Accuracy of delirium risk factors in adult intensive care unit patients

Objective: To assess the accuracy measurements for predisposing and precipitating Risk Factors for delirium in an adult Intensive Care Unit. Method: Cohort, prospective study with patients over 18 who had been hospitalized for over 24 hours and were able to communicate. The patients were assessed once a day until the onset of delirium or permanence in the Intensive Care Unit. Instruments were employed to track delirium, characterize the sample, and identify the risk factors. Descriptive statistics was employed for sample characterization and accuracy tests for risk factors. Results: The included patients amounted to 102, 31 of which presented delirium. The predisposing predictive risk factors were hypoalbuminemia, American Society of Anesthesiology over three, severity, altered tissue perfusion, dehydration, and being a male, whereas precipitating predictive factors were physical restraint, infection, pharmacological agent, polypharmacy, anemia, altered renal function, dehydration, invasive devices, altered tissue perfusion and altered quality and quantity of sleep. Conclusion: An accurate identification of predisposing and precipitating risk factors may contribute to planning preventive measures against delirium.

Influence of Cold-TRP Receptors on Cold-Influenced Behaviour

The transient receptor potential (TRP) channels, TRPA1 and TRPM8, are thermo-receptors that detect cold and cool temperatures and play pivotal roles in mediating the cold-induced vascular response. In this study, we investigated the role of TRPA1 and TRPM8 in the thermoregulatory behavioural responses to environmental cold exposure by measuring core body temperature and locomotor activity using a telemetry device that was surgically implanted in mice. The core body temperature of mice that were cooled at 4 °C over 3 h was increased and this was accompanied by an increase in UCP-1 and TRPM8 level as detected by Western blot. We then established an effective route, by which the TRP antagonists could be administered orally with palatable food. This avoids the physical restraint of mice, which is crucial as that could influence the behavioural results. Using selective pharmacological antagonists A967079 and AMTB for TRPA1 and TRPM8 receptors, respectively, we show that TRPM8, but not TRPA1, plays a direct role in thermoregulation response to whole body cold exposure in the mouse. Additionally, we provide evidence of increased TRPM8 levels after cold exposure which could be a protective response to increase core body temperature to counter cold.

Patient Factors That Influence Reliable Delirium Assessments in a Medical Intensive Care Unit During the Routine Clinical Practice

This study aimed to determine patient and therapeutic characteristics of patients in the medical intensive care unit (MICU) that contribute to inconsistent results of delirium assessments performed during routine clinical practice. Therefore, electronic health records were reviewed and compared with secondary data collected from the same medical ICU patients who were assessed using the Confusion Assessment Method in the ICU (CAM-ICU). Of 5,241 cases involving 762 patients, 827 (15.78%) cases showed disagreement between assessments. Continuous renal replacement therapy, physical restraint use, and altered mental status were factors that increased the likelihood of inconsistencies between assessments. A significant positive correlation was found between the CAM-ICU disagreement rate and the total number of assessments per month. To maximize the reliability of delirium assessments, individual-targeted approaches considering the patient’s level of consciousness and type of treatment implemented are required, along with ensuring a stable, and regulated working environment and customized educational programs.

Stress-impaired reward pathway promotes distinct feeding behavior patterns

Psychosocial stress can impact feeding behavior outcomes. Although many studies have examined alterations to food intake, little is known about how stress affects feeding behavior patterns. To determine the impact of psychological stress on feeding behavior patterns, mice were subjected to various psychosocial stressors (social isolation, intermittent high-fat-diet, or physical restraint) prior to timed observations in a feeding arena that incorporated multiple bait loci. In addition, in vivo microdialysis was used to assess the effects of stressors on the reward system by measuring dopamine levels in the nucleus accumbens (NAcc) shell. Impaired feeding behavior patterns characterized by significant deviations in bait selection (i.e. fixated feeding) and prolonged periods of eating (i.e. protracted feeding) were observed in stressed mice relative to non-stressed controls. In addition to clear behavioral effects, the stressors also negatively impacted dopamine levels at the nucleus accumbens shell. Normalization of dopamine reversed the fixated feeding behavior, whereas specifically inhibiting neuronal activity in the dopaminergic neurons of the ventral tegmental area that project to the nucleus accumbens shell caused similar impairments in feeding. Given that the deviations were not consistently accompanied by changes in the amount of bait consumed, body weight, or metabolic factors, the qualitative effects of psychosocial stressors on feeding behavior likely reflect perturbations to a critical pathway in the mesolimbic dopamine system. These findings provide compelling evidence that aberrations in feeding behavior patterns can be developed as sensitive biomarkers of psychosocial stress and possibly a prodromal state of neuropsychiatric diseases.

Limited Use Only. How Can the Design of an Everyday Object Evoke an Initiation of Use in Chronic Stroke Survivors

