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Pre-operative Screening: Early Identification of Patients at Risk for Delirium in Cardiac Surgery
170
Abstracts
Although prescribing medication is not directly recommended by the guidelines, this was the most frequently used management strategy in this study. Prescribing medication may not be useful in all cases. doi:10.1016/j.jpsychores.2017.03.291
85 Delirium in the Intensive Care Setting: A Re-evaluation of the Validity and Psychometric Properties of the CAM-ICU and ICDSC versus the DSM-IV-TR Diagnosis B. Soenkea, G. Davidb, M. Rafaelc, R. Andrea, S. Mariab, J. Josefa a
University Hospital Zurich, Zurich, Switzerland University Basel, Basel, Switzerland c University Zurich, Zurich, Switzerland b
Introduction: In the intensive care setting, delirium is a common occurrence with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their appropriateness with respect to their psychometric properties, however, still remains controversial. Methods: In this prospective cohort study, the Confusion Assessment Method for Intensive Care Units (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM-IV-TR diagnostic criteria and diagnosis of delirium with respect to their validity and psychometric properties. Results: Out of 289 patients, 210 patients with matching CAMICU, ICDSC and DSM-IV-TR diagnosis were included. Between the scales, the prevalence of delirium ranged from 23.3 % with the CAMICU, to 30.5% with the ICDSC, to 43.8% with the DSM-IV-TR criteria. The CAM-ICU showed only moderate concurrent validity (Cohen’s κ 0.44) and sensitivity (50%), however, high specificity (95%). The ICDSC also reached moderate agreement (Cohen’s κ 0.60) and sensitivity (63%), while being very specific (95%). Between the CAM-ICU and the ICDSC, the concurrent validity was again only moderate (Cohen’s κ 0.56), however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively). Conclusion: Surprisingly, neither the CAM-ICU nor the ICDSC, common tools in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity, nor sensitivity or positive prediction versus the DSM-IV-TR diagnosis, while being very specific. Thus, the non-prediction by the CAM-ICU or ICDSC did not refute the presence of delirium. Between the CAM-ICU and ICDSC, the ICDSC proved to be the more accurate instrument. doi:10.1016/j.jpsychores.2017.03.292
86 Diversity of reason for consultation in frequent users of unscheduled care: A possible marker of somatic symptom disorder S. Steginka, A. Elliotta, C. Burtonb a
University of Aberdeen, Aberdeen, United Kingdom University of Sheffield, Sheffield, United Kingdom
b
Aims: We aimed to examine the diversity of the reasons for consultation in high users of unscheduled care services. Somatic Symptom Disorders and (Illness Anxiety Disorder) commonly lead to help-seeking for symptoms, often in multiple body systems. We hypothesised that (a) older patients should have greater diversity in
reasons for consultation than younger patients due to the increase in multi-morbidity with age; (b) that high diversity in younger adults is a potential marker of SSD-related processes; (c) that patients who also consulted for a mental health reason would have greater diversity (particularly in younger adults) owing to the co-occurence of common mental disorders with SSDs. Methods: We analysed data from 13,488 patients (2.7% of all callers) who made 5 or more calls to NHS24 (the NHS Scotland primary care out of hours service) in 2011 using an anonymised national dataset. We allocated the reason for consultation for each episode to one of 11 categories, representing a range of bodily systems from data collected by call handlers. For each patient we estimated diversity of reasons for consultation using Shannon Entropy, a statistical measure of diversity widely used in ecology. Results: Older and younger frequent attenders had broadly similar diversity in reasons for consultation. Multiple linear regression showed that having a mental health consult was associated with greater diversity of reason for consultation after adjusting for age and number of consultations. There was no significant interaction between age and mental health consultation on diversity. The study had the advantage of a very large dataset, but the disadvantage that mental and physical health were not measured directly. Conclusions: Adult frequent attenders at unscheduled care have substantial diversity of reasons for consultation at all ages and this diversity is increased in people who also consult with a mental health problem. Diversity of reason for consult may be a useful flag for frontline clinicians to suspect SSDs and health anxiety in frequent attenders. doi:10.1016/j.jpsychores.2017.03.293
