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Delir bei Patienten mit Schlaganfall

Eine kritische Literaturanalyse zur Feststellung der Risikofaktoren

Delirium in stroke patients

Critical analysis of statistical procedures for the identification of risk factors

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Zusammenfassung

Hintergrund

Delirien gehören zu den relevanten Komplikationen nach einem akuten Schlaganfall. Das Delir ist ein multifaktorielles Geschehen und mit einer Vielzahl von interagierenden Risikofaktoren.

Problemstellung

Den assoziierten Risikofaktoren des Delirs bei Patienten mit einem Schlaganfall liegen oftmals limitierte klinische Studien zugrunde. Statistische Verfahren sowie klinische Relevanz der vorgefunden Risikofaktoren sind hier zu hinterfragen.

Methode

Es wurde eine Sekundäranalyse von klinisch relevanten Studien durchgeführt, die Aussagen zu klinischer Relevanz und statistischer Signifikanz von delirassoziierten Risikofaktoren bei Schlaganfall machten. Für die Transparenz der Regressionsanalysen wurden die Gütekriterien von Ottenbacher zugrunde gelegt. Die identifizierten Risikofaktoren wurden mittels Bonferroni-Methode auf falsch positive Hypothesenbildung durch multiple Tests untersucht. Im Hinblick auf klinische Relevanz erfolgte eine literaturbasierte Diskussion.

Ergebnisse

Eingeschlossen wurden 9 klinische Studien. Keine erfüllte alle Voraussetzungen, die an die Berichterstattung von Regressionsanalysen nach Ottenbacher gestellt wurden. Von 108 delirassoziierten Risikofaktoren waren auf dem Signifikanzniveau p < 0,05 insgesamt 48 (44,4 %) signifikant, von denen sich 28 (58,3 %) nach Bonferroni-Korrektur als falsch positiv erwiesen. Nach literaturbasierter Diskussion bestand lediglich bei 4 Risikofaktoren (Demenz bzw. kognitive Einschränkung, totaler Anteriorinfarkt, schwerer Infarkt und Infektionen) die Annahme auf statische Signifikanz und klinische Relevanz.

Schlussfolgerungen

Die in der vorliegenden Literatur verwendeten statistischen Verfahren und deren Ergebnisse können angezweifelt werden. Eine Post-hoc-Analyse und kritische Reflexion reduziert die möglichen delirassoziierten Risikofaktoren auf wenige klinisch relevante Faktoren.

Abstract

Background

Delirium is a relevant complication following an acute stroke. It is a multifactor occurrence with numerous interacting risk factors that alternately influence each other.

Problem

The risk factors of delirium in stroke patients are often based on limited clinical studies. The statistical procedures and clinical relevance of delirium related risk factors in adult stroke patients should therefore be questioned.

Method

This secondary analysis includes clinically relevant studies that give evidence for the clinical relevance and statistical significance of delirium-associated risk factors in stroke patients. The quality of the reporting of regression analyses was assessed using Ottenbacher’s quality criteria. The delirium-associated risk factors identified were examined with regard to statistical significance using the Bonferroni method of multiple testing for forming incorrect positive hypotheses. This was followed by a literature-based discussion on clinical relevance.

Results

Nine clinical studies were included. None of the studies fulfilled all the prerequisites and assumptions given for the reporting of regression analyses according to Ottenbacher. Of the 108 delirium-associated risk factors, a total of 48 (44.4%) were significant, whereby a total of 28 (58.3%) were false positive after Bonferroni correction. Following a literature-based discussion on clinical relevance, the assumption of statistical significance and clinical relevance could be found for only four risk factors (dementia or cognitive impairment, total anterior infarct, severe infarct and infections).

Conclusions

The statistical procedures used in the existing literature are questionable, as are their results. A post-hoc analysis and critical appraisal reduced the number of possible delirium-associated risk factors to just a few clinically relevant factors.

