Delirio en ancianos / Delirium in older people

Octubre 23, 2015. No. 2123Octubre, mes de lucha contra cáncer de mama.

Intervenciones para la prevención del delirio en las personas mayores en la atención institucional a largo plazo. Interventions for preventing delirium in older people in institutional long-term care. Clegg A, Siddiqi N, Heaven A, Young J, Holt R. Cochrane Database Syst Rev. 2014 Jan 31;1:CD009537. doi: 10.1002/14651858.CD009537.pub2. Abstract BACKGROUND: Delirium is a common and distressing complication of a range of stressor events including infection, new medications and environment change that is often experienced by older people with frailty and dementia. Older people living in institutional long-term care (LTC)are at high risk of delirium, which increases the risk of admission to hospital, development of or worsening of dementia, and mortality.Delirium is also associated with substantial healthcare costs. Although it is possible to prevent delirium in the hospital setting by providing multicomponent delirium prevention interventions it is currently unclear whether interventions to prevent delirium in LTCare effective. OBJECTIVES: To assess the effectiveness of interventions for preventing delirium in older people in long term care. SEARCH METHODS: We searched ALOIS (www.medicine.ox.ac.uk/alois) - the Cochrane Dementia and Cognitive Improvement Group's Specialised Register- on 23 April 2013. The search was as sensitive as possible to identify all studies on ALOIS relating to delirium. We ran additional separate searches in major healthcare databases, trial registers, the Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources, to ensure that the search was as comprehensive as possible. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single- and multi componentn on-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence. DATA COLLECTION AND ANALYSIS: Two independent review authors examined the titles and abstracts of citations identified by the search for eligibility and extracted data, with any disagreements settled by consensus. Primary outcomes were prevalence, incidence and severity of delirium. Secondary outcomes included new diagnosis of dementia, activities of daily living, quality of life and adverse outcomes. We used risk ratios (RRs)as measures of treatment effect for dichotomous outcomes and hazard ratios (HR) for time to event data.Main results We included two trials that recruited 3636 participants.Both were complex single-component non-pharmacological delirium prevention interventions. Risk of bias for many items was unclear due to inadequate reporting. Notably, there was no evidence of blinding of trial participants or assessors in either trial. One small cluster-RCT (n = 98) of a hydration-based intervention reported no reduction in delirium incidence in the intervention group compared to control (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00, analysis not adjusted for clustering, very low quality evidence). Results were imprecise and there were serious limitations evident in trial design.One large cluster-RCT (n = 3538) of a computerised system to identify medications that may contribute to delirium risk and trigger a pharmacist-led medication review reported a large reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51, moderat equality evidence) but no clear evidence of reduction in hospital admissions (HR 0.89, CI 0.72 to 1.10, moderate quality evidence), in mortality (HR 0.88, CI 0.66 to 1.17, moderate quality evidence) or in falls risk (HR 1.03, CI 0.92 to 1.15, moderate quality evidence).Authors' conclusions Our review identified very limited evidence on interventions for preventing deliriumin older people in LTC. Introduction of a software based intervention to identify medications that could contribute to delirium risk so that a pharmacist-led medication review and monitoring plan can be initiated may reduce incidence of delirium for older people in institutional LTC. This is based on one large RCT in the United States and may not be practical in other countries which do not have comparable information technology services available in care homes. Our review identified only one ongoing pilot trial of a multicomponent delirium prevention intervention and no trials of pharmacological agents. Future trials of computerised medication management systems and multicomponent non-pharmacological and pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence based care for this vulnerable group. PDF Efectos de dos métodos de anestesia-analgesia sobre la incidencia de delirio postoperatorio en los ancianos operados de cirugía mayor torácica y abdominal Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial. Li YW, Li HJ, Li HJ1, Feng Y, Yu Y, Guo XY, Li Y, Zhao BJ, Hu XY, Zuo MZ, Zhang HY, Wang MR, Ji P,Yan XY, Wu YF, Wang DX. BMC Anesthesiol. 2015 Oct 13;15(1):144. doi: 10.1186/s12871-015-0118-5. Abstract BACKGROUND: Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality. Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium. Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery. Compared with general anesthesia alone and postoperative intravenous analgesia, combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery. However, whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown. METHODS/DESIGN: This is a multicenter, open-label, randomized, parallel-controlled clinical trial. One thousand eight hundred elderly patients (age range 60-90 years) who are scheduled to undergo major thoracic or abdominal surgery are randomized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia. The primary outcome is the 7-day incidence of postoperative delirium. Secondary outcomes include the duration of postoperative delirium, the intensity of pain during the first three days after surgery, the 30-day incidences of postoperative non-delirium complications, the length of stay in hospital after surgery and 30-day all-cause mortality. DISCUSSION: Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Reacciones adversas en geriatría/Adverse drug reactions in geriatrics

Octubre 22, 2015. No. 2122Octubre, mes de lucha contra cáncer de mama.

