Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Journal of Neurology
Published in: Journal of Neurology 7/2022

Open Access 14-02-2022 | Stroke | Original Communication

Delirium on stroke units: a prospective, multicentric quality-improvement project

Authors: Peter Nydahl, Friederike Baumgarte, Daniela Berg, Manuela Bergjan, Christoph Borzikowsky, Christiana Franke, Diana Green, Anisa Hannig, Hans Christian Hansen, Armin Hauss, Uta Hansen, Rahel Istel, Norma Krämer, Karita Krause, Renée Lohrmann, Mohammad Mohammadzadeh-Vazifeh, Jürgen Osterbrink, Frederick Palm, Telse Petersen, Bernd Schöller, Henning Stolze, Max Zilezinski, Johannes Meyne, Nils G. Margraf

Published in: Journal of Neurology | Issue 7/2022

Login to get access

Abstract

Background

Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management.

Methods

Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others.

Results

Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved.

Conclusions

Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke.

Registry

DRKS, DRKS00021436. Registered 04/17/2020, www.​drks.​de/​DRKS00021436.
Appendix
Available only for authorised users
Literature
1.
2.
Caeiro L, Ferro JM, Albuquerque R, Figueira ML (2004) Delirium in the first days of acute stroke. J Neurol 251(2):171–178PubMedCrossRef
3.
Carin-Levy G, Mead GE, Nicol K, Rush R, van Wijck F (2012) Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review. J Neurol 259(8):1590–1599PubMedCrossRef
4.
Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW (2021) Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 47(10):1089–1103PubMedCrossRef
5.
American-Psychiatric-Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, ArlingtonCrossRef
6.
Maldonado JR (2008) Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin 24(4):789–856PubMedCrossRef
7.
Müllges W (2014) Ätiologie und therapie des delirs. Aktuelle Neurologie 4:586–596
8.
Nydahl P, Margraf NG, Ewers A (2017) Delirium in stroke patients: critical analysis of statistical procedures for the identification of risk factors. Med Klin Intensivmed Notfmed
9.
Girard TD, Thompson JL, Pandharipande PP, Brummel NE, Jackson JC, Patel MB et al (2018) Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med 6(3):213–222PubMedPubMedCentralCrossRef
10.
11.
Svenningsen H, Egerod I, Videbech P, Christensen D, Frydenberg M, Tønnesen EK (2013) Fluctuations in sedation levels may contribute to delirium in ICU patients. Acta Anaesthesiol Scand 57(3):288–293PubMedCrossRef
12.
Shaw RC, Walker G, Elliott E, Quinn TJ (2019) Occurrence rate of delirium in acute stroke settings: systematic review and meta-analysis. Stroke 50(11):3028–3036PubMedCrossRef
13.
Nydahl P, Dewes M, Dubb R, Hermes C, Kaltwasser A, Krotsetis S et al (2017) Survey among critical care nurses and physicians about delirium management. Nurs Crit Care 23:23–29PubMedCrossRef
14.
Krotsetis S, Nydahl P, Dubb R, Hermes C, Kaltwasser A, von Haken R (2017) Status quo of delirium management in German-speaking countries: comparison between intensive care units and wards. Intensive Care Med 44:252–253PubMedCrossRef
15.
Morandi A, Davis D, Taylor JK, Bellelli G, Olofsson B, Kreisel S et al (2013) Consensus and variations in opinions on delirium care: a survey of European delirium specialists. Int Psychogeriatr 25(12):2067–2075PubMedPubMedCentralCrossRef
16.
Luetz A, Balzer F, Radtke FM, Jones C, Citerio G, Walder B et al (2014) Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists. PLoS ONE 9(11):e110935PubMedPubMedCentralCrossRef
17.
Saller T, Dossow V, Hofmann-Kiefer K (2016) Knowledge and implementation of the S3 guideline on delirium management in Germany. Anaesthesist 65(10):755–762PubMedCrossRef