87 Pre-operative Screening: Early Identification of Patients at Risk for Delirium in Cardiac Surgery R. Styra, E. Larsen Toronto General Hospital, Toronto, Canada Aims: Assessments of preoperative psychological and cognitive function are used inconsistently and their prognostic value for delirium has been understudied. The objective of this study is to identify cognitive and psychological pre-operative risk factors for post-operative delirium in cardiac surgery patients. Method: Three hundred and ninety five (395) cardiac surgery patients who were referred for assessment of cognitive impairment, psychiatric disorders, or substance use prior to cardiac surgery were assessed by a psychiatrist using a focused psychiatric history and the Mini-Mental State Exam (MMSE). Patients were followed by the same psychiatrist during their post-operative stay to assess for delirium, and CAM or NEECHAM scores were also noted. Variables considered for analysis were MMSE scores, psychiatric diagnosis, previous delirium, CVA, and high level use of either alcohol or benzodiazepines. Results: Delirium occurred in 103 (26.1%) of subjects who were 57.7% male and were significantly older compared to non-delirious subjects (pb.0001). The mean MMSE score for delirious subjects (M=25.7) was significantly lower than non-delirious (M= 26.9) subjects (p=.0005). Cognitive impairment defined as having a MMSE b25 (36.5%) was significantly more prevalent (32%) than among those without delirium (17.8%) (p=.006). Preoperative use of benzodiazepines at an equivalence of 2mg/day of lorazepam was significantly more prevalent among delirious patients (11.7%) than patients without delirium (4.1%) (p=.028). Lastly, patients who experienced delirium were significantly more likely to have had postoperative delirium in the past; (17.5% vs. 6.5%, p= .007). All
Abstracts
variables were found significant after univariate and multivariate regression, and are independent risk factors. Depression rates between the two subject groups were insignificant (p=0.533) as were cerebrovascular accidents (p= 0.213) or heavy alcohol use (p=0.207). Current or past street drug use was not significant nor was substance use comorbidity with current or past history of psychiatric disorders. Conclusions: Increasing age, cognitive impairment, previous incidence of delirium and high use of benzodiazepines are independent pre-operative risk factors for delirium in our cardiac surgery population. Preoperative screening merits routine inclusion in protocols aimed at prevention and early identification of patients at risk for delirium. doi:10.1016/j.jpsychores.2017.03.294
171
Visible cognitive deficit was typical of sub-cortical abnormalities, can depend on immunological disturbance and make quality of life worse. In our observation, CD4+nadir is important risk medical factor of cognitive and emotional decline, but lower level of current CD4+ cells have negative impact on QoL. doi:10.1016/j.jpsychores.2017.03.295
89 Management strategies for medically unexplained symptoms in general practice: A qualitative study T. Terpstraa, J. Gola, P. Lucassenb, J. Houwenb, J. Rosmalena, T. Olde Hartmanb a
88 Neuropsychological Functioning and Quality of Life among HIVpositive men who have sex with men treated with effective antiretroviral therapy B. Szymańskaa, G. Cholewińskaa, N. Gawronb, A. Plutab, M. Sobańskab, E. Łojekb, E. Firląg-Burkackaa, A. Horbanc, P. Bieńkowskid, R. Bornsteine a
Hospital for Infectious Diseases, Warsaw, Poland University of Warsaw, Warsaw, Poland c Medical University of Warsaw, Warsaw, Poland d Institute of Psychiatry and Neurology in Warsaw, Warsaw, Poland e Ohio State University, United States b
Aims: Highly active antiretroviral therapy (HAART) regimens have resulted in substantial improvements in the systemic health care of HIV infected persons and increased survival times. Despite of successful therapy, cognitive dysfunction, emotional impairments and worse quality of life have been still observed in HIV-infected individuals, which can depend on multivariable factors and have a dramatic impact on functional ability in day-to-day productivity. The aim of study was to determine the neuropsychological differences between HIV-infected (HIV+) MSM and uninfected (HIV-) control group and relationship of cognitive and emotional functioning with quality of life (QoL) and medical factors during HIV infection. Method: Ninety five HIV(+) individuals and 95 HIV-uninfected controls, matched on socio-demographic variables participated in the study. HIV(+) group was characterized by 6,5 years average duration of infection (SD=5,8); with CD4+ nadir M=265,2cell/μL, SD= 147,5; current CD4+ M=586,1cell/μL, SD=217, with undetectable viral load. The participants performed battery of standard neuropsychological tests and psychological questionnaires. In the study were used t-Student analysis, nonparametric tests (U Manna Whitneya) and Pearson’s correlations. Results: In our data we observed that HIV-positive individuals achieved worse outcomes in attention and working memory t(188)=4.009; pb0.01 and language t(188)=2.628; pb0.01 tasks. In addition, they obtained worse results in storage t(188)=2.287; pb0.05 and retrieval t(188)=2.346; pb0.05 process of learning. Moreover, HIVpositive group demonstrated higher level of anxiety t(180)=2.065; pb0.05 and depression t(180)=1.998; pb0.05 than controls. In HIV(+) group, we observed positive correlation between general cognitive functioning (GCF), nadir CD4+ cells (r=0.291; pb0.05) and QoL (r=0.307; pb0.05). Furthermore, lower results of QoL correlated with worse level of current CD4+ cells (r=0.245; pb0.05). Conclusion: Despite of effective antiretroviral therapy, the HIV(+) men who have sex with men showed changes in the neuropsychological functioning as compare to the control group.
