Health Disparities in Delirium

Abstract Racial and ethnic minority populations in the US experience greater cumulative disease burden, as well as social and economic barriers, stressors, and limited advocacy/access to culturally informed healthcare. This increased risk burden is expected to be associated with an increased risk for delirium during acute care encounters. Previous studies on health disparity and delirium are limited and report equivocal findings regarding delirium incidence, possibly related to sample bias or non-validated measures. Risk for delirium during acute care in health disparity populations (HDP) that include Black African Americans (BAA) and Hispanic-Latinx (HL) has not been systematically studied using validated measures. We conducted a retrospective analysis utilizing our delirium program (ADAPT) registry that systematically assessed all hospitalized patients through their entire hospital stay for the years 2018-2019 (36K patients, 80% NHW, 11% HL, 9% BAA). The Confusion Assessment Method (CAM and CAM-ICU) and Richmond Agitation Sedation Scale (RASS) were used as screening assessments to identify delirium. We know from previous studies that negative CAM results in our environment have high specificity. The incidence of delirium between populations was compared using a chi-square test. Delirium incidence was higher in HDP (BAA combined with HL) compared to NHW in 71-80yo (16.0% vs 12.6%, p=0.003). Delirium incidence was not different in all other age groups compared; <65yo (p=0.191), 61-70yo (p=0.223), 81-90yo (p=0.644). Understanding the association, or lack thereof, between health disparities, ethnic and race-based risks for delirium is expected to provide important insights into more focused delirium assessment, prevention and mitigation strategies in these populations.

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Post-operative delirium in older patients following cancer related and other high-risk surgeries.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e24024 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e24024-e24024

Author(s):

Rawad Elias ◽

Ilene Staff ◽

Stephen Thompson ◽

Christine Waszynski ◽

Jennifer Zanchi ◽

...

Keyword(s):

Risk Factors ◽

Older Adults ◽

Logistic Regression ◽

High Risk ◽

Tertiary Care ◽

Confusion Assessment Method ◽

Assessment Method ◽

Chi Square ◽

Targeted Interventions ◽

Increased Risk

e24024 Background: Older adults are at increased risk for postoperative delirium (POD). This risk might be higher in patients with cancer as underlying malignancy and its complications predispose individuals to develop delirium. Therefore, it is important to evaluate the onset of delirium in this patient population especially as POD is associated with increased risk of rehospitalization, decline in cognitive function, morbidity and mortality. Methods: We performed a retrospective review of patients aged ≥ 70 years admitted January 2017 through July 2019 to a tertiary care referral center for a high-risk surgery, defined as associated with a mortality risk greater than 1%. Cancer related surgeries (CRS) were identified through cross matching with Cancer Registry. Patients who had delirium assessment in the postoperative setting using the Confusion Assessment Method (CAM) were included. Chi-square tests of proportion, Wilcoxon Ranked Sum and multivariate logistic regression analyses were conducted. Results: A total of 2340 patients were included in this analysis, 315 of whom had (CRS). Overall, the age (median, IQR) of patients at surgery was 76 years (72-80) and the length of stay (LOS) was 7 (4-11) days. Patients receiving CRS were younger (75, 72-79) than those with non-CRS (76, 72-81) (p = 0.022); had a shorter post-operative LOS (4, 2-7 vs. 5, 3-8; p > 0.001), and were less likely to develop POD (7.6% vs. 16.1%; p < 0.001). Among patients receiving CSR, those who developed POD were older (78 vs. 74; p = 0.008) and had longer post-operative LOS (14.0 vs. 4.0; p < 0.001). Those having experienced radiotherapy (RT) for cancer within the year before the surgery, were more likely to develop POD (40.0% vs. 6.6% p. < 0.001). Chemotherapy in the year prior to surgery did not increase the risk of POD (6.1% vs. 7.8%; p = 0.721). Among those having non-CRS, a cancer diagnosis did not affect POD. A logistic regression predicting POD indicated that the lower likelihood of POD following CRS was independent of age or gender (OR = 0.40; p < .001); RT within one year prior was independent predictor of higher POD (OR = 5.48; p = 0.003). Our data presentation will include further analysis of POD risk factors. Conclusions: Although older adults receiving CRS were significantly less likely to develop delirium than patients with other high-risk surgeries, it is still important to evaluate POD in this population due to its impact of patients’ outcomes. Further understanding of POD risk factors, such as preoperative RT, would allow the development of targeted interventions that might lessen the risk.

