Occurrence Rate of Delirium in Acute Stroke Settings: Systematic Review and Meta-Analysis
Abstract
Background and Purpose—
Delirium is associated with increased mortality, length of stay, and poor functional outcome following critical illness. The epidemiology of delirium in stroke is poorly described. We sought to collate evidence around occurrence (incidence or prevalence) of delirium in acute stroke.
Methods—
We searched multiple cross-disciplinary electronic databases using a prespecified search strategy, complemented by hand searching. Eligible studies described delirium in acute (first 6 weeks) stroke. We compared delirium occurrence using random-effects models to describe summary estimates. We assessed risk of bias using the Newcastle-Ottawa tool, incorporating this in sensitivity analyses. We performed subgroup analyses for delirium diagnostic method (confusion assessment method scoring, clinical diagnosis, other), duration and timing of delirium assessment (>1 or <1 week), and performed meta-regression based on the year of publication.
Results—
Of 8822 titles, we included 32 papers (6718 participants) in the quantitative analysis. Summary estimate for occurrence of delirium was 25% (95% CI, 20%–30%; moderate quality evidence). Limiting to studies at low risk of bias (22 studies, 4422 participants), the occurrence rate was 23% (95% CI, 17%–28%). Subgroup summary estimates suggest that delirium occurrence may vary with assessment method: confusion assessment method, 21% (95% CI, 16%–27%); clinical diagnosis, 27% (95% CI, 19%–38%); other, 32% (95% CI, 22%–43%) but not with duration and timing of assessment. Meta-regression suggested decline in occurrence of delirium comparing historical to more recent studies (slope, 0.03 [SE, 0.004]; P<0.0001).
Conclusions—
Delirium is common, affecting 1 in 4 acute stroke patients. Reported rates of delirium may be dependent on assessment method. Our estimate of delirium occurrence could be used for audit, to plan intervention studies, and inform clinical practice.
Clinical Trial Registration—
URL: http://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42015029251.
Introduction
See related article, p 3265
Delirium is a serious neuropsychiatric complication of critical illness. Delirium adversely affects mortality and functional outcomes in many healthcare settings.1 There are limited published data on delirium in stroke, but available evidence suggests a similar pattern of higher mortality and poorer outcome.2 Evidence-based intervention for delirium is described,3 and recent guidance emphasizes the importance of routinely observing and testing for delirium in high-risk groups such as unscheduled older adult hospital admissions.4 International stroke guidelines do not explicitly mention delirium, but screening for delirium in acute stroke settings is increasingly performed.5
Estimates from studies describing delirium rates following stroke have varied considerably.6,7 Methodological factors may have influenced the delirium rates described.8 Some studies have tested for delirium over a defined time period9 while others have only described point prevalence.10 Equally, the assessment methods used to detect delirium11 have varied across studies.12–14 It is also possible that delirium rates may have changed over time. Delirium is said to be a marker of quality of care,15 and in the context of improving stroke care in the last decade, temporal change in rates of delirium seem plausible. Active screening for delirium may have led to increased detection rate, or better care processes may have led to reduced rates. Any attempt to review delirium epidemiology needs to address these points.
A contemporary synthesis of the available literature that offers robust estimates of rates of delirium in stroke could be useful for clinical practice, policy, and research. The aim of this review was to collate the available evidence to allow a description of the occurrence (the combination of incident [develops after admission] and prevalent [present on admission]) delirium in patients hospitalized with acute stroke. Our secondary aims were to look at the effect of method of delirium assessment, timing and duration of assessment, and temporal change.
Methods
The data that support these systematic review findings are presented in the main article and the online-only Data Supplement; any other study level data not included in these materials are available from the corresponding author on reasonable request.
We followed Preferred Reporting in Systematic Review and Meta-Analysis guidance for the conduct and reporting of this review. We created a protocol, available through the Prospero registry (registration number, CRD4201502951; submitted, November 13, 2015; http://www.crd.york.ac.uk/PROSPERO/).
Each aspect of the review was performed by at least 2 reviewers trained in systematic review methodology (R.C.S., G.W., E.E.) with access to a third arbitrator (T.J.Q.) as required.
Search Strategy
Electronic database searching used a sensitive search strategy, employing validated search filters for concepts of stroke and delirium (Methods I in the online-only Data Supplement) combined with the boolean operator and. We searched multiple cross-disciplinary electronic databases: MEDLINE (OVID), EMBASE (OVID), PsycINFO (EBSCO), psycARTICLES (EBSCO), CINAHL (EBSCO), and Alois (Cochrane), from inception to June 2018.