University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation, Groningen, Netherlands b Department of Primary & Community Care, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands Aims: General practitioners (GPs) have a central position in the care of patients with medically unexplained symptoms (MUS). However, GPs find patients with MUS challenging as they think that effective management strategies are lacking. In research, little attention is paid to which management strategies GPs use, particularly with regard to which self-management strategies they advise patients with MUS in order to reduce and cope with their complaints. The aim of this study is to describe and to gain insight into self-management strategies for MUS advised by GPs. Methods: A qualitative observational study was performed in which videos and transcripts of 39 general practice consultations involving patients with MUS were analyzed with regard to management strategies for MUS, following the principles of constant comparative analysis. Results: GPs used six different management strategies: advice on self-management strategies, prescription of medication, referral, additional tests, follow-up consultations, and wait-and-see. GPs typically take action if confronted with patients with MUS, as they used active management strategies in each consultation, while waitand-see was observed only once. Over half of all management strategies were somatically oriented. An in-depth thematic analysis of the advised self-management strategies resulted in the following themes: changing cognitions and emotions, dealing with the medical system, body-related advice, keeping a symptom diary, resting, nutritional advice, environmental adjustments and reading leaflets. Remarkably, advised self-management strategies remained often vague, and communication with regard to these strategies was ambivalent. Conclusion: GPs take action on MUS, but struggle in providing advice on self-management strategies. This might indicate that GPs question the effectiveness of self-management strategies.
doi:10.1016/j.jpsychores.2017.03.296
90 Health anxiety by proxy: A new concept with important treatment implications M.V. Thorgaarda, L. Frostholma, L. Walkerb, J.S. Jensena, B. Morinaa, H. Lindegaardc, L. Salomonsend, C.U. Raska
Abstracts
Although prescribing medication is not directly recommended by the guidelines, this was the most frequently used management strategy in this study. Prescribing medication may not be useful in all cases. doi:10.1016/j.jpsychores.2017.03.291
85 Delirium in the Intensive Care Setting: A Re-evaluation of the Validity and Psychometric Properties of the CAM-ICU and ICDSC versus the DSM-IV-TR Diagnosis B. Soenkea, G. Davidb, M. Rafaelc, R. Andrea, S. Mariab, J. Josefa a
University Hospital Zurich, Zurich, Switzerland University Basel, Basel, Switzerland c University Zurich, Zurich, Switzerland b
Introduction: In the intensive care setting, delirium is a common occurrence with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their appropriateness with respect to their psychometric properties, however, still remains controversial. Methods: In this prospective cohort study, the Confusion Assessment Method for Intensive Care Units (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM-IV-TR diagnostic criteria and diagnosis of delirium with respect to their validity and psychometric properties. Results: Out of 289 patients, 210 patients with matching CAMICU, ICDSC and DSM-IV-TR diagnosis were included. Between the scales, the prevalence of delirium ranged from 23.3 % with the CAMICU, to 30.5% with the ICDSC, to 43.8% with the DSM-IV-TR criteria. The CAM-ICU showed only moderate concurrent validity (Cohen’s κ 0.44) and sensitivity (50%), however, high specificity (95%). The ICDSC also reached moderate agreement (Cohen’s κ 0.60) and sensitivity (63%), while being very specific (95%). Between the CAM-ICU and the ICDSC, the concurrent validity was again only moderate (Cohen’s κ 0.56), however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively). Conclusion: Surprisingly, neither the CAM-ICU nor the ICDSC, common tools in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity, nor sensitivity or positive prediction versus the DSM-IV-TR diagnosis, while being very specific. Thus, the non-prediction by the CAM-ICU or ICDSC did not refute the presence of delirium. Between the CAM-ICU and ICDSC, the ICDSC proved to be the more accurate instrument. doi:10.1016/j.jpsychores.2017.03.292
86 Diversity of reason for consultation in frequent users of unscheduled care: A possible marker of somatic symptom disorder S. Steginka, A. Elliotta, C. Burtonb a
University of Aberdeen, Aberdeen, United Kingdom University of Sheffield, Sheffield, United Kingdom
b
Aims: We aimed to examine the diversity of the reasons for consultation in high users of unscheduled care services. Somatic Symptom Disorders and (Illness Anxiety Disorder) commonly lead to help-seeking for symptoms, often in multiple body systems. We hypothesised that (a) older patients should have greater diversity in