<p>Stroke causes significant damage to the brain and affects 15 million people annually worldwide. Symptoms commonly affect one or both limbs on one side of the body, limiting ability to perform daily activities. The preferential use of the less affected limb for performing everyday activities in the form of compensatory movement is a common phenomenon after a stroke and can lead to a “learned nonuse” of the affected arm and hand. This learned behaviour can be overcome by applying a physical restraint on the less affected arm to initiate use of the affected one. Stroke interventions that use physical restraint are criticised for being labour intensive and expensive and having a limited focus on the home environment of the stroke survivor. This study aimed to design everyday objects that restrain movement to initiate the use of the affected arm and hand. It was undertaken from a pragmatist theoretical perspective, using a human-centred design approach to develop an understanding of the users’ needs and create design solutions that addressed the observed problem. A qualitative multimethod approach helped understanding of how the restraining effect needs to be delivered to initiate use of the affected arm, and which everyday objects are key in daily activities post-stroke. The research through design methodology was employed for developing expansive and serial design prototypes to test how the restraint could be incorporated into a design prototype. The prototypes were evaluated with health professionals and chronic stroke survivors to validate the intended initiation of use. Findings of this study indicate that the development of learned nonuse is multifactorial and occurs over time. The current use of restraint in clinical practice focuses on reminding the survivor to use the affected arm and hand rather than physically restraining its use. It was emphasised by the therapists that a behaviour change is a crucial element in overcoming learned nonuse in the long-term. The evaluation of the design prototypes indicated that the design of the object needs to take into consideration the conceptual model the user has of the object and the interaction needs to be feasible to perform for the stroke survivor. Five different design strategies were developed to restrain movement and elicit an initiation of use. The restraining effect that is evoked by the design strategies can vary between the different users. Additionally, the object needs to provide sufficient feedforward to initiate the use of the affected arm and hand, increase self-efficacy beliefs, provide a repetitive and increasingly challenging movement, provide feedback and sensory input to secure engagement in the process. A behaviour change is an essential element to overcome the learned nonuse in the long-term. A behaviour contract was, therefore, incorporated in the form of the design components to facilitate such a change. At this stage it is unclear which strategy offers the greatest potential to evoke an initiation of use and if the behaviour contract contributes to overcoming the learned nonuse. Further studies are needed to increase the restraining effect and usability of the design prototypes and validate the long-term impact.</p>

Limited Use Only. How Can the Design of an Everyday Object Evoke an Initiation of Use in Chronic Stroke Survivors

<p>Stroke causes significant damage to the brain and affects 15 million people annually worldwide. Symptoms commonly affect one or both limbs on one side of the body, limiting ability to perform daily activities. The preferential use of the less affected limb for performing everyday activities in the form of compensatory movement is a common phenomenon after a stroke and can lead to a “learned nonuse” of the affected arm and hand. This learned behaviour can be overcome by applying a physical restraint on the less affected arm to initiate use of the affected one. Stroke interventions that use physical restraint are criticised for being labour intensive and expensive and having a limited focus on the home environment of the stroke survivor. This study aimed to design everyday objects that restrain movement to initiate the use of the affected arm and hand. It was undertaken from a pragmatist theoretical perspective, using a human-centred design approach to develop an understanding of the users’ needs and create design solutions that addressed the observed problem. A qualitative multimethod approach helped understanding of how the restraining effect needs to be delivered to initiate use of the affected arm, and which everyday objects are key in daily activities post-stroke. The research through design methodology was employed for developing expansive and serial design prototypes to test how the restraint could be incorporated into a design prototype. The prototypes were evaluated with health professionals and chronic stroke survivors to validate the intended initiation of use. Findings of this study indicate that the development of learned nonuse is multifactorial and occurs over time. The current use of restraint in clinical practice focuses on reminding the survivor to use the affected arm and hand rather than physically restraining its use. It was emphasised by the therapists that a behaviour change is a crucial element in overcoming learned nonuse in the long-term. The evaluation of the design prototypes indicated that the design of the object needs to take into consideration the conceptual model the user has of the object and the interaction needs to be feasible to perform for the stroke survivor. Five different design strategies were developed to restrain movement and elicit an initiation of use. The restraining effect that is evoked by the design strategies can vary between the different users. Additionally, the object needs to provide sufficient feedforward to initiate the use of the affected arm and hand, increase self-efficacy beliefs, provide a repetitive and increasingly challenging movement, provide feedback and sensory input to secure engagement in the process. A behaviour change is an essential element to overcome the learned nonuse in the long-term. A behaviour contract was, therefore, incorporated in the form of the design components to facilitate such a change. At this stage it is unclear which strategy offers the greatest potential to evoke an initiation of use and if the behaviour contract contributes to overcoming the learned nonuse. Further studies are needed to increase the restraining effect and usability of the design prototypes and validate the long-term impact.</p>

Between Restrictive and Supportive Devices in the Context of Physical Restraints: Findings from a Large Mixed-Method Study Design

Physical restraints are still a common problem across healthcare settings: they are triggered by patient-related factors, nurses, and context-related factors. However, the role of some devices (e.g., bed rails), and those applied according to relatives’/patients’ requests have been little investigated to date. A mixed-method study in 2018, according to the Good Reporting of a Mixed Methods Study criteria was performed. In the quantitative phase, patients with one or more physical restraint(s) as detected through observation of a single index day in 37 Italian facilities (27 long-term, 10 hospital units, =4562 patients) were identified. Then, for each patient with one or more restraint(s), the nurse responsible was interviewed to gather purposes and reasons for physical restraints use. A thematic analysis of the narratives was conducted to (a) clarify the decision-making framework that had been used and (b) to assess the differences, if any, between hospital and long-term settings. The categories ‘Restrictive’ and ‘Supportive’ devices aimed at ‘Preventing risks’ and at ‘Promoting support’, respectively, have emerged. Reasons triggering ‘restrictive devices’ involved patients’ risks, the health professionals’ and/or the relatives’ concerns. In contrast, the ‘supportive’ ones were triggered by patients’ problems/needs. ‘Restrictive’ and ‘Supportive’ devices were applied based on the decision of the team or through a process of shared decision-making involving relatives and patients. According to the framework that emerged, long-term care patients are at increased risk of being treated with ‘restrictive devices’ (Odds Ratio 1.87, Confidence Interval 95% 1.44; 2.43; p < 0.001) as compared to those hospitalized. This study contributes to the improvement in knowledge of the definition, classification and measurement of physical devices across settings.