Delirium in Hospitalized Older Adults
N Engl J Med 2017; 377:1456-1466October 12, 2017DOI: 10.1056/NEJMcp1605501
The word Vitamin does not occur once in the NEJM article
Hospital induced delirium 2X more likely if low vitamin D – April 2015
*Delirium 24 percent more likely for each 2.5 ng lower vitamin D (313,000 patients) – Feb 2019
Other Hospital problems with low vitamin D
- 2X more likely to get hospital infection if low vitamin D (10 ng) when enter – Oct 2013
- Superbug (Clostridium difficile) 4.7X more of a problem if low vitamin D – Sept 2013
- 18 fewer hospital days if given 500,000 IU of vitamin D while ventilated in ICU – RCT June 2016
- Surgical outcomes are better for higher levels of Vitamin D – systematic review May 2015
- Pneumonia Risk, intensity, and mortality all associated with low vitamin D
- Postoperative cognitive dysfunction 8 X more likely if low vitamin D – March 2018
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This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.
A 75-year-old man is admitted for scheduled major abdominal surgery. He is functionally independent, with mild forgetfulness. His intraoperative course is uneventful, but on postoperative day 2, severe confusion and agitation develop. What is going on? How would you manage this patient’s care? Could his condition have been prevented?
THE CLINICAL PROBLEM
Although delirium has been described in the medical literature for more than two millennia, the condition is still frequently not recognized, evaluated, or managed appropriately.1,2 Delirium is also known as acute confusional state, altered mental status, and toxic metabolic encephalopathy, among more than 30 descriptive terms.3 Delirium can be thought of as acute brain failure 4 and is the final common pathway of multiple mechanisms, similar to acute heart failure. The official definition of delirium in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),5 requires a disturbance in attention and awareness that develops acutely and tends to fluctuate (Table 1)
Diagnostic Criteria for Delirium.). The pathophysiological mechanisms of delirium remain poorly understood; leading models include neurotransmitter imbalance and neuroinflammation.1,2,7,8
KEY CLINICAL POINTS: Delirium in Hospitalized Older Adults
- Delirium is an acute confusional state that is extremely common among hospitalized elders and is strongly associated with poor short-term and long-term outcomes.
- The risk of delirium can be assessed according to the presence of predisposing (baseline) and precipitating (acute) factors. The more predisposing factors that are present, the fewer precipitating factors that are required to cause delirium.
- The first step in delirium management is accurate diagnosis; a brief validated instrument that assesses features in the Confusion Assessment Method algorithm is recommended.
- After receiving a diagnosis of delirium, patients require a thorough evaluation for reversible causes; all correctable contributing factors should be addressed.
- Behavioral disturbances should be managed with nonpharmacologic approaches first. If required for patient safety, low doses of high-potency antipsychotic agents are usually the treatment of choice (off-label use). Treatment should be targeted to specific behaviors and stopped as soon as possible.
- Proactive, multifactorial interventions and geriatrics consultation have been shown to reduce the incidence, severity, and duration of delirium.