reasons for consultation than younger patients due to the increase in multi-morbidity with age; (b) that high diversity in younger adults is a potential marker of SSD-related processes; (c) that patients who also consulted for a mental health reason would have greater diversity (particularly in younger adults) owing to the co-occurence of common mental disorders with SSDs. Methods: We analysed data from 13,488 patients (2.7% of all callers) who made 5 or more calls to NHS24 (the NHS Scotland primary care out of hours service) in 2011 using an anonymised national dataset. We allocated the reason for consultation for each episode to one of 11 categories, representing a range of bodily systems from data collected by call handlers. For each patient we estimated diversity of reasons for consultation using Shannon Entropy, a statistical measure of diversity widely used in ecology. Results: Older and younger frequent attenders had broadly similar diversity in reasons for consultation. Multiple linear regression showed that having a mental health consult was associated with greater diversity of reason for consultation after adjusting for age and number of consultations. There was no significant interaction between age and mental health consultation on diversity. The study had the advantage of a very large dataset, but the disadvantage that mental and physical health were not measured directly. Conclusions: Adult frequent attenders at unscheduled care have substantial diversity of reasons for consultation at all ages and this diversity is increased in people who also consult with a mental health problem. Diversity of reason for consult may be a useful flag for frontline clinicians to suspect SSDs and health anxiety in frequent attenders. doi:10.1016/j.jpsychores.2017.03.293
87 Pre-operative Screening: Early Identification of Patients at Risk for Delirium in Cardiac Surgery R. Styra, E. Larsen Toronto General Hospital, Toronto, Canada Aims: Assessments of preoperative psychological and cognitive function are used inconsistently and their prognostic value for delirium has been understudied. The objective of this study is to identify cognitive and psychological pre-operative risk factors for post-operative delirium in cardiac surgery patients. Method: Three hundred and ninety five (395) cardiac surgery patients who were referred for assessment of cognitive impairment, psychiatric disorders, or substance use prior to cardiac surgery were assessed by a psychiatrist using a focused psychiatric history and the Mini-Mental State Exam (MMSE). Patients were followed by the same psychiatrist during their post-operative stay to assess for delirium, and CAM or NEECHAM scores were also noted. Variables considered for analysis were MMSE scores, psychiatric diagnosis, previous delirium, CVA, and high level use of either alcohol or benzodiazepines. Results: Delirium occurred in 103 (26.1%) of subjects who were 57.7% male and were significantly older compared to non-delirious subjects (pb.0001). The mean MMSE score for delirious subjects (M=25.7) was significantly lower than non-delirious (M= 26.9) subjects (p=.0005). Cognitive impairment defined as having a MMSE b25 (36.5%) was significantly more prevalent (32%) than among those without delirium (17.8%) (p=.006). Preoperative use of benzodiazepines at an equivalence of 2mg/day of lorazepam was significantly more prevalent among delirious patients (11.7%) than patients without delirium (4.1%) (p=.028). Lastly, patients who experienced delirium were significantly more likely to have had postoperative delirium in the past; (17.5% vs. 6.5%, p= .007). All
Abstracts
variables were found significant after univariate and multivariate regression, and are independent risk factors. Depression rates between the two subject groups were insignificant (p=0.533) as were cerebrovascular accidents (p= 0.213) or heavy alcohol use (p=0.207). Current or past street drug use was not significant nor was substance use comorbidity with current or past history of psychiatric disorders. Conclusions: Increasing age, cognitive impairment, previous incidence of delirium and high use of benzodiazepines are independent pre-operative risk factors for delirium in our cardiac surgery population. Preoperative screening merits routine inclusion in protocols aimed at prevention and early identification of patients at risk for delirium. doi:10.1016/j.jpsychores.2017.03.294
171
Visible cognitive deficit was typical of sub-cortical abnormalities, can depend on immunological disturbance and make quality of life worse. In our observation, CD4+nadir is important risk medical factor of cognitive and emotional decline, but lower level of current CD4+ cells have negative impact on QoL. doi:10.1016/j.jpsychores.2017.03.295
89 Management strategies for medically unexplained symptoms in general practice: A qualitative study T. Terpstraa, J. Gola, P. Lucassenb, J. Houwenb, J. Rosmalena, T. Olde Hartmanb a