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Literatur

  1. Assmann SF, Pocock SJ, Enos LE et al (2000) Subgroup analysis and other (mis)uses of baseline data in clinical trials. Lancet 355:1064–1069

    Article  CAS  PubMed  Google Scholar 

  2. Bender R, Lange S (2001) Adjusting for multiple testing – when and how? J Clin Epidemiol 54:343–349

    Article  CAS  PubMed  Google Scholar 

  3. Bortz J, Schuster C (2010) Statistik. Springer, Berlin

    Google Scholar 

  4. Bouwmeester W, Zuithoff NPA, Mallett S et al (2012) Reporting and methods in clinical prediction research: a systematic review. PLOS Med 9:1–12

    Article  PubMed  Google Scholar 

  5. Caeiro L, Ferro JM, Albuquerque R et al (2004) Delirium in the first days of acute stroke. J Neurol 251:171–178

    Article  PubMed  Google Scholar 

  6. Dahl MH, Rønning OM, Thommessen B (2010) Delirium in acute stroke – prevalence and risk factors. Acta Neurol Scand Suppl 122:39–43

    Article  Google Scholar 

  7. European Delirium A, American Delirium S (2014) The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Med 12:141

    Article  Google Scholar 

  8. Famakin BM (2014) The immune response to acute focal cerebral Ischemia and associated post-stroke Immunodepression: a focused review. Aging Dis 5:307–326

    PubMed  PubMed Central  Google Scholar 

  9. Fong TGDD, Growdon ME, Albuquerque A, Inouye SK (2015) The interface between delirium and dementia in elderly adults. Lancet Neurol 18:823–832

    Article  Google Scholar 

  10. Fong TG, Davis D, Growdon ME et al (2015) The interface between delirium and dementia in elderly adults. Lancet Neurol 14:823–832

    Article  PubMed  PubMed Central  Google Scholar 

  11. Frontera JA (2011) Delirium and sedation in the ICU. Neurocrit Care 14:463–474

    Article  PubMed  Google Scholar 

  12. Gordi T, Khamis H (2004) Simple solution to a common statistical problem: interpreting multiple tests. Clin Ther 26:780–786

    Article  PubMed  Google Scholar 

  13. Grover SGA, Kate N, Malhotra S, Mattoo SK, Chakrabarti S, Avasthi A (2014) Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile? Gen Hosp Psychiatry 36:187–191

    Article  PubMed  Google Scholar 

  14. Gurr B, Ibbitson J (2012) How does cognitive ability affect stroke rehabilitation outcomes? Int J Ther Rehabil 8:187–191

    Google Scholar 

  15. Gustafson YEO, Sture T, Bucht A, Gösta K (1991) Acute confusional states (delirium) in stroke patients. Cerebrovasc Dis 1:257–264

    Article  Google Scholar 

  16. Hannawi Y, Hannawi B, Rao CP et al (2013) Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis 35:430–443

    Article  CAS  PubMed  Google Scholar 

  17. Henon H, Lebert F, Durieu I et al (1999) Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome. Stroke 30:773–779

    Article  CAS  PubMed  Google Scholar 

  18. Heuschmann PU, Busse O, Wagner M, Endres M, Villringer A, Röther J, Kolom-Insky-Rabas PL, Berger K, Kompetenznetzwerk Schlaganfall, Deutsche Schlaganfall Gesellschaft, Stiftung Deutsche Schlaganfall-Hilfe (2010) Schlaganfallhäufigkeit und Versorgung von Schlaganfallpatienten in Deutschland. Akt Neurol 37:333–340

    Article  Google Scholar 

  19. Holtta EH, Laurila JV, Laakkonen ML et al (2014) Precipitating factors of delirium: stress response to multiple triggers among patients with and without dementia. Exp Gerontol 59:42–46

    Article  CAS  PubMed  Google Scholar 

  20. Hufschmidt A, Lücking CH, Rauer S (2013) Neurologie kompakt. Thieme, Stuttgart

    Google Scholar 

  21. Hunziker S, Mchugh W, Sarnoff-Lee B et al (2012) Predictors and correlates of dissatisfaction with intensive care. Crit Care Med 40:1554–1561

    Article  PubMed  PubMed Central  Google Scholar 

  22. Keselman HJ, Cribbie R, Holland B (2002) Controlling the rate of Type I error over a large set of statistical tests. Br J Math Stat Psychol 55:27–39

    Article  CAS  PubMed  Google Scholar 

  23. Langhorne P, Stott DJ, Robertson L et al (2000) Medical complications after stroke: a multicenter study. Stroke 31:1223–1229

    Article  CAS  PubMed  Google Scholar 

  24. Lees R, Corbet S, Johnston C et al (2013) Test accuracy of short screening tests for diagnosis of delirium or cognitive impairment in an acute stroke unit setting. Stroke 44:3078–3083