18.
Trogrlić Z, Ista E, Ponssen HH, Schoonderbeek JF, Schreiner F, Verbrugge SJ et al (2016) Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals. Nurs Crit Care 22:133–140PubMedCrossRef
19.
Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T et al (2015) Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 175(4):512–520PubMedPubMedCentralCrossRef
20.
21.
Lele AV, Moheet AM (2020) Neurocritical care quality improvement practices: a survey of members of the Neurocritical Care Society. Neurocrit Care 32(1):295–301PubMedCrossRef
22.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D (2016) SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 25(12):986–992PubMedCrossRef
23.
Weiss B, Paul N, Spies CD, Ullrich D, Ansorge I, Salih F et al. (2021) Influence of patient-specific covariates on test validity of two delirium screening instruments in neurocritical care patients (DEMON-ICU). Neurocrit Care, pp 1–11
24.
Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE (2008) The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 168(5):508–513PubMedCrossRef
25.
Gusmao-Flores D, Salluh JIF, Chalhub RÁ, Quarantini LC (2012) The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit Care 16(4):R115PubMedPubMedCentralCrossRef
26.
van Velthuijsen EL, Zwakhalen SM, Warnier RM, Mulder WJ, Verhey FR, Kempen GI (2016) Psychometric properties and feasibility of instruments for the detection of delirium in older hospitalized patients: a systematic review. Int J Geriatr Psychiatry 31(9):974–989PubMedCrossRef
27.
Jones RN, Cizginer S, Pavlech L, Albuquerque A, Daiello LA, Dharmarajan K et al (2019) Assessment of instruments for measurement of delirium severity: a systematic review. JAMA Intern Med 179(2):231–239PubMedPubMedCentralCrossRef
28.
Cinar F, Eti AF (2019) Evaluation of postoperative delirium: validity and reliability of the nursing delirium screening scale in the Turkish Language. Dement Geriatr Cogn Dis Extra 9(3):362–373PubMedPubMedCentralCrossRef
29.
Lutz A, Radtke FM, Franck M, Seeling M, Gaudreau JD, Kleinwachter R et al (2008) The Nursing Delirium Screening Scale (NU-DESC). Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie AINS 43(2):98–102PubMedCrossRef
30.
Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A et al (2008) Comparison of three scores to screen for delirium in the recovery room. Br J Anaesth 101(3):338–343PubMedCrossRef
31.
Hargrave A, Bastiaens J, Bourgeois JA, Neuhaus J, Josephson SA, Chinn J et al (2017) Validation of a nurse-based delirium-screening tool for hospitalized patients. Psychosomatics 58(6):594–603PubMedPubMedCentralCrossRef
32.
Bergjan M, Zilezinski M, Schwalbach T, Franke C, Erdur H, Audebert HJ et al (2020) Validation of two nurse-based screening tools for delirium in elderly patients in general medical wards. BMC Nurs 19:72PubMedPubMedCentralCrossRef
33.
Nydahl P, Bartoszek G, Binder A, Paschen L, Margraf NG, Witt K et al (2017) Prevalence for delirium in stroke patients: a prospective controlled study. Brain Behav 7(8):e00748PubMedPubMedCentralCrossRef
34.
Chow S, Shao J, Wang H (2008) Sample size calculations in clinical research, 2nd edn. Chapman & Hall/CRC Biostatistics Series, London
35.
Ludolph P, Stoffers-Winterling J, Kunzler AM, Rösch R, Geschke K, Vahl CF et al (2020) Non-pharmacologic multicomponent interventions preventing delirium in hospitalized people. J Am Geriatr Soc 68(8):1864–1871PubMedCrossRef
36.
Sahawneh F, Boss L (2021) Non-pharmacologic interventions for the prevention of delirium in the intensive care unit: an integrative review. Nurs Crit Care 26(3):166–175PubMedCrossRef
37.