88 Neuropsychological Functioning and Quality of Life among HIVpositive men who have sex with men treated with effective antiretroviral therapy B. Szymańskaa, G. Cholewińskaa, N. Gawronb, A. Plutab, M. Sobańskab, E. Łojekb, E. Firląg-Burkackaa, A. Horbanc, P. Bieńkowskid, R. Bornsteine a
Hospital for Infectious Diseases, Warsaw, Poland University of Warsaw, Warsaw, Poland c Medical University of Warsaw, Warsaw, Poland d Institute of Psychiatry and Neurology in Warsaw, Warsaw, Poland e Ohio State University, United States b
Aims: Highly active antiretroviral therapy (HAART) regimens have resulted in substantial improvements in the systemic health care of HIV infected persons and increased survival times. Despite of successful therapy, cognitive dysfunction, emotional impairments and worse quality of life have been still observed in HIV-infected individuals, which can depend on multivariable factors and have a dramatic impact on functional ability in day-to-day productivity. The aim of study was to determine the neuropsychological differences between HIV-infected (HIV+) MSM and uninfected (HIV-) control group and relationship of cognitive and emotional functioning with quality of life (QoL) and medical factors during HIV infection. Method: Ninety five HIV(+) individuals and 95 HIV-uninfected controls, matched on socio-demographic variables participated in the study. HIV(+) group was characterized by 6,5 years average duration of infection (SD=5,8); with CD4+ nadir M=265,2cell/μL, SD= 147,5; current CD4+ M=586,1cell/μL, SD=217, with undetectable viral load. The participants performed battery of standard neuropsychological tests and psychological questionnaires. In the study were used t-Student analysis, nonparametric tests (U Manna Whitneya) and Pearson’s correlations. Results: In our data we observed that HIV-positive individuals achieved worse outcomes in attention and working memory t(188)=4.009; pb0.01 and language t(188)=2.628; pb0.01 tasks. In addition, they obtained worse results in storage t(188)=2.287; pb0.05 and retrieval t(188)=2.346; pb0.05 process of learning. Moreover, HIVpositive group demonstrated higher level of anxiety t(180)=2.065; pb0.05 and depression t(180)=1.998; pb0.05 than controls. In HIV(+) group, we observed positive correlation between general cognitive functioning (GCF), nadir CD4+ cells (r=0.291; pb0.05) and QoL (r=0.307; pb0.05). Furthermore, lower results of QoL correlated with worse level of current CD4+ cells (r=0.245; pb0.05). Conclusion: Despite of effective antiretroviral therapy, the HIV(+) men who have sex with men showed changes in the neuropsychological functioning as compare to the control group.
University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation, Groningen, Netherlands b Department of Primary & Community Care, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands Aims: General practitioners (GPs) have a central position in the care of patients with medically unexplained symptoms (MUS). However, GPs find patients with MUS challenging as they think that effective management strategies are lacking. In research, little attention is paid to which management strategies GPs use, particularly with regard to which self-management strategies they advise patients with MUS in order to reduce and cope with their complaints. The aim of this study is to describe and to gain insight into self-management strategies for MUS advised by GPs. Methods: A qualitative observational study was performed in which videos and transcripts of 39 general practice consultations involving patients with MUS were analyzed with regard to management strategies for MUS, following the principles of constant comparative analysis. Results: GPs used six different management strategies: advice on self-management strategies, prescription of medication, referral, additional tests, follow-up consultations, and wait-and-see. GPs typically take action if confronted with patients with MUS, as they used active management strategies in each consultation, while waitand-see was observed only once. Over half of all management strategies were somatically oriented. An in-depth thematic analysis of the advised self-management strategies resulted in the following themes: changing cognitions and emotions, dealing with the medical system, body-related advice, keeping a symptom diary, resting, nutritional advice, environmental adjustments and reading leaflets. Remarkably, advised self-management strategies remained often vague, and communication with regard to these strategies was ambivalent. Conclusion: GPs take action on MUS, but struggle in providing advice on self-management strategies. This might indicate that GPs question the effectiveness of self-management strategies.
doi:10.1016/j.jpsychores.2017.03.296
90 Health anxiety by proxy: A new concept with important treatment implications M.V. Thorgaarda, L. Frostholma, L. Walkerb, J.S. Jensena, B. Morinaa, H. Lindegaardc, L. Salomonsend, C.U. Raska