References from reviews and other relevant studies were assessed for additional titles. We hand searched relevant high-impact journals: Stroke (American Heart Association); International Journal of Stroke (World Stroke Organisation), and Age and Aging (British Geriatrics Society) for relevant articles published between January 2010 and June 2018. Process continued until no new titles were found.
If relevant abstracts were discovered but the paper was not available, the author was contacted regarding publication status. Where relevant data were not available in the published article, we also contacted authors. We translated foreign language papers.
Population
Acute stroke was defined as the period from ictus to 6 weeks post-event. The definition of stroke was based on World Health Organisation definition.16 We included studies where transient ischemic attack or minor stroke were admitted. Where studies included a mixed population of stroke and subarachnoid hemorrhage or traumatic brain injury, we excluded those studies where these groups comprised >15% of the total population, as their psychological sequela may differ from other stroke syndromes.
Inclusion/Exclusion
We screened titles and abstracts for relevance on the basis of the following inclusion and exclusion criteria. Studies describing human stroke survivors in any language were considered. Cross-sectional, prospective, and other cohort study designs were eligible. We excluded case studies with too few patients to gain reliable conclusions (<20 patients with stroke) and studies of delirium tremens. Case-control studies and randomized control trials were excluded because they would not give representative population data. Although we searched Grey literature, we restricted inclusion to studies published in peer-reviewed journals.
Data Extraction
We extracted data from eligible papers to a prespecified and piloted proforma, based on the Cochrane data extraction tool.17 We extracted an estimate of delirium rate, corresponding variance, and details relevant to subgroup analyses. We recorded inclusion/exclusion criteria of the studies and whether patients were excluded on the basis of stroke impairments or preexisting psychiatric diagnosis, including dementia.
We assessed internal and external validity using the Newcastle-Ottawa assessment for cross-sectional studies.18 The tool was modified for this study by making the exposure stroke and the outcome delirium. The modified tool was piloted on 2 papers and refined as necessary (Methods II in the online-only Data Supplement). We assessed each domain and made a judgement on risk of bias at study level.
We made an assessment of overall strength of evidence based on the Grading of Recommendations, Assessment, Development and Evaluation framework, modified to be suitable for an observational epidemiology question.19 We assessed risk of bias, consistency of results (heterogeneity), directness (applicability of included studies to research question), precision (based on CIs of summary estimate), and publication bias (funnel plot).
Analyses
As a validation of our search strategy, we compared included studies from our initial search to a list of 3 preselected papers relevant to the topic, to ensure these papers were returned and selected.8,20,21
We created a forest plot of all estimates and 95% CIs. Given the likely heterogeneity in the included datasets, we favored random-effects models for summary estimates of delirium occurrence. We assessed for heterogeneity using a visual assessment of forest plots and a quantitative assessment (Higgin I2).
We conducted sensitivity analyses based on quality assessment, limiting analysis to those studies judged to be at low risk of bias in all areas or where only 1 area was uncertain. We performed subgroup analyses based on method of assessment, period, and duration of assessment. For assessment method, we categorized as clinical diagnosis (using recognized clinical classification such as Diagnostic and Statistics Manual),22 confusion assessment method14 (the most widely used delirium assessment tool), and other. We categorized period of assessment as timing of assessment in relation to stroke (patients tested at <1 or >1 week); duration of assessment compared single assessment to multiple assessments. To assess for temporal change in delirium occurrence, we inspected the forest plot rearranged in chronological order performed meta-regression of log delirium rate against year of study. We assessed publication bias using a funnel plot. All quantitative analyses were performed using Comprehensive Meta-Analysis (version 2.2).
Results
With duplicates removed, we assessed 8822 titles. Of 132 full text papers assessed, 326,7,9,10,12-14,21-46 were included in quantitative analysis (6718 patients). The review included cohorts from 19 different countries. Only 1 eligible article was not published in English (Russian),29 and study author assisted with data extraction in English. Six relevant abstracts were not included as authors reported that full papers had not been written and there were no immediate plans to do this (Figure 1). Our search strategy was proven valid as our 3 preselected papers were returned on initial search.
