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PubMed2006

Incidence of delirium and associated mortality in hematopoietic