Department of Neurology, University Medicine Greifswald, Germany (R.F., S.W., T.A., R.K., C.W., B.v.S.).
Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Germany (A.M.).
Stroke. 2021 Jan;52(2):471-478. doi: 10.1161/STROKEAHA.120.031019. Epub 2020 Dec 31.
Poststroke delirium (PSD) is an independent predictor of unfavorable outcome. Despite its individual and socioeconomic burden, its frequency, clinical course, and routine detection remain unresolved. This study aimed to assess psychometric properties of established delirium screening tools and investigate the natural course of PSD.
This study investigated patients presenting with high-risk transient ischemic attacks or ischemic stroke within 24 hours during a 3-month period. Twice-daily screenings for PSD were done using the confusion assessment method, nursing delirium scale, and rapid delirium assessment, and evaluated for noninferiority against Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. We investigated demographic and stroke characteristics as predictors of PSD, neurological deficits as predictors of false screening results, and conducted a simulation study to estimate the best timing to identify PSD.
We enrolled 141 patients (73.8±10.4 years of age, 61 female) with a mean National Institutes of Health Stroke Scale score of 6.4±6.5. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition based PSD incidence was 39%, which manifested within 24 hours in 25% and 72 hours in almost all cases. The confusion assessment method was the only screening tool noninferior to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ratings providing a sensitivity of 82% and specificity of 80%. Age (odds ratio, 1.07 [1.02-1.13] per year, =0.004) and National Institutes of Health Stroke Scale (odds ratio, 1.24 [1.15-1.34] per point, <0.001) were predictors of PSD. False-positive screening results were associated with stroke-induced disorientation (odds ratio, 6.1 [3.2-11.61], <0.001) and neglect (odds ratio, 2.17 [1.22-3.87], =0.008). Simulations revealed that one in 4 cases is missed with less than daily screenings.
PSD is a common complication of stroke and transient ischemic attack. Detection is challenged by confounding effects such as focal neurological deficits and the necessity for at least daily screenings. Future studies are required to investigate implementation of these findings in clinical routine. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03930719.
卒中后谵妄（PSD）是不良预后的独立预测因素。尽管其对个人和社会经济造成了负担，但它的频率、临床过程和常规检测仍未得到解决。本研究旨在评估已建立的谵妄筛查工具的心理测量特性，并研究 PSD 的自然病程。
本研究纳入了在 3 个月期间内 24 小时内出现高风险短暂性脑缺血发作或缺血性卒中的患者。使用意识模糊评估法、护理谵妄量表和快速谵妄评估法，每天两次对 PSD 进行筛查，并评估其与《精神障碍诊断与统计手册（第五版）》标准相比的非劣效性。我们调查了人口统计学和卒中特征作为 PSD 的预测因素、神经功能缺损作为假阳性筛查结果的预测因素，并进行了一项模拟研究以估计识别 PSD 的最佳时间。
我们纳入了 141 名患者（73.8±10.4 岁，61 名女性），平均 NIHSS 评分为 6.4±6.5。基于《精神障碍诊断与统计手册（第五版）》的 PSD 发生率为 39%，其中 25%在 24 小时内表现出来，几乎所有病例在 72 小时内表现出来。意识模糊评估法是唯一与《精神障碍诊断与统计手册（第五版）》评分相比具有非劣效性的筛查工具，其敏感性为 82%，特异性为 80%。年龄（每增加 1 岁，比值比为 1.07[1.02-1.13]，=0.004）和 NIHSS（每增加 1 分，比值比为 1.24[1.15-1.34]，<0.001）是 PSD 的预测因素。假阳性筛查结果与卒中引起的定向障碍（比值比为 6.1[3.2-11.61]，<0.001）和忽视（比值比为 2.17[1.22-3.87]，=0.008）有关。模拟结果显示，少于每日筛查会漏诊约 1/4 的病例。
PSD 是卒中及短暂性脑缺血发作的常见并发症。由于局灶性神经功能缺损等混杂因素的影响，以及至少每日筛查的必要性，对 PSD 的检测具有挑战性。需要进一步的研究来调查这些发现在临床常规中的应用。
