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Impact of delirium on acute stroke outcomes: A systematic review and meta-analysis

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Abstract

Delirium is a common complication in acute stroke patients. A 2011 meta-analysis showed an increased risk of in-hospital mortality and mortality within 12 months post-stroke, longer hospitalization durations, and increased likelihood of being discharged to a nursing home for patients experiencing post-stroke delirium. There is a need for an updated meta-analysis with several new studies having been since published. The PubMed and Scopus databases were screened for relevant studies. Inclusion criteria were as follows: retrospective or prospective studies reporting on the effects of delirium accompanying acute stroke on mortality, functional outcomes, length of hospital stay and need for re-admission. Strength of association was presented as pooled adjusted relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Statistical analysis was done using STATA version 16.0. The meta-analysis included 22 eligible articles. Eighteen of the 22 studies were prospective follow ups. Included studies were of good quality. Post-stroke delirium was associated with increased risk of in-hospital mortality, as well as mortality within 12 months post-stroke. Patients with delirium experienced increased hospital stay durations, were at greater risk for hospital readmission, and showed elevated risk for poor functional outcome. Compared to those who did not have delirium, stroke patients with delirium were 42% less likely to be discharged to home. Acute stroke patients with delirium are at an increased risk for poor short- and long-term outcomes. More research is needed to identify the best set of interventions to manage such patients and improve outcomes.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Marcantonio ER (2017) Delirium in Hospitalized Older Adults. N Engl J Med 377(15):1456–1466

    Article  PubMed  PubMed Central  Google Scholar 

  2. Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ (2020) Delirium. Nat Rev Dis Prim 6(1):90

    Article  PubMed  Google Scholar 

  3. Fuchs S, Bode L, Ernst J, Marquetand J, von Känel R, Böttger S (2020) Delirium in elderly patients: Prospective prevalence across hospital services. Gen Hosp Psychiatr 67:19–25

    Article  Google Scholar 

  4. Ospina JP, King F IV, Madva E, Celano CM (2018) Epidemiology, mechanisms, diagnosis, and treatment of delirium: a narrative review. Clin Med Ther 1(1):3

    Google Scholar 

  5. Al Farsi RS, Al Alawi AM, Al Huraizi AR, Al-Saadi T, Al-Hamadani N, Al Zeedy K et al (2023) Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study. J Clin Med 12(12):3897

    Article  PubMed  PubMed Central  Google Scholar 

  6. 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):3028–3036

    Article  PubMed  Google Scholar 

  7. Hshieh TT, Inouye SK, Oh ES (2020) Delirium in the elderly. Clin Geriatr Med 36(2):183–199

    Article  PubMed  Google Scholar 

  8. Maldonado JR (2018) Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatr 33(11):1428–1457

    Article  Google Scholar 

  9. Kowalska K, Klimiec E, Weglarczyk K, Pera J, Slowik A, Siedlar M et al (2018) Reduced ex vivo release of pro-inflammatory cytokines and elevated plasma interleukin-6 are inflammatory signatures of post-stroke delirium. J Neuroinflammation. 15(1):111. https://doi.org/10.1186/s12974-018-1156-y. [cited 2021 Nov 8]

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Ahmed S, Leurent B, Sampson EL (2014) Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age Ageing 43(3):326–333

    Article  PubMed  PubMed Central  Google Scholar 

  11. Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 275(11):852–7

    Article  CAS  PubMed  Google Scholar 

  12. Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC (2023) Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 6(1):e2249950

    Article  PubMed  PubMed Central  Google Scholar 

  13. Franco JG, Valencia C, Bernal C, Ocampo MV, Trzepacz PT, de Pablo J et al (2010) Relationship between cognitive status at admission and incident delirium in older medical inpatients. J Neuropsychiatry Clin Neurosci 22(3):329–337

    Article  PubMed  Google Scholar 

  14. Gravante F, Giannarelli D, Pucci A, Gagliardi AM, Mitello L, Montagna A, Latina R (2021) Prevalence and risk factors of delirium in the intensive care unit: An observational study. Nurs Crit Care 26(3):156–165

    Article  PubMed  Google Scholar 

  15. Wakefield BJ (2002) Risk for acute confusion on hospital admission. Clin Nurs Res 11(2):153–172

    Article  PubMed  Google Scholar 

  16. Sandberg O, Franklin KA, Bucht G, Gustafson Y (2001) Sleep apnea, delirium, depressed mood, cognition, and ADL ability after stroke. J Am Geriatr Soc 49(4):391–397

    Article  CAS  PubMed  Google Scholar 

  17. Oldenbeuving AW, de Kort PLM, Jansen BPW, Algra A, Kappelle LJ, Roks G (2011) Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology 76(11):993–999