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Abstract P153: Multiple Vulnerabilities to Health Disparities and Incident Heart Failure in the Reasons for Geographic and Racial Differences in Stroke Study

Circulation ◽

10.1161/circ.141.suppl_1.p153 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Laura C Pinheiro ◽

Evgeniya Reshetnyak ◽

Madeline R Sterling ◽

Emily B Levitan ◽

Monika M Safford ◽

...

Keyword(s):

Heart Failure ◽

Health Disparities ◽

Social History ◽

Racial Differences ◽

Age Groups ◽

Cumulative Effect ◽

Annual Household Income ◽

Cox Models ◽

Stroke Study ◽

Increased Risk

Background: Multiple socially determined vulnerabilities (SDV) to health disparities often cluster within the same individual. Previous studies have shown that SDV are separately associated with increased risk of heart failure (HF). As there may be a cumulative effect of these SDVs in the same individual, understanding their joint impact on the incidence of HF is critical. Methods: REGARDS is a national prospective cohort study that recruited 30,239 adults <45 years of age from 2003-2007 with ongoing follow-up. We followed participants free of HF at baseline for incident HF hospitalization through December 31, 2016. Guided by the Healthy People 2020 framework, we examined 10 potential SDVs, retaining those that were associated with incident HF (p<0.10) and creating a count of SDV (0, 1, 2, 3+). We used Cox models to examine associations between the SDV count and incident HF, adjusting for potential confounders. Since disparities in HF have been shown to be greatest in younger individuals models were stratified by age. Results: The 25,790 participants were followed for a median of 10.1 years (IQR 6.5, 11.9); their mean age at baseline was 64.8, 55%% were women, and 40% were blacks. In age-adjusted models, Black race, low educational attainment, low annual household income, zip code poverty, poor public health infrastructure, and lack of health insurance were significantly associated with incident HF. In fully adjusted models, among those 45-64 years, compared to having no SDV, having a SDV was significantly associated with incident HF, with a trend toward a higher count conferring greater risk (Fig. 1). There was no association in other age groups. Conclusions: An increased number of SDVs was associated with risk of incident HF hospitalization among adults <65 years, even after adjustment for cardiovascular risk factors. Using a simple count of SDVs that could be incorporated into the social history during clinical assessment may identify younger individuals at increased risk of incident HF.

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Impact of Delirium and Its Motor Subtypes on Stroke Outcomes

Stroke ◽

10.1161/strokeaha.120.026425 ◽

2021 ◽

Vol 52 (4) ◽

pp. 1322-1329

Author(s):

Ivã Taiuan Fialho Silva ◽

Pedro Assis Lopes ◽

Tiago Timotio Almeida ◽

Saint Clair Ramos ◽

Ana Teresa Caliman Fontes ◽

...

Keyword(s):

Functional Outcome ◽

Functional Dependence ◽

Confusion Assessment Method ◽

Assessment Method ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Risk Of Death ◽

Increased Risk ◽

And Behavior ◽

The Relationship

Background and Purpose: Delirium is an acute and fluctuating impairment of attention, cognition, and behavior. Although common in stroke, studies that associate the clinical subtypes of delirium with functional outcome and death are lacking. We aimed to evaluate the influence of delirium occurrence and its different motor subtypes over stroke patients’ prognosis. Methods: Prospective cohort of stroke patients with symptom onset within 72 hours before research admission. Delirium was diagnosed by Confusion Assessment Method for the Intensive Care Unit, and its motor subtypes were defined according to the Richmond Agitation-Sedation Scale. The main outcome was functional dependence or death (modified Rankin Scale>2) at 90 days comparing: delirium versus no delirium patients; and between motor subtypes. Secondary outcomes included modified Rankin Scale score >2 at 30 days and 90-day-mortality. Results: Two hundred twenty-seven patients were enrolled. Delirium occurred in 71 patients (31.3%), with the hypoactive subtype as the most frequent, in 41 subjects (57.8%). Delirium was associated with increased risk of death and functional dependence at 30 and 90 days and higher 90-day mortality. Multivariate analysis showed delirium (odds ratio, 3.28 [95% CI, 1.17–9.22]) as independent predictor of modified Rankin Scale >2 at 90 days. Conclusions: Delirium is frequent in stroke patients in the acute phase. Its occurrence—specifically in mixed and hypoactive subtypes—seems to predict worse outcomes in this population. To our knowledge, this is the first study to prospectively investigate differences between delirium motor subtypes over functional outcome three months poststroke. Larger studies are needed to elucidate the relationship between motor subtypes of delirium and functional outcomes in the context of acute stroke.

