***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair . DESIGN Pilot double-masked r and omized placebo-controlled trial . SETTING Large academic medical center . PARTICIPANTS Sixteen individuals aged 70 and older with hip fracture . INTERVENTION Donepezil 5 mg or placebo was r and omly allocated and initiated within 24 hours of surgery , preoperatively or postoperatively . Daily treatment was continued for 30 days or until side effects or the clinical situation required termination . MEASUREMENTS All outcomes were ascertained masked to treatment status . Information on drug tolerability and safety was obtained from the participant , nurse , and medical record . Delirium presence and severity were measured during daily hospital interviews and at 2 , 4 , and 6 weeks after surgery after a st and ardized assessment using the Confusion Assessment Method ( CAM ) and the Memorial Delirium Assessment Scale ( MDAS ) . RESULTS Participants in the donepezil and placebo arms had similar baseline characteristics . Participants in the donepezil arm experienced significantly more side effects . In longitudinal models , there were no significant differences between the donepezil and placebo arms with regard to delirium presence over time ( odds ratio = 0.9 , 95 % confidence interval ( CI ) = 0.4 - 2.3 ) or delirium severity over time ( effect size = -0.2 on 30-point MDAS scale , 95%CI = -1.5 - 1.2 ) . CONCLUSION Participants r and omized to donepezil had no significant improvement in delirium presence or severity but experienced more side effects . Overall , sufficient evidence was not found from this pilot study to warrant a definitive Phase III trial Introduction Postoperative delirium , arbitrarily defined as occurring within 5 days of surgery , affects up to 50 % of patients older than 60 after a major operation . This geriatric syndrome is associated with longer intensive care unit and hospital stay , readmission , persistent cognitive deterioration and mortality . No effective preventive methods have been identified , but preliminary evidence suggests that EEG monitoring during general anaesthesia , by facilitating reduced anaesthetic exposure and EEG suppression , might decrease incident postoperative delirium . This study hypothesises that EEG-guidance of anaesthetic administration prevents postoperative delirium and downstream sequelae , including falls and decreased quality of life . Methods and analysis This is a 1232 patient , block-r and omised , double-blinded , comparative effectiveness trial . Patients older than 60 , undergoing volatile agent-based general anaesthesia for major surgery , are eligible . Patients are r and omised to 1 of 2 anaesthetic approaches . One group receives general anaesthesia with clinicians blinded to EEG monitoring . The other group receives EEG-guidance of anaesthetic agent administration . The outcomes of postoperative delirium ( ≤5 days ) , falls at 1 and 12 months and health-related quality of life at 1 and 12 months will be compared between groups . Postoperative delirium is assessed with the confusion assessment method , falls with ProFaNE consensus questions and quality of life with the Veteran 's R AND 12-item Health Survey . The intention-to-treat principle will be followed for all analyses . Differences between groups will be presented with 95 % CIs and will be considered statistically significant at a two-sided p<0.05 . Ethics and dissemination Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES ) is approved by the ethics board at Washington University . Recruitment began in January 2015 . Dissemination plans include presentations at scientific conferences , scientific publications , internet-based educational material s and mass media . Trial registration number NCT02241655 ; Pre- results IMPORTANCE No highly effective interventions to prevent delirium have been identified . OBJECTIVE To examine whether ramelteon , a melatonin agonist , is effective for the prevention of delirium . DESIGN , SETTING , AND PARTICIPANTS A multicenter , rater-blinded , r and omized placebo-controlled trial was performed in intensive care units and regular acute wards of 4 university hospitals and 1 general hospital . Eligible patients were 65 to 89 years old , newly admitted due to serious medical problems , and able to take medicine orally . Patients were excluded from the study if they had an expected stay or life expectancy of less than 48 hours . INTERVENTIONS Sixty-seven patients were r