Across 32 included studies, there was variation in the included patients (Tables 1 and 2; Table I in the online-only Data Supplement) and variation in delirium occurrence: range, 6.7%6 to 61%32 (Figure 2A and 2B). There was substantial statistical heterogeneity in the results; I2 value, 93.6%. The summary value of delirium occurrence was 25% (95% CI, 20%–30%). For comparison, the fixed effects estimate was 24% (95% CI, 23%–25%).
| Author | Country | Sample, n | Setting | Type of Stroke | Delirium Assessment* | Excluded Stroke Impairments | Excluded Psychiatric Syndromes |
|---|---|---|---|---|---|---|---|
| Alvarez-Perez and Paiva40 | Portugal | 1072 | Stroke | All stroke | Case note review DSM | No | No |
| Caeiro et al23 | Portugal | 218 | ASU | All stroke (SAH, 12.84%) | DSM | Not reported | Not reported |
| Dahl et al24 | Norway | 178 | SU | All stroke | CAM | Not reported | Not reported |
| Dostović et al38 | Bosnia and Herzegovia | 233 | SU | All stroke | DSM | Yes, aphasia | Yes, dementia |
| Fassbender et al25 | Germany | 23 | Hyperacute SU | Ischemic stroke | DSM | No | Yes |
| Gustafson et al7 | Sweden | 145 | SU | All stroke, TIA | DSM | Yes, decreased GCS, aphasia | Not reported |
| Gustafson et al13 | Sweden | 83 | SU | Supratentorial cerebral infarction | DSM | Yes, decreased GCS | Yes |
| Henon et al26 | France | 202 | SU | All stroke | DSM | No | Yes |
| Hosoya et al41 | Japan | 239 | Stroke care center | All stroke* | Other (ICSDC) | Not reported | Not reported |
| Infante et al42 | Italy | 100 | Tertiary stroke care center | Acute stroke | DSM, 4AT | Yes, aphasia | Yes |
| Kara et al27 | Turkey | 150 | Neurology department | Unspecified | DSM | Yes, aphasia | Not reported |
| Kostalova et al28 | Czech Republic | 100 | SU | All stroke | Clinical | Not reported | Yes |
| Kowalska et al43 | Poland | 144 | Neurology department | Ischemic stroke | CAM | Yes, aphasia | Not reported |
| Kozak et al12 | Turkey | 60 | SU | All stroke | DSM, DRS | Yes, aphasia | Yes |
| Kutlubaev et al29 | Russia | 96 | SU | Unspecified | DSM | Not reported | Yes |
| Lees et al9 | Scotland | 101 | SU | All stroke | CAM | No | No |
| Lees et al30 | Scotland | 51 | SU | All stroke | CAM | No | No |
| Lim et al6 | Korea | 576 | SU | All stroke | CAM | Not reported | Not reported |
| Mc Manus et al31 | England | 82 | SU | All stroke | CAM | Not reported | Not reported |
| Mitasova et al14 | Czech Republic | 129 | SU | All stroke | CAM | Not reported | Yes |
| Miu and Yeung32 | Japan | 314 | SU | All stroke | CAM | Not reported | Yes |
| Mori and Yamadori33 | Japan | 41 | Neurology service | RMCA stroke | Clinical | Yes, prior stroke, aphasia | Yes |
| Naidech et al10 | The United States | 114 | SU | ICH | CAM | Not reported | Not reported |
| Nydahl et al39 | Germany | 309 | SU | All stroke | CAM | Not reported | Not reported |
| Ojagbemi et al34 | Nigeria | 101 | ASU | All stroke | CAM, DSM | Yes, aphasia | No |
| Oldenbeuving et al21 | The Netherlands | 527 | SU | All stroke | CAM | Not reported | Not reported |
| Pasinska et al44 | Poland | 750 | SU | All stroke | CAM | Not reported | Not reported |
| Reding et al35 | The United States | 44 | Rehabilitation unit | Unspecified | Clinical | No | No |
| Rosenthal et al45 | The United States | 150 | Neuro-ICU | ICH | CAM | Not reported | Not reported |
| Sheng et al36 | Australia | 156 | SU | All stroke | Clinical | Not reported | Yes |
| Song et al46† | Korea | 54 | SU | Unspecified | Other (DOS) | Yes, aphasia | Yes |
| Turco et al37 | Italy | 176 | Rehabilitation unit | Unspecified | CAM | No | No |
4AT indicates 4 A’s Test; CAM, confusion assessment method; DOS, Delirium Observation Screening Scale; DRS, Delirium Rating Scale; DSM, Diagnostic and Statistics Manual; ICH, intracerebral hemorrhage; ICSDC, Intensive Care Delirium Screening Checklist; SAH, subarachnoid hemorrhage; SU, stroke unit; and TIA, transient ischemic attack.