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Adverse Neonatal Birth Outcomes Among Adolescent Pregnancies in Kampala, Uganda Between 2015 –2018

10.21203/rs.3.rs-92844/v1 ◽

2020 ◽

Author(s):

Robert Serunjogi ◽

Linda Barlow-Mosha ◽

Daniel Mumpe-Mwanja ◽

Dhelia Williamson ◽

Diana Valencia ◽

...

Keyword(s):

Birth Outcomes ◽

Adolescent Mothers ◽

Birth Defects ◽

Age Groups ◽

Sub Saharan Africa ◽

Adverse Birth Outcomes ◽

Chi Square ◽

Older Mothers ◽

Neonatal Deaths ◽

Increased Risk

Abstract Background: Uganda has one of the highest adolescent pregnancy rates in sub-Saharan Africa. We compared the risk of adverse birth outcomes between adolescents (age 12-19 years) and older mothers (age 20-34 years) in four urban hospitals.Methods: Maternal demographics, HIV status, and birth outcomes of all live births, stillbirths, and spontaneous abortions delivered from August 2015 to December 2018 were extracted from a hospital-based birth defects surveillance database. Differences in the distributions of maternal and infant characteristics by maternal age groups were tested with Pearson’s chi-square. Adjusted odds ratios (aORs) and 95% Confidence Intervals (CI) were calculated using logistic regression to compare the prevalence of adverse birth outcomes among adolescents to older mothers.Results: A total of 100,189 births were analyzed, with 11.1% among adolescent mothers and 89.0% among older mothers. Adolescent mothers had an increased risk of preterm delivery (aOR: 1.14; CI: 1.06-1.23), low birth weight (aOR: 1.46; CI: 1.34-1.59), and early neonatal deaths (aOR: 1.58; CI: 1.23-2.02). Newborns of adolescent mothers had an increased risk of major external birth defects (aOR: 1.33; CI: 1.02-1.76), specifically, gastroschisis (aOR: 3.20; CI: 1.12-9.13) compared to older mothers. The difference between the prevalence of gastroschisis among adolescent mothers (7.3 per 10,000 births; 95% CI: 3.7-14.3) was statistically significant when compared to older mothers (1.6 per 10,000 births; 95% CI: 0.9-2.6).Conclusions: This study found that adolescent mothers had an increased risk for several adverse birth outcomes compared to older mothers, similar to findings in the region and globally. Interventions are needed to improve birth outcomes in this vulnerable population.

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Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study

Journal of Anesthesia ◽

10.1007/s00540-020-02805-8 ◽

2020 ◽

Vol 34 (5) ◽

pp. 675-687

Author(s):

Yan Zhang ◽

Shu-Ting He ◽

Bin Nie ◽

Xue-Ying Li ◽

Dong-Xin Wang

Keyword(s):

Observational Study ◽

General Anesthesia ◽

Postoperative Delirium ◽

Prospective Observational Study ◽

Confusion Assessment Method ◽

Assessment Method ◽

Emergence Delirium ◽

Confusion Assessment ◽

Increased Risk ◽

Pacu Stay

Abstract Background The clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery. Methods This prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model. Results A total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735, P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days. Conclusions Emergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes. Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR-OOC-17012734

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Comparative analysis of perinatal outcomes and birth defects amongst adolescent and older Ugandan mothers: evidence from a hospital-based surveillance database

Reproductive Health ◽

10.1186/s12978-021-01115-w ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Robert Serunjogi ◽

Linda Barlow-Mosha ◽

Daniel Mumpe-Mwanja ◽

Dhelia Williamson ◽

Diana Valencia ◽

...

Keyword(s):