    Article  PubMed  Google Scholar 

  25. Maldonado JR (2008) Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin 24:789–856

    Article  CAS  PubMed  Google Scholar 

  26. Mcmanus J, Pathansali R, Hassan H et al (2009) The course of delirium in acute stroke. Age Ageing 38:385–389

    Article  PubMed  Google Scholar 

  27. Melkas S, Laurila JV, Vataja R et al (2012) Post-stroke delirium in relation to dementia and long-term mortality. Int J Geriatr Psychiatry 27:401–408

    PubMed  Google Scholar 

  28. Mikolajczyk RT, Disilvesto A, Zhang J (2008) Evaluation of logistic regression reporting in current obstetrics and gynecology literature. Obstet Gynecol 111:413–419

    Article  PubMed  Google Scholar 

  29. Mitasova A, Kostalova M, Bednarik J et al (2012) Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 40:484–490

    Article  PubMed  Google Scholar 

  30. Miu DK, Yeung JC (2013) Incidence of post-stroke delirium and 1‑year outcome. Geriatr Gerontol Int 13:123–129

    Article  PubMed  Google Scholar 

  31. Müllges W (2014) Ätiologie und Therapie des Delirs. Aktuelle Neurol 4:586–596

    Google Scholar 

  32. National Institute for Health and Care Excellence (2010) DELIRIUM: diagnosis, prevention and management. Clinical guideline, Bd. 103. National Institute for Health and Care Excellence, London

    Google Scholar 

  33. Norström F (2015) Poor quality in the reporting and use of statistical methods in public health – the case of unemployment and health. Arch Public Health 73:56

    Article  PubMed  PubMed Central  Google Scholar 

  34. Nydahl P (2016) Delirprävalenz bei PatientInnen mit Schlaganfall auf einer Stroke-Unit. Institut für Pflegewissenschaft. Paracelsus Medizinische Privatuniversität, Salzburg

    Google Scholar 

  35. Oldenbeuving AW, De Kort PL, Jansen BP et al (2011) Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology 76:993–999

    Article  CAS  PubMed  Google Scholar 

  36. Ottenbacher KJ, Ottenbacher HR, Tooth L et al (2004) A review of two journals found that articles using multivariable logistic regression frequently did not report commonly recommended assumptions. J Clin Epidemiol 57:1147–1152

    Article  PubMed  Google Scholar 

  37. Pandharipande P, Jackson J, Ely EW (2005) Delirium: acute cognitive dysfunction in the critically ill. Curr Opin Crit Care 11:360–368

    PubMed  Google Scholar 

  38. Pourhoseingholi MA, Baghestani AR, Vahedi M (2012) How to control confounding effects by statistical analysis. Gastroenterol Hepatol Bed Bench 5:79–83

    PubMed  PubMed Central  Google Scholar 

  39. Riedel B, Browne K, Silbert B (2014) Cerebral protection: inflammation, endothelial dysfunction, and postoperative cognitive dysfunction. Curr Opin Anaesthesiol 27:89–97

    Article  CAS  PubMed  Google Scholar 

  40. Roden M, Simmons BB (2014) Delirium superimposed on dementia and mild cognitive impairment. Postgrad Med 126:129–137

    Article  PubMed  Google Scholar 

  41. Sainani KL (2009) The problem of multiple testing. PM R 1:1098–1103

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  44. Simone MJ, Tan ZS (2011) The role of inflammation in the pathogenesis of delirium and dementia in older adults: a review. CNS Neurosci Ther 17:506–513

    Article  CAS  PubMed  Google Scholar 

  45. Stoltzfus JC (2011) Logistic regression: a brief primer. Acad Emerg Med 18:1099–1104

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Pflegeforschung, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Brunswiker Str. 10, 24105, Kiel, Deutschland

    P. Nydahl MScN

  2. Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland

    N. G. Margraf

  3. Institut für Pflegewissenschaft und -praxis, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich

    A. Ewers

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  1. P. Nydahl MScN
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Correspondence to P. Nydahl MScN.

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P. Nydahl, N.G. Margraf und A. Ewers geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Nydahl, P., Margraf, N.G. & Ewers, A. Delir bei Patienten mit Schlaganfall. Med Klin Intensivmed Notfmed 112, 258–264 (2017). https://doi.org/10.1007/s00063-016-0257-6

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