Reacciones adversas en poblaciones especiales. El anciano Adverse drug reactions in special populations - the elderly. Davies EA, O'Mahony MS. Br J Clin Pharmacol. 2015 Oct;80(4):796-807. doi: 10.1111/bcp.12596. Epub 2015 May 22. Abstract The International Conference on Harmonization considers older people a 'special population', as they differ from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics and greater vulnerability to adverse drug reactions (ADRs). Medical practice is often based on single disease guidelines derived from clinical trials that have not included frail older people or those with multiple morbidities. This presents a challenge caring for older people, as drug doses in trials may not be achievable in real world patients and risks of ADRs are underestimated in clinical trial populations. The majority of ADRs in older people are Type A, potentially avoidable and associated with commonly prescribed medications. Several ADRs are particularly associated with major adverse consequences in the elderly and their reduction is therefore a clinical priority. Falls are strongly associated with benzodiazepines, neuroleptics, antidepressants and antihypertensives. There is good evidence for medication review as part of a multifactorial intervention to reduce falls risk in community dwelling elderly. Multiple medications also contribute to delirium, another multifactorial syndrome resulting in excess mortality particularly in frail older people. Clostridium difficile associated with use of broad spectrum antibiotics mainly affects frail older people and results in prolonged hospital stay with substantial morbidity and mortality. Antipsychotics increase the risk of stroke by more than three-fold in patients with dementia. Inappropriate prescribing can be reduced by adherence to prescribing guidelines, suitable monitoring and regular medication review. Given the heterogeneity within the older population, providing individualized care is pivotal to preventing ADRs. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Raquia vs bloqueos periféricos en cirugía de cadera/Spinal vs peripheral nerve blocks for hip surgery

Octubre 20, 2015. No. 2120Octubre, mes de lucha contra cáncer de mama.

Comparación entre raquia unilateral y bloqueo paravertebral  L1 combinado con bloqueo compartamental del psoas y nervio ciático en pacientes con prótesis parcial de cadera Comparison of unilateral spinal anesthesia and L1 paravertebral block combined with psoas compartment and sciatic nerve block in patients to undergo partial hip prosthesis. Demirel I1, Ozer AB, Duzgol O, Bayar MK, Karakurt L, Erhan OL. Eur Rev Med Pharmacol Sci. 2014;18(7):1067-72. Abstract OBJECTIVES: Just as hip prosthesis, most of the patients undergoing orthopedic lower extremity surgery (OLES) belong to the advanced age group. Sciatic nerve block combined with psoas compartment block is used as a technique alternative to central neuraxial block and GA. In geriatric patients that will undergo partial hip prosthesis, the effects of the methods of unilateral spinal anesthesia (SA) and L1 paravertebral block combined with psoas compartment block (PCB) and sciatic nerve block (PCSL) on peroperative hemodynamic parameters and the duration of need for postoperative analgesia were studied. PATIENTS AND METHODS: Fifty patients from the ASA III-IV group were randomly divided into two groups. Group SA was administered spinal anesthesia with hyperbaric bupivacaine (2 ml, 0.5%) from the selected intervertebral distance (L4-L5 or L3-L4) in lateral position. Group PCSL was administered L1 paravertebral block combined with PCB and sciatic nerve block with bupivacaine hydrochloride (total 35 ml). Hemodynamic parameters (HR: heart rate and MAP: mean artery pressure) were recorded in pre- and post-intervention 5-minute intervals. The initial time of the need for analgesia of patients were evaluated postoperatively. RESULTS: Any failure in methods implemented on patients in either group was not observed. Times of anesthesia and surgical preparation ofpatients were observed to have significantly prolonged in the PCSL compared to Group SA (p < 0.005). Hundred and 5th and 110th min. mean arterial pressures of patients was found to be significantly higher in Group SA compared to Group PCSL (p < 0.05). The initial time of the need for analgesia was observed to be significantly prolonged in Group PCSL (432.80 ± 236.77 min) compared to Group SA (185.40 ± 171.40 min) (p < 0.001). CONCLUSIONS: Unilateral SA conducted with bupivacaine hydrochloride and PCSL block technique provided a hemodynamically similar activity in the perioperative period in patients that underwent partial hip operation. However, PCSL block implementation extended the initial time of the need for analgesia in postoperative period. PCSL method could be selected in cases belonging to such group of patients. PCSL block can be a alternative anesthetic tecniques in patients that underwent partial hip operation. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Info preoperatoria en pediatria / Preop information in pediatrics

Octubre19, 2015. No. 2119Octubre, mes de lucha contra cáncer de mama.

¿Que información preopoeratoria desean los padres de los niños que se serán operados? What preoperative information do the parents of children undergoing surgery want? Sartori J, Espinoza P, Díaz MS, Ferdinand C, Lacassie HJ, González A. Rev Chil Pediatr. 2015 Oct 8. pii: S0370-4106(15)00182-5. doi: 10.1016/j.rchipe.2015.06.021. Abstract INTRODUCTION: Parents feel fear and anxiety before surgery is performed on their child, and those feelings could obstruct their preparation for the surgery. Preoperative information could relieve those feelings. OBJECTIVE: To determine the preoperative information needs of parents of children undergoing elective surgery. PATIENTS AND METHOD: A study was conducted on the parents of children who underwent elective surgery. Demographic data of parents were recorded. Preoperative information received or would like to have received was assessed in terms of contents, methods, opportunity, place and informant. Descriptive statistics were used. RESULTS: Thirteen hundred parents were surveyed. More than 80% of them want preoperative information about anaesthesia, surgery, preoperative fasting, drugs and anaesthetic complications, monitoring, intravenous line management, pain treatment, postoperative feeding, anxiety control, hospitalisation room, recovery room, and entertainment in recovery room. Most want to be informed verbally, one to two weeks in advance and not on the same day of surgery. The informant should be the surgeon and in his office. In addition, they want information through leaflets, videos and simulation workshops, or guided tours. CONCLUSIONS: Parents need complete preoperative information about anesthesia, surgery and postoperative care, received verbally and in advance. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015