Birth Outcomes ◽

Adolescent Mothers ◽

Birth Defects ◽

Age Groups ◽

Perinatal Outcomes ◽

Sub Saharan Africa ◽

Adverse Birth Outcomes ◽

Chi Square ◽

Increased Risk ◽

Surveillance Database

Abstract Background Uganda has one of the highest adolescent pregnancy rates in sub-Saharan Africa. We compared the risk of adverse birth outcomes between adolescents (age 12–19 years) and mothers (age 20–34 years) in four urban hospitals. Methods Maternal demographics, HIV status, and birth outcomes of all live births, stillbirths, and spontaneous abortions delivered from August 2015 to December 2018 were extracted from a hospital-based birth defects surveillance database. Differences in the distributions of maternal and infant characteristics by maternal age groups were tested with Pearson’s chi-square. Adjusted odds ratios (aORs) and 95% confidence intervals (CI) were calculated using logistic regression to compare the prevalence of adverse birth outcomes among adolescents to mothers 20–34 years. Results A total of 100,189 births were analyzed, with 11.1% among adolescent mothers and 89.0% among older mothers. Adolescent mothers had an increased risk of preterm delivery (aOR: 1.14; CI 1.06–1.23), low birth weight (aOR: 1.46; CI 1.34–1.59), and early neonatal deaths (aOR: 1.58; CI 1.23–2.02). Newborns of adolescent mothers had an increased risk of major external birth defects (aOR: 1.33; CI 1.02–1.76), specifically, gastroschisis (aOR: 3.20; CI 1.12–9.13) compared to mothers 20–34 years. The difference between the prevalence of gastroschisis among adolescent mothers (7.3 per 10,000 births; 95% CI 3.7–14.3) was statistically significant when compared to mothers 20–34 years (1.6 per 10,000 births; 95% CI 0.9–2.6). Conclusions This study found that adolescent mothers had an increased risk for several adverse birth outcomes compared to mothers 20–34 years, similar to findings in the region and globally. Interventions are needed to improve birth outcomes in this vulnerable population.

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Cerebrospinal Fluid Concentration of Neurogranin in Hip Fracture Patients with Delirium

Journal of Alzheimer s Disease ◽

10.3233/jad-201341 ◽

2021 ◽

pp. 1-11

Author(s):

Nathalie Bodd Halaas ◽

Henrik Zetterberg ◽

Ane-Victoria Idland ◽

Anne-Brita Knapskog ◽

Leiv Otto Watne ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Hip Fracture ◽

Elective Surgery ◽

Confusion Assessment Method ◽

Assessment Method ◽

Sensitivity Analyses ◽

Synaptic Dysfunction ◽

Increased Risk ◽

Fluid Concentration ◽

Early Alzheimer’S Disease

Background: Delirium is associated with an increased risk of incident dementia and accelerated progression of existing cognitive symptoms. Reciprocally, dementia increases the risk of delirium. Cerebrospinal fluid (CSF) concentration of the dendritic protein neurogranin has been shown to increase in early Alzheimer’s disease (AD), likely reflecting synaptic dysfunction and/or degeneration. Objective: To elucidate the involvement of synaptic dysfunction in delirium pathophysiology, we tested the association between CSF neurogranin concentration and delirium in hip fracture patients with different AD-biomarker profiles, while comparing them to cognitively unimpaired older adults (CUA) and AD patients. Methods: The cohort included hip fracture patients with (n = 70) and without delirium (n = 58), CUA undergoing elective surgery (n = 127), and AD patients (n = 46). CSF was collected preoperatively and diagnostically in surgery and AD patients respectively. CSF neurogranin concentrations were analyzed in all samples with an in-house ELISA. Delirium was assessed pre-and postoperatively in hip fracture patients by trained investigators using the Confusion Assessment Method. Hip fracture patients were further stratified based on pre-fracture dementia status, delirium subtype, and AD fluid biomarkers. Results: No association was found between delirium and CSF neurogranin concentration (main analysis: delirium versus no delirium, p = 0.68). Hip fracture patients had lower CSF neurogranin concentration than AD patients (p = 0.001) and CUA (p = 0.035) in age-adjusted sensitivity analyses. Conclusion: The findings suggest that delirium is not associated with increased CSF neurogranin concentration in hip fracture patients, possibly due to advanced neurodegenerative disease and age and/or because synaptic degeneration is not an important pathophysiological process in delirium.

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Methionine synthase A2756G polymorphism associated with an increased risk of head and neck cancer

International Journal of Scientific Reports ◽

10.18203/issn.2454-2156.intjscirep20202537 ◽

2020 ◽

Vol 6 (7) ◽

pp. 237

Author(s):

Muhammad Tahir ◽

Aamir Khattak ◽

Haroon Rashid

Keyword(s):