*
If SAH was included in the population, numbers are described.
†
Two-group study; the control group of normal care was used in the review.
| Author | Sample Size | Mean Age, y | Women, n (%) | Delirium Cases, n | Percentage Delirium, % |
|---|---|---|---|---|---|
| Alvarez-Perez and Paiva40 | 1072 | 68.0 (median), range: 77.0–83.0 | 507 (47.3%) | 118 | 10.2 |
| Caeiro et al23 | 218 | 57.0±13.0 | 88 (40.4%) | 29 | 13.0 |
| Dahl et al24 | 178 | 73.0 | 76 (42.7%) | 18 | 10.0 |
| Dostović et al38 | 233 | Not recorded | Not recorded | 59 | 25.3 |
| Fassbender et al25 | 23 | 72.0 (median), range: 39.0–89.0 | 12 (52.2%) | 9 | 39.0 |
| Gustafson et al7 | 145 | 73.0, range: 40.0–101.0 | 55 (37.9%) | 69 | 48.0 |
| Gustafson et al13 | 83 | 74.7±8.1 | 31 (37.3%) | 35 | 42.0 |
| Henon et al26 | 202 | 75.0 (median), range: 45.0–101.0 | 105 (52.0%) | 49 | 24.3 |
| Hosoya et al41 | 239 | 75.0±1.3 | Not available for subgroup | 80 | 33.5 |
| Infante et al42 | 100 | 79.0 (median), range: 19.0–93.0 | Not recorded | 50 | 50.0 |
| Kara et al27 | 150 | 68.0±1.9 | 45 (30.0%) | 42 | 28.0 |
| Kostalova et al28 | 100 | 73.5±11.5 | 47 (47.0%) | 43 | 43.0 |
| Kowalska et al43 | 144 | 69.0 (median), range: 63.0–79.0 | 61 (42.4%) | 31 | 21.5 |
| Kozak et al12 | 60 | 66.2±12.5 | 31 (51.7%) | 11 | 18.3 |
| Kutlubaev et al29 | 96 | 68.0±10.5 | 46 (47.9%) | 22 | 23.0 |
| Lees et al9 | 101 | 74.0 (median), IQR: 64.0–85.0 | Not available for subgroup | 11 | 11.0 |
| Lees et al30 | 51 | 74.0 (median), range: 67.0–84.0 | 28 (54.9%) | 8 | 16.0 |
| Lim et al6 | 576 | 65.2 (median), range: 23.0–93.0 | 208 (36.1%) | 38 | 6.7 |
| Mc Manus et al31 | 82 | 66.4±15.9 | 31 (37.8%) | 23 | 28.0 |
| Mitasova et al14 | 129 | 71.2±11.5 | 57 (44.2%) | 55 | 42.6 |
| Miu and Yeung32 | 314 | 72.9±10.3 | 151 (48.1%) | 86 | 27.4 |
| Mori and Yamadori33 | 41 | 68.2±10.9 | 15 (36.6%) | 25 | 61.0 |
| Naidech et al10 | 114 | 63.0±13.8 | 52 (45.6%) | 31 | 27.0 |
| Nydahl et al39 | 309 | Not recorded | Not recorded | 33 | 10.7 |
| Ojagbemi et al34 | 101 | 61.1±12.9 | 47 (46.5%) | 33 | 33.3 |
| Oldenbeuving et al21 | 527 | 72.0 (median), range: 29.0–96.0 | 239 (45.4%) | 62 | 11.8 |
| Pasinska et al44 | 750 | 71.8±13.1 | 398 (53.1%) | 203 | 27.1 |
| Reding et al35 | 44 | 66.0±13.0 | 25 (56.8%) | 4 | 9.0 |
| Rosenthal et al45 | 150 | Not recorded | Not available for subgroup | 53 | 30.0 |
| Sheng et al36 | 156 | 79.2±6.7 | 73 (46.8%) | 39 | 25.0 |
| Song et al46 | 54 | 73.7±6.7 | 25 (46.3%) | 13 | 24.0 |
| Turco et al37 | 176 | 81.7±6.4 | 118 (67.0%) | 58 | 33.0 |
IQR indicates interquartile range.