Rood PJ, Zegers M, Ramnarain D, Koopmans M, Klarenbeek T, Ewalds E et al (2021) The impact of nursing delirium preventive interventions in the intensive care unit: a multicenter cluster randomized controlled trial. Am J Respir Crit Care Med 204:682–691PubMedCrossRef
38.
Rice KL, Bennett MJ, Berger L, Jennings B, Eckhardt L, Fabré-LaCoste N et al (2017) A pilot randomized controlled trial of the feasibility of a multicomponent delirium prevention intervention versus usual care in acute stroke. J Cardiovasc Nurs 32(1):E1-e10PubMedCrossRef
39.
Smith M, Meyfroidt G (2017) Critical illness: the brain is always in the line of fire. Intensive Care Med 43(6):870–873PubMedCrossRef
40.
Shaw R, Drozdowska B, Taylor-Rowan M, Elliott E, Cuthbertson G, Stott DJ et al (2019) Delirium in an acute stroke setting, occurrence, and risk factors. Stroke 50(11):3265–3268PubMedCrossRef
41.
Haley MN, Casey P, Kane RY, Darzins P, Lawler K (2019) Delirium management: let’s get physical? A systematic review and meta-analysis. Australas J Age 38:231–241CrossRef
42.
Bernhardt J, Churilov L, Ellery F, Collier J, Chamberlain J, Langhorne P et al (2016) Prespecified dose-response analysis for a very early rehabilitation trial (AVERT). Neurology 86(23):2138–2145PubMedPubMedCentralCrossRef
43.
Shi Q, Presutti R, Selchen D, Saposnik G (2012) Delirium in acute stroke: a systematic review and meta-analysis. Stroke 43(3):645–649PubMedCrossRef
44.
Dziegielewski C, Skead C, Canturk T, Webber C, Fernando SM, Thompson LH et al (2021) Delirium and associated length of stay and costs in critically ill patients. Crit Care Res Pract 2021:6612187PubMedPubMedCentral
45.
Green S, Reivonen S, Rutter LM, Nouzova E, Duncan N, Clarke C et al (2018) Investigating speech and language impairments in delirium: a preliminary case-control study. PLoS ONE 13(11):e0207527PubMedPubMedCentralCrossRef
46.
Romoli M, Eusebi P, Forlivesi S, Gentile M, Giammello F, Piccolo L et al (2021) Stroke network performance during the first COVID-19 pandemic stage: a meta-analysis based on stroke network models. Int J Stroke 16:17474930211041202CrossRef
47.
Pabón-Martínez BA, Rodríguez-Pulido LI, Henao-Castaño AM (2021) The family in preventing delirium in the intensive care unit: scoping review. Enferm Intensiva (Engl Ed)
Metadata
Title
Delirium on stroke units: a prospective, multicentric quality-improvement project
Authors
Peter Nydahl
Friederike Baumgarte
Daniela Berg
Manuela Bergjan
Christoph Borzikowsky
Christiana Franke
Diana Green
Anisa Hannig
Hans Christian Hansen
Armin Hauss
Uta Hansen
Rahel Istel
Norma Krämer
Karita Krause
Renée Lohrmann
Mohammad Mohammadzadeh-Vazifeh
Jürgen Osterbrink
Frederick Palm
Telse Petersen
Bernd Schöller
Henning Stolze
Max Zilezinski
Johannes Meyne
Nils G. Margraf
Publication date
14-02-2022
Publisher
Springer Berlin Heidelberg
Published in
Journal of Neurology / Issue 7/2022
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI
https://doi.org/10.1007/s00415-022-11000-6

Other articles of this Issue 7/2022

Journal of Neurology 7/2022 Go to the issue

Original Communication

Home-monitoring of vital capacity in people with a motor neuron disease

Original Communication

Time to onset and duration of botulinum toxin efficacy in movement disorders

Review

Neurologic manifestations of giant cell arteritis

Original Communication

Effectiveness of rituximab vs. ocrelizumab for the treatment of primary progressive multiple sclerosis: a real-world observational study

Original Communication

Measuring the functional impact of cognitive impairment in Huntington’s disease

Original Communication

Reclassification of patients with tremor syndrome and comparisons of essential tremor and essential tremor-plus patients