Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2012
ReviewUnderstanding terminology of delirium and long-term cognitive impairment in critically ill patients.
Delirium, an acute brain dysfunction, frequently affects intensive care unit (ICU) patients during the course of a critical illness. Besides the acute morbidities, ICU survivors often experience long-term sequelae in the form of cognitive impairment (LTCI-CI). Though delirium and LTCI-CI are associated with adverse outcomes, little is known on the terminology used to define these acute and chronic co-morbidities. ⋯ Second, we report on the epidemiology of LTCI-CI and compare its definition to other forms of cognitive impairments. In particular, we define mild cognitive impairment, dementia and finally postoperative cognitive dysfunction. Future research is needed to interpret the trajectories of LTCI-CI, to differentiate it from neurodegenerative diseases and to provide a formal disease classification.
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Best Pract Res Clin Anaesthesiol · Sep 2012
ReviewDelirium detection and monitoring outside the ICU.
Delirium affects many patients in hospital settings but is under-detected and associated with a range of adverse health-care outcomes, including institutionalisation and elevated mortality. Detection is essential because it leads to identification and management of precipitants and assessment and management of distress caused by hallucinations and delusions. Moreover, delirium may affect communication and, thus, assessment of pain. ⋯ Informal and formal methods of assessment of the features are covered. We describe some of the main rating scales used in delirium screening and severity grading. Incorporating formal and systematic screening and assessment into everyday clinical practice can substantially improve delirium diagnosis and treatment.
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Best Pract Res Clin Anaesthesiol · Sep 2012
ReviewAn update on delirium in the postoperative setting: prevention, diagnosis and management.
Delirium is a serious and pervasive problem in the postoperative setting. Research to date has identified a number of key risk factors implicated in the development of delirium after surgical intervention, including advanced age, pre-existing cognitive impairment, lower pre-morbid functional status and history of psychiatric illness. ⋯ Recent research has identified more sophisticated management of pain and sedation protocols as a way to prevent or mitigate delirium, with promising results. This chapter reviews the most recent literature pertaining to the prevention, diagnosis and management of postoperative delirium.
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Best Pract Res Clin Anaesthesiol · Sep 2012
ReviewOptimising the recognition of delirium in the intensive care unit.
Delirium affects up to 80% of critically ill patients and negatively influences patient outcome. Consensus guidelines advocate that a validated screening tool like the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) be used to identify delirium rather than a subjective approach. ⋯ Implementation of a large-scale delirium screening effort is both feasible and sustainable and should be accompanied by both didactic and bedside education. An ICU clinical road map should be used on a daily basis that promotes delirium assessment, establishes a targeted sedation goal and defines the analgesic/sedative regimen that is best suited to maintain patient comfort, prevent delirium and promote wakefulness.
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Delirium is a prevalent organ dysfunction in critically ill patients associated with significant morbidity and mortality, requiring advancements in the clinical and research realms to improve patient outcomes. Increased clinical recognition and utilisation of delirium assessment tools, along with clarification of specific risk factors and presentations in varying patient populations, will be necessary in the future. ⋯ Multicentre randomised controlled trials of interventional therapies will then need to be performed to test their ability to improve clinical outcomes. Physical and cognitive rehabilitation measures need to be further examined as additional means of improving outcomes from delirium in the hospital setting.