    Article  CAS  PubMed  Google Scholar 

  18. Markus R, Reutens DC, Kazui S, Read S, Wright P, Pearce DC et al (2004) Hypoxic tissue in ischaemic stroke: persistence and clinical consequences of spontaneous survival. Brain J Neurol 127(Pt 6):1427–1436

    Article  CAS  Google Scholar 

  19. Hoffman WE, Wheeler P, Edelman G, Charbel FT, Torres NJ, Ausman JI (2000) Hypoxic brain tissue following subarachnoid hemorrhage. Anesthesiology 92(2):442–446

    Article  CAS  PubMed  Google Scholar 

  20. Oldenbeuving AW, de Kort PLM, Jansen BPW, Roks G, Kappelle LJ (2007) Delirium in acute stroke: a review. Int J Stroke Off J Int Stroke Soc 2(4):270–275

    Article  CAS  Google Scholar 

  21. Dahl MH, Rønning OM, Thommessen B (2010) Delirium in acute stroke–prevalence and risk factors. Acta Neurol Scand Suppl 190:39–43

    Article  Google Scholar 

  22. Alvarez-Perez FJ, Paiva F (2017) Prevalence and Risk Factors for Delirium in Acute Stroke Patients. A Retrospective 5-Years Clinical Series. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc. 26(3):567–73

    Article  Google Scholar 

  23. Shi Q, Presutti R, Selchen D, Saposnik G (2012) Delirium in acute stroke: a systematic review and meta-analysis. Stroke 43(3):645–649

    Article  PubMed  Google Scholar 

  24. Wells G, Shea B, O’Connell D, Robertson J, Peterson J, Welch V et al (2014) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Available from: https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 8 Nov 2021

  25. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions [Internet]. [cited 2021 Jul 31]. Available from: https://training.cochrane.org/handbook/current. Accessed 31 July 2021

  26. Miu DKY, Yeung JCY (2013) Incidence of post-stroke delirium and 1-year outcome. Geriatr Gerontol Int 13(1):123–129

    Article  PubMed  Google Scholar 

  27. Kotfis K, Bott-Olejnik M, Szylińska A, Listewnik M, Rotter I. Characteristics, Risk Factors And Outcome Of Early-Onset Delirium In Elderly Patients With First Ever Acute Ischemic Stroke - A Prospective Observational Cohort Study. Clin Interv Aging [Internet]. 2019 Oct 21 [cited 2021 Nov 8];14:1771–82. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814355/. Accessed 8 Nov 2021

  28. Qu J, Chen Y, Luo G, Zhong H, Xiao W, Yin H (2018) Delirium in the Acute Phase of Ischemic Stroke: Incidence, Risk Factors, and Effects on Functional Outcome. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc 27(10):2641–2647

    Article  Google Scholar 

  29. Pasińska P, Wilk A, Kowalska K, Szyper-Maciejowska A, Klimkowicz-Mrowiec A (2019) The long-term prognosis of patients with delirium in the acute phase of stroke: PRospective Observational POLIsh Study (PROPOLIS). J Neurol 266(11):2710–2717

    Article  PubMed  PubMed Central  Google Scholar 

  30. Vahidy FS, Bambhroliya AB, Meeks JR, Rahman O, Ely EW, Slooter AJC et al (2019) In-hospital outcomes and 30-day readmission rates among ischemic and hemorrhagic stroke patients with delirium. PLoS ONE 14(11):e0225204

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Klimiec-Moskal E, Lis A, Pera J, Slowik A, Dziedzic T. Subsyndromal delirium is associated with poor functional outcome after ischaemic stroke. 2019 [cited 2021 Nov 8]; Available from: https://dl.uswr.ac.ir/handle/Hannan/54384. Accessed 8 Nov 2021

  32. Dostović Z, Smajlović D, Sinanović O, Vidović M (2009) Duration of delirium in the acute stage of stroke. Acta Clin Croat 48(1):13–17

    PubMed  Google Scholar 

  33. Mc Manus JT, Pathansali R, Ouldred E, Stewart R, Jackson SHD (2011) Association of delirium post-stroke with early and late mortality. Age Ageing 40(2):271–274

    Article  PubMed  Google Scholar 

  34. Sheng AZ, Shen Q, Cordato D, Zhang YY, Yin Chan DK (2006) Delirium within three days of stroke in a cohort of elderly patients. J Am Geriatr Soc 54(8):1192–1198

    Article  PubMed  Google Scholar 

  35. Melkas S, Laurila JV, Vataja R, Oksala N, Jokinen H, Pohjasvaara T et al (2012) Post-stroke delirium in relation to dementia and long-term mortality. Int J Geriatr Psychiatr 27(4):401–408