We judged 22 studies (n=4422 participants) to have low risk of bias. The main reason for scoring high or uncertain risk of bias was around selection of the population (13 of 32 papers [41%]), with studies excluding those patients likely to be at the highest risk of delirium, for example, preexisting dementia or severe stroke (Table 3). On sensitivity analysis limited to studies considered low risk of bias, summary value for delirium occurrence was 23% (95% CI, 18%–28%; Figure I in the online-only Data Supplement).
| Patient Selection | Ascertainment Stroke | Ascertainment Delirium | Analysis | |
|---|---|---|---|---|
| Alvarez-Perez and Paiva40 | * | † | ‡ | ‡ |
| Caeiro et al23 | * | ‡ | ‡ | ‡ |
| Dahl et al24 | ‡ | ‡ | ‡ | ‡ |
| Dostović et al38 | † | ‡ | ‡ | ‡ |
| Fassbender et al25 | † | * | ‡ | ‡ |
| Gustafson et al7 | ‡ | ‡ | ‡ | ‡ |
| Gustafson et al13 | ‡ | * | ‡ | ‡ |
| Henon et al26 | ‡ | ‡ | ‡ | ‡ |
| Hosoya et al41 | † | ‡ | * | ‡ |
| Infante et al42 | * | * | ‡ | ‡ |
| Kara et al27 | ‡ | * | ‡ | ‡ |
| Kostalova et al28 | ‡ | ‡ | ‡ | ‡ |
| Kowalska et al43 | ‡ | ‡ | ‡ | ‡ |
| Kozak et al12 | * | ‡ | ‡ | ‡ |
| Kutlubaev et al29 | ‡ | ‡ | ‡ | ‡ |
| Lees et al9 | ‡ | * | ‡ | ‡ |
| Lees et al30 | ‡ | * | ‡ | ‡ |
| Lim et al6 | ‡ | * | ‡ | ‡ |
| Mc Manus et al31 | ‡ | * | ‡ | ‡ |
| Mitasova et al14 | ‡ | * | ‡ | ‡ |
| Miu and Yeung32 | † | * | ‡ | ‡ |
| Mori and Yamadori33 | † | † | ‡ | ‡ |
| Naidech et al10 | * | ‡ | ‡ | ‡ |
| Nydahl et al39 | ‡ | ‡ | ‡ | ‡ |
| Ojagbemi et al34 | ‡ | ‡ | ‡ | ‡ |
| Oldenbeuving et al21 | ‡ | ‡ | ‡ | ‡ |
| Pasinska et al44 | ‡ | ‡ | ‡ | ‡ |
| Reding et al35 | † | ‡ | † | ‡ |
| Rosenthal et al45 | ‡ | ‡ | ‡ | ‡ |
| Sheng et al36 | ‡ | ‡ | ‡ | ‡ |
| Song et al46 | * | * | ‡ | ‡ |
| Turco et al37 | † | † | ‡ | ‡ |
*
Uncertain risk.
†
High risk.
‡
Low risk of bias.
There were 26 different tests used in the assessment of delirium or cognition across the 32 papers. On subgroup analysis by method assessment, validated clinical diagnosis (Diagnostic and Statistics Manual; n=11 studies; n=1827 participants) gave a summary estimate of 27% (95% CI, 19%–38%); confusion assessment method (n=15 studies; n=3702 participants) gave a summary estimate of 21% (95% CI, 16%–27%); other diagnosis (n=6 studies; n=634 participants) gave a summary value of 32% (95% CI, 22%–43%; Figure II in the online-only Data Supplement).
On subgroup analysis describing period of assessment, testing for <1 week (n=15 studies; n=2592 participants) gave a summary delirium occurrence of 24% (95% CI, 18%–31%) while testing for >1 week (n=16 studies; n=3887 participants) gave a summary estimate of 24% (95% CI, 18%–31%; Figure III in the online-only Data Supplement). On exploratory subgroup analysis of studies, only assessing participants at one time point (n=16 studies; n=2594 participants), summary value for delirium was 24% (95% CI, 19%–31%) while studies conducting repeat (>1) assessments (n=15 studies; n=3052 participants) had a summary value of 26% (95% CI, 20%–33%; Figure IV in the online-only Data Supplement).
Meta-regression showed an inverse relationship between year of study and delirium occurrence (slope, 0.03 [SE, 0.004]; P<0.0001; Figure 3). The more recent studies reported lower delirium occurrence, for example, 1987 delirium occurrence, 0.61 (95% CI, 0.45–0.75; 1 paper); 2017 delirium occurrence, 0.16 (95% CI, 0.13–0.18; 4 papers).