Multivariate Analysis ◽

Head And Neck ◽

Univariate Analysis ◽

Age Groups ◽

Cancer Control ◽

Methionine Synthase ◽

P Value ◽

Chi Square ◽

Increased Risk ◽

And Control

Background: The 5-methyltetrahydrofolate-homocysteine methyltransferase gene (MTR) encodes the methionine synthase enzyme (OMIM 156570). Methionine synthase synthesizes methionine by re-methylation of homocysteine. A single nucleotide variation MTR-A2756G may affects the function of methionine synthase enzyme, which could lead to the development of head and neck squamous cell carcinoma (HNSCC).Methods: In current study, 292 HNSCC patients and 324 normal individuals without any history of cancer (control) were enrolled. EDTA whole blood samples of patients and control individuals were collected, and DNA was extracted. All samples were genotyped for MTR-A2756G polymorphism using polymerase chain reaction-restriction fragment length polymorphism. Frequency of polymorphism was compared between HNSCC patients and control individuals. The association of MTR-A2756G polymorphism with risk factors was statistically analysed through multivariate analysis (multiple logistic regression) whereas univariate analysis (chi square) was performed for group comparisons. Results: Univariate analysis revealed that the frequency of groups like age, smoking and MTR-A2756G genotype was different in HNC patients and controls (p value <0.05). Multivariate analysis showed that smoking (adjusted OR, 3.7; 95% CI, 2.3-6.0), age groups 41-50 years (adjusted OR, 3.6; 95% CI, .9-6.7) and >60 years (adjusted OR, 3.5; 95% CI, 1.7-7.3), MTR-A2756G genotype (adjusted OR, 2.1; 95% CI, 1.3-3.5) is associated with increased risk of HNSCC.Conclusions: Our data suggests that the MTR-A2756G polymorphism is associated with the occurrence of HNSCC in Pakistani population while the individuals between 40 to 50 years of age and tobacco smokers are at a greater risk of developing HNSCC.

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Comparison of delirium detection tools in acute care

Zeitschrift für Gerontologie und Geriatrie ◽

10.1007/s00391-021-02003-5 ◽

2022 ◽

Author(s):

Simone Brefka ◽

Gerhard Wilhelm Eschweiler ◽

Dhayana Dallmeier ◽

Michael Denkinger ◽

Christoph Leinert

Keyword(s):

Acute Care ◽

Acute Care Hospital ◽

Confusion Assessment Method ◽

Assessment Method ◽

Rapid Review ◽

Special Focus ◽

Clinical Settings ◽

Care Hospital ◽

Cognitive Changes ◽

Medline Search

Abstract Background Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection. Objective and methods Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings. Results A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only. Conclusion Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings.

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Association of MTR A2756G Gene Polymorphism with Risk of Head and Neck Cancer

Life and Science ◽

10.37185/lns.1.1.82 ◽

2020 ◽

Vol 1 (3) ◽

pp. 6

Author(s):

Muhammad Tahir ◽

Aamer Ali Khattak ◽

Erum Monis ◽

Sana Gul

Keyword(s):

Head And Neck ◽

Age Groups ◽

P Value ◽

Chi Square ◽

Normal Individuals ◽

Increased Risk ◽

Significant Difference ◽

Pcr Rflp ◽

Chi Square Test ◽

History Of

Objective: To perform genotyping for MTR A2756G polymorphism and identification of risk factors associated with head and neck squamous cell carcinoma (HNSCC). Study Design: Cross section, comparative study. Place and Duration of Study: The study was carried out at the Department of Biochemistry of Quaid-i- Azam University, Islamabad from October 2014 to August 2015. Materials and Methods: In this study, 292 diagnosed patients HNSCC and 324 normal individuals without any history of cancer were enrolled. Blood samples of patients and controls were collected in ethylenediamine tetra acetic acid (EDTA) and DNA was extracted using conventional method. All samples were genotyped for the MTR A2756G polymorphism using PCR-RFLP. Frequency of polymorphism was compared between HNSCC patients andcontrols. MultipleLogisticRegression(MLR)andchi-squaretestwasperformedtoexaminetheassociation of MTR A2756G polymorphism with risk factor. Results: Chi-square test of independence showed statistically significant difference among the variables of age, smoking and MTR A2756G genotype (p-value<0.05). Multivariate analysis showed that smoking (adjusted OR, 3.7; 95% CI, 2.3 – 6.0), age groups 41 – 50 years (adjusted OR, 3.6; 95% CI, .9 – 6.7) and > 60 years (adjusted OR, 3.5; 95% CI, 1.7 – 7.3), MTR 2756 AG genotype (adjusted OR, 2.1; 95% CI, 1.3 – 3.5) is associated with increased risk of HNSCC. Conclusion: The results suggest that the genetic polymorphism MTR A2756G is associated with the occurrence of HNSCC in the Pakistani population while the individuals between 40 to 50 years of age and those who are smokers are at a greater risk of developing HNSCC.

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