and omly assigned using the sealed envelope method to receive ramelteon ( 8 mg/d ; 33 patients ) or placebo ( 34 patients ) every night for 7 days . MAIN OUTCOMES AND MEASURES Incidence of delirium , as defined by the Diagnostic and Statistical Manual of Mental Disorders ( Fourth Edition ) . RESULTS Ramelteon was associated with a lower risk of delirium ( 3 % vs 32 % ; P = .003 ) , with a relative risk of 0.09 ( 95 % CI , 0.01 - 0.69 ) . Even after risk factors were controlled for , ramelteon was still associated with a lower incidence of delirium ( P = .01 ; odds ratio , 0.07 [ 95 % CI , 0.008 - 0.54 ] ) . The Kaplan-Meier estimates of time to development of delirium were 6.94 ( 95 % CI , 6.82 - 7.06 ) days for ramelteon and 5.74 ( 5.05 - 6.42 ) days for placebo . Comparison by log-rank test showed that the frequency of delirium was significantly lower in patients taking ramelteon  than in those taking placebo ( χ(2 ) = 9.83 ; P = .002 ) . CONCLUSIONS AND RELEVANCE Ramelteon administered nightly to elderly patients admitted for acute care may provide protection against delirium . This finding supports a possible pathogenic role of melatonin neurotransmission in delirium . TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trials Registry Identifier : UMIN000005591 BACKGROUND : Postoperative delirium in the intensive care unit ( ICU ) is a frequent complication after cardiac or thoracic surgery and is associated with increased morbidity and mortality . METHODS : In this single-center sub study of the BAG-RECALL trial ( NCT00682825 ) , we screened patients after cardiac or thoracic surgery in the ICU twice daily for delirium using the Confusion Assessment Method for the ICU . The primary outcome was the incidence of delirium in patients who had been r and omized to intraoperative Bispectral Index (BIS)-guided and end-tidal anesthetic concentration-guided depth of anesthesia protocol s. As a secondary analysis , a Bayesian stochastic search variable selection strategy was used to rank a field of c and i date risk factors for delirium , followed by binary logistic regression . RESULTS : Of 310 patients assessed , 28 of 149 ( 18.8 % ) in the BIS group and 45 of 161 ( 28.0 % ) in the end-tidal anesthetic concentration group developed postoperative delirium in the ICU ( odds ratio 0.60 , 95 % confidence interval , 0.35–1.02 , P= 0.058 ) . Low average volatile anesthetic dose , intraoperative transfusion , ASA physical status , and European System for Cardiac Operative Risk Evaluation were identified as independent predictors of delirium . CONCLUSIONS : A larger r and omized study should determine whether brain monitoring with BIS or an alternative method decreases delirium after cardiac or thoracic surgery . The association between low anesthetic concentration and delirium is a surprising finding and could reflect that patients with poor health are both more sensitive to the effects of volatile anesthetic drugs and are also more likely to develop postoperative delirium . Investigation of c and i date methods to prevent delirium should be prioritized in view of the established association between postoperative delirium and adverse patient outcomes Objective : to evaluate the performance of the 4 ‘ A ’s Test ( 4AT ) in screening for delirium in older patients . The 4AT is a new test for rapid screening of delirium in routine clinical practice . Design : prospect i ve study of consecutively admitted elderly patients with independent 4AT and reference st and ard assessment s. Setting : an acute geriatrics ward and a department of rehabilitation . Participants : two hundred and thirty-six patients ( aged ≥70 years ) consecutively admitted over a period of 4 months . Measurements : in each centre , the 4AT was administered by a geriatrician to eligible patients within 24 h of admission . Reference st and ard delirium diagnosis ( DSM-IV-TR criteria ) was obtained within 30 min by a different geriatrician who was blind to the 4AT score . The presence of dementia was assessed using the Alzheimer 's Question naire and the informant section of the Clinical Dementia Rating scale . The main outcome measure was the accuracy of the 4AT in diagnosing delirium . Results : patients were 83.9 ± 6.1 years old , and the majority were women ( 64 % ) . Delirium was detected in 12.3 % ( n = 29 ) , dementia in 31.2 % ( n = 74 ) and a combination of both in 7.2 % ( n = 17 ) . The 4AT had a sensitivity of 89.7 % and specificity 84.1 % for delirium . The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population , 0.92 in patients without dementia and 0.89 in patients with dementia . Conclusions : the 4AT is a sensitive and specific method of screening for delirium  in hospitalised older people . Its brevity and simplicity support its use in routine clinical practice Background Most previous studies on the efficacy of antipsychotic medication for the treatment of delirium have reported that there is no significant difference between typical and atypical antipsychotic medications . It is known , however , that older age might be a predictor of poor response to antipsychotics in the treatment of delirium . The objective of this study was to compare the efficacy and safety of haloperidol versus three atypical antipsychotic medications ( risperidone , olanzapine , and quetiapine ) for the treatment of delirium with consideration of patient age . Methods This study was a 6-day , prospect i ve , comparative clinical observational study of haloperidol versus atypical antipsychotic medications ( risperidone , olanzapine , and quetiapine ) in patients with delirium at a tertiary level hospital . The subjects were referred to the consultation-liaison psychiatric service for management of delirium and were screened before enrollment in this study . A total of 80 subjects were assigned to receive either haloperidol ( N = 23 ) , risperidone ( N = 21 ) , olanzapine ( N = 18 ) , or quetiapine ( N = 18 ) . The efficacy was evaluated using the Korean version of the Delirium Rating Scale-Revised-98 ( DRS-K ) and the Korean version of the Mini Mental Status Examination ( K-MMSE ) . The safety was evaluated by the Udvalg Kliniske Undersogelser side effect rating scale . Results There were no significant differences in mean DRS-K severity or K-MMSE scores among the four groups at baseline . In all groups , the DRS-K severity score decreased and the K-MMSE score increased significantly over the study period . However , there were no significant differences in the improvement of DRS-K or K-MMSE scores among the four groups . Similarly , cognitive and non-cognitive subscale DRS-K scores decreased regardless of the treatment group . The treatment response rate was lower in patients over 75 years old than in patients under 75 years old . Particularly , the response rate to olanzapine was poorer in the older age group . Fifteen subjects experienced a few adverse events , but there were no significant differences in adverse event profiles among the four groups . Conclusions Haloperidol , risperidone , olanzapine , and quetiapine were equally efficacious and safe in the treatment of delirium . However , age is a factor that needs to be considered when making a choice of antipsychotic medication for the treatment of delirium . Trial registration Clinical Research Information Service , Republic of Korea , ( http://cris.nih.go.kr/cris/en/ search /basic _ search .jsp , Registered Trial No. KCT0000632 ) Background : Postoperative delirium is common in patients recovering from cardiac surgery . Tight glucose control has been shown to reduce mortality and morbidity . Therefore , the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic – normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery . Methods : The authors enrolled 198 adult patients having cardiac surgery in this r and omized , double-blind , single-center trial . Patients were r and omly assigned to either tight intraoperative glucose control with a hyperinsulinemic – normoglycemic clamp ( target blood glucose , 80 to 110 mg/dl ) or st and ard therapy ( conventional insulin administration with blood glucose target , < 150 mg/dl ) .  Delirium was assessed using a comprehensive delirium battery . The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment . A positive Conf 
    Output:
    
Measures of severity , such as the Confusion Assessment Method –Severity Score , can aid in monitoring response to treatment , risk stratification , and assessing prognosis .
Nonpharmacologic approaches focused on risk factors such as immobility , functional decline , visual or hearing impairment , dehydration , and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment .
Conclusions and Relevance Advances in diagnosis can improve recognition and risk stratification of delirium .
Prevention of delirium using nonpharmacologic approaches is documented to be effective , while pharmacologic prevention and treatment of delirium remains controversial