with ischemic had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). Delirious patients had a greater degree of functional impairment at discharge (p = 0.01), three (p = 0.01), six months (p = 0.01) and one year (p = 0.01) after stroke. Conclusion: Delirious patients have a significantly higher mortality, lower cumulative survival and a greater degree of functional disability in the first year after stroke.
Risk Factors for Delirium in the Acute Stroke
InTech eBooks, 2012
According to the World Health Organization (WHO), stroke is defined as the sudden development of focal or global symptoms and signs of disturbance of cerebral function lasting more than 24 hours or leading to death, as a result of the pathological processes of vascular origin (Thorvaldsen et al., 1995). The basic classification of stroke, according to the type of pathological process, is into ischemic stroke, which comprises 70-85%, and hemorrhagic. An ischemic stroke develops due to the inability of supply to brain tissue oxygen and glucose due to occlusion vessel. If the "outbursts" of blood within the brain mass, there is intracerebral hemorrhage, which makes 15-20% of strokes, while the penetration of the blood in the subarachnoid space, usually as a result of aneurysm rupture, leading to a subarachnoid hemorrhage, which makes 5-10% of all strokes. Stroke leads to focal or multifocal neuropsychological disorders. Given that in clinical stroke in the forefront of motor deficits, disturbance of consciousness and disturbance of speech functions, a very common disorder and the function of other organ systems, most of the neuropsychological symptoms are observed after the acute phase when the general and neurological status stabilized, or when we are able to perform certain neuropsychological tests (Dostović, 2007). Stroke leads to the different degree of physical, cognitive and psychosocial dysfunctioning. The recovery of patients depends on the severity of disability, the rehabilitation program, but also the subsequent maintenance of achieved function, as well as care and support of family and environment. 1.2 Delirium According to the International Classification of Diseases and Related Health Problems-Tenth Revision of 1994 delirium, not caused by alcohol or other psychoactive substances, is etiologically nonspecific organic cerebral syndrome, characterized by the simultaneous disturbance of consciousness and attention, perception, thinking, psychomotor behavior, www.intechopen.com Mental Illnesses-Understanding, Prediction and Control www.intechopen.com Risk Factors for Delirium in the Acute Stroke 283 of delirium was higher in patients taking five or more medications with moderate anticholinergic activity (Lindsesay et al., 2002). Exposure anticholinergic medication was independently and specifically associated with an increase in delirium in elderly patients diagnosed with delirium (Han et al., 2001). Anticholinesterase activity is increasing in the plasma of patients with delirium. Over the years the loss of cholinergic reserve and focal loss of acetylcholine in the nucleus basalis Meynerti may be the reason that delirium is common in the elderly and patients with dementia. Abnormal termination of the hypothalamic-pituitary-adrenal lines may play a role in the pathophysiology of delirium after acute stroke (Olsson, 1999). Type II receptors for glucocorticoids, which are present during the high-level (stress) hormones, are heavily expressed in the hippocampus, and intact hipocampal formations, seem to be necessary for adequate negative feedback. Stroke and complications (pain and infection) are stress conditions, the leading to an increase glucocortikoid production, which is not adequately suppressed. Gustafson et al. (1993) have registered higher corticoid levels and abnormal response to dexamethasone suppression test in patients with acute stroke. Immediately after the stroke, delirium is associated with increased sensitivity to corticoadrenal adrenocorticotropic hormonal stimulation and the decrease in glucocorticoid negative feedback. Corticoids are known to disrupt attention and memory. Several neurotransmitter systems have been implicated, in particular acetylcholine and dopamine, but also serotonin, noradrenalin and gamma amino butyric acid (GABA). Functional acetylcholine (ACh) deficiency has received most support (Trzepacz , 2000). ACh is involved in several functions that are affected in delirium: arousal, attention, delusions, visual hallucinations, motor activity and memory (Lindsesay et al., 2002). The evidence for ACh involvement in delirium is strong. Anticholinergic drugs can cause delirium in susceptible patients (White, 2002; Lindsesay et al., 2002). With respect to other neurotransmitter systems, dopamine may also be implicated (Trzepacz, 2000). Dopamine and ACh neurotransmitter systems interact closely and often reciprocally and an imbalance between the two could underlie delirium syndromes. There is evidence that dopamine excess can cause delirium and that dopamine antagonists, particularly neuroleptics, modify the symptoms of delirium (Itil & Fink, 1966). Glucocorticoids are also potentially implicated in delirium; and delirium has been reported in Cushing's syndrome. Despite being a frequent complication of stroke, the pathophysiology of delirium in the a c u t e s t r o k e i s p o o r l y u n d e r s t o o d. T h e r e i s n o d a t a o n h o w a n a c u t e s t r o k e a f f e c t s neurotransmitter levels in the brain. Drugs with ACh activity are, however, associated with an increased risk of delirium in the acute stroke setting (Caeiro et al., 2004). Recently, hypoperfusion in the frontal, parietal, and pontine regions have been demonstrated using single photon emission computed tomography (SPECT) scanning in patients with delirium (Fong et al., 2006). It is possible that hypoperfusion, in addition to the acute brain injury, may play an important role in the onset of delirium post-stroke. In addition, one study has found an association between delirium and hypercortisolism in the acute stroke setting (Gustafson, 1993). The pathogenesis of delirium in general remains unknown (White S, 2002). There are several possible mechanisms for the development of delirium (Table 1).
Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review
Journal of Neurology, 2012
Delirium is a common complication in acute stroke yet there is uncertainty regarding how best to screen for and diagnose delirium after stroke. We sought to establish how delirium after stroke is identified, its incidence rates and factors predicting its development. We conducted a systematic review of studies investigating delirium in acute stroke. We searched The Cochrane Collaboration, MEDLINE, EMBASE, CINHAL, PsychINFO, Web of Science, British Nursing Index, PEDro and OT Seeker in October 2010. A total of 3,127 citations were screened, full text of 60 titles and abstracts were read, of which 20 studies published between 1984 and 2010 were included in this review. The methods most commonly used to identify delirium were generic assessment tools such as the Delirium Rating Scale (n = 5) or the Confusion Assessment Method (n = 2) or both (n = 2). The incidence of delirium in acute stroke ranged from 2.3-66%, with our meta-analysis random effects approach placing the rate at 26% (95% CI 19-33%). Of the 11 studies reporting risk factors for delirium, increased age, aphasia, neglect or dysphagia, visual disturbance and elevated cortisol levels were associated with the development of delirium in at least one study. The outcomes associated with the condition are increased morbidity and mortality. Delirium is found in around 26% of stroke patients. Difference in diagnostic and screening procedures could explain the wide variation in frequency of delirium. There are a number of factors that may predict the development of the condition.
Impact of delirium on the outcome of stroke: a prospective, observational, cohort study
Journal of Neurology
Introduction Delirium is an acute fluctuating disorder of attention and awareness, which often complicates the clinical course of several conditions, including acute stroke. The aim of the present study was to determine whether delirium occurrence impacts the outcome of patients with acute stroke. Methods The study design is single center, prospective, observational. We consecutively enrolled patients admitted to the stroke unit from April to October 2020. Inclusion criteria were age ≥ 18 years and diagnosis of acute stroke. Exclusion criteria were stroke mimics, coma, and terminal conditions. All patients were screened for delirium upon admission, within 72 h, and whenever symptoms suggesting delirium occurred by means of the Confusion Assessment Method for Intensive Care Unit and the Richmond Agitation Sedation Scale. Outcomes were evaluated with the 90-days modified Rankin Scale (mRS) by telephone interview. Results The final study cohort consisted of 103 patients (62 men; median...
The assessment of delirium in patients with stroke in an intensive care unit – Integrative Literature Review (Atena Editora), 2024
Introduction: Cerebral Vascular Accident (CVA) causes changes at various levels in users, which can trigger delirium. However, it appears that identifying delirium in the initial phase of stroke is difficult in the presence of neurological deficits. For this reason, delirium is a common complication in an Intensive Care Unit (ICU), making regular monitoring of users' signs/symptoms crucial, with the need to use credible assessment instruments. Objectives: Analyze delirium assessment instruments; select the best scale to assess delirium in patients with stroke; identify obstacles that hinder the application of delirium assessment tools in patients with stroke. Methodology: This is an Integrative Literature Review, for which electronic databases such as Medline and CINHAL were used to carry out the research, using the PI[C]O method, and, finally, seven articles were selected scientific studies with a publication time frame between 2019 and 2021. Results: Ischemic stroke (IS) has a higher incidence. When applying instruments to assess the presence of delirium, the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) is the instrument that presents the most limitations, as it requires interaction with users, unlike the Intensive Care Delirium Screening Checklist (ICDSC) which is observational. Still, other articles refer to the Confusion Assessment Method (CAM) and the Montreal Cognitive Assessment (MoCA) as more appropriate instruments. Conclusion: Delirium is often difficult to detect, as many cases can go unnoticed, especially in patients with stroke. Therefore, the currently existing assessment instruments were analyzed and it was found that the most used is the CAM-ICU, considering that it is not entirely suitable due to its limited capacity to explain an initial mental state that presents changes. The obstacles that make assessment most difficult are the neurological deficits present in patients with stroke, which can be confused with signs/symptoms related to delirium.