Our funnel plot analysis suggested no substantial publication bias (Figure V in the online-only Data Supplement). The overall assessment of quality of evidence was graded as moderate. We deducted points for inconsistency in individual study estimates, and because of uncertain risk of bias, we chose the moderate descriptor (Figure 1).
Discussion
Our systematic review suggests high rates of delirium in stroke; with around one in 4 having delirium in the acute period. Although there were issues with heterogeneity and risk of bias, our estimates remained reasonably robust in a series of sensitivity and subgroup analyses.
To put our results in context, a previous review of delirium poststroke, published in 2010, gave a similar estimate of incident events (26%; range, 2%–66%).8 However, the majority of papers included in our review (23 papers [72%]) were published since 2010, demonstrating the growing interest in this area. The between-study heterogeneity will, in part, relate to case mix, and we note differing ages and comorbidities of included populations. Recent estimates of delirium in medical inpatients, excluding stroke, suggest occurrence of 20% reaching >40% in older adults.47 In a review of delirium in critical care, delirium occurrence ranged from 45% to 87%.48 Stroke is an emergency condition typically seen in older adults, and so, one may have expected delirium occurrence to be closer to the 40% reported in these populations.
Various approaches were used to assess for delirium. If we consider clinical diagnosis using Diagnostic and Statistics Manual or similar as gold standard, our results suggest that assessment with the confusion assessment method screening tool may underestimate delirium, while use of bespoke and nonvalidated tools may over estimate, albeit there was some uncertainty and CIs overlapped. Various assessments of cognition were used, many of which are not recommended in delirium assessment guidance.5 It is notable that the outliers in our analyses, on the whole, used nonvalidated approaches to delirium assessment.
Our subgroup analysis describing period of assessment suggested no difference when comparing longer and shorter assessment. Intuitively, assessing over a longer period should give higher occurrence as there is a longer time for incident delirium secondary to complications of stroke. Our data are consistent with previous studies where majority delirium was detected on the first day of admission and the remainder appeared within the next 5 days.14 This front loading of delirium could be due to the patient conditions tending to be worse on admission and then improving with specialist stroke unit care. The same pattern is seen with delirium in acute medical admissions49 and highlights that screening and preventive interventions need to be delivered as soon as possible.
Our meta-regression confirms a temporal trend toward decreasing delirium incidence over time. There are many potential reasons for this encouraging result, and the explanation is likely to be multifactorial. One plausible reason is that the specialist multidisciplinary care offered in stroke units is similar to the multicomponent interventions proven to reduce delirium incidence in older adult inpatients.15 This may also explain why our rates of delirium occurrence, while high, are lower than seen in other critical care settings.
Through our comprehensive search strategy, stringent inclusion/exclusion criteria, assessment of risk of bias, and prespecified subgroup analyses, we feel we offer a valid summary of the published literature on delirium in stroke. There are caveats to the interpretation and application of Grading of Recommendations, Assessment, Development and Evaluation and funnel plots in observational epidemiology, and as with any systematic review, conclusions are limited by the validity of the studies available in the published literature.
There are reasons to suspect that the real-world occurrence of delirium may be higher than our estimates. This is reflected in our Grading of Recommendations, Assessment, Development and Evaluation assessment of moderate quality. We note that many of the studies in our review excluded patients with prestroke dementia—a factor which is common and associated with incident delirium. Other studies excluded patients with aphasia, severe illness, or those unable to be tested, all of which are likely to systematically underestimate delirium. We recognize the difficulty in performing neuropsychological assessment in those with such impairments, but assessment for delirium is possible with sufficient time and training.
We have described a high occurrence of delirium in acute stroke. Our data can be used for audit, to plan intervention studies, and inform clinical practice. The relatively high rates of delirium should be a call to action, as delirium is a serious20 yet potentially preventable condition.3 The frequency of delirium is similar to frequency of other stroke complications such as aspiration pneumonia and venous thromboembolism. Evidence-based assessment and preventive interventions have reduced morbidity and mortality from these complications; yet at present, delirium is not prioritized in stroke guidelines. Staff in the hyperacute units should be especially vigilant as delirium seems to be most common in the first few days post-ictus.
Acknowledgments
We are grateful to Dr Mansur Kutlubaev who translated his article.
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© 2019 American Heart Association, Inc.
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Received: 21 January 2019
Revision received: 17 July 2019
Accepted: 25 July 2019
Published online: 26 September 2019
Published in print: November 2019
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Medical Research Scotland supported this work. Dr Quinn is supported by a joint Chief Scientist Office/Stroke Association Senior Clinical Lectureship.
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