    Article  Google Scholar 

  36. Hénon H, Lebert F, Durieu I, Godefroy O, Lucas C, Pasquier F et al (1999) Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome. Stroke 30(4):773–779

    Article  PubMed  Google Scholar 

  37. Gustafson Y, Olsson T, Eriksson S, Asplund K, Bucht G. Acute Confusional States (Delirium) in Stroke Patients. Cerebrovasc Dis [Internet]. 1991 [cited 2021 Nov 8];1(5):257–64. Available from: https://www.karger.com/Article/FullText/108852. Accessed 8 Nov 2021

  38. Ojagbemi A, Bello T, Elugbadebo O, Owolabi M, Baiyewu O (2020) Different Cognitive and Functional Outcomes in Attenuated and Full Delirium Syndromes Among Recent Stroke Survivors. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc 29(11):105251

    Article  Google Scholar 

  39. Caeiro L, Ferro JM, Albuquerque R, Figueira ML (2004) Delirium in the first days of acute stroke. J Neurol 251(2):171–178

    Article  PubMed  Google Scholar 

  40. Nydahl P, Bartoszek G, Binder A, Paschen L, Margraf NG, Witt K, et al. Prevalence for delirium in stroke patients: A prospective controlled study. Brain Behav [Internet]. 2017 Jun 23 [cited 2021 Nov 8];7(8):e00748. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5561309/. Accessed 8 Nov 2021

  41. Kozak HH, Uğuz F, Kılınç İ, Uca AU, SerhatTokgöz O, Akpınar Z et al (2017) Delirium in patients with acute ischemic stroke admitted to the non-intensive stroke unit: Incidence and association between clinical features and inflammatory markers. Neurol Neurochir Pol 51(1):38–44

    Article  PubMed  Google Scholar 

  42. Turco R, Bellelli G, Morandi A, Gentile S, Trabucchi M (2013) The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation. J Geriatr Psychiatry Neurol 26(2):63–68

    Article  PubMed  Google Scholar 

  43. Zaitoun AM, Elsayed DAF, Ramadan BM, Gaffar HAA. Assessment of the risk factors and functional outcome of delirium in acute stroke. Egypt J Neurol Psychiatry Neurosurg [Internet]. 2019 Feb 20 [cited 2021 Nov 8];55(1):17. Available from: https://doi.org/10.1186/s41983-019-0059-x

  44. Fialho Silva IT, Assis Lopes P, Timotio Almeida T, Ramos SC, CalimanFontes AT, Guimarães Silva D et al (2021) Impact of Delirium and Its Motor Subtypes on Stroke Outcomes. Stroke 52(4):1322–1329

    Article  CAS  PubMed  Google Scholar 

  45. McManus J, Pathansali R, Hassan H, Ouldred E, Cooper D, Stewart R, Macdonald A, Jackson S (2009) The course of delirium in acute stroke. Age Ageing 38(4):385–389

    Article  PubMed  Google Scholar 

  46. Ali S, Patel M, Jabeen S, Bailey RK, Patel T, Shahid M, et al. Insight into Delirium. Innov Clin Neurosci [Internet]. 2011 Oct [cited 2021 Nov 8];8(10):25–34. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225129/. Accessed 8 Nov 2021

  47. Mansutti I, Saiani L, Palese A. Detecting delirium in patients with acute stroke: a systematic review of test accuracy. BMC Neurol [Internet]. 2019 Dec 2 [cited 2021 Nov 8];19(1):310. Available from: https://doi.org/10.1186/s12883-019-1547-4

  48. Makin SDJ, Wardlaw J (2014) Predicting delirium after a stroke. J Neurol Neurosurg Psychiatry 85(4):357

    Article  PubMed  Google Scholar 

  49. 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):1590–1599

    Article  CAS  PubMed  Google Scholar 

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Funding

Zhejiang Province Traditional Chinese Medicine Science and Technology Plan Project (No.: 2020ZB183).

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Authors and Affiliations

  1. Department of Geriatry, Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine, No. 208, Huancheng East Road, Hangzhou, 310006, Zhejiang Province, China

    Xiao Gong, Shu Jin, Yong Zhou, Lihua Lai & Wanyi Wang

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Contributions

XG, SJ conceived and designed the study; YZ, LH were involved in literature search and data collection; LH and WY analyzed the data; XG, SJ wrote the paper; and WY reviewed and edited the manuscript. All authors read and approved the final manuscript.

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Correspondence to Xiao Gong.

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Gong, X., Jin, S., Zhou, Y. et al. Impact of delirium on acute stroke outcomes: A systematic review and meta-analysis. Neurol Sci 45, 1897–1911 (2024). https://doi.org/10.1007/s10072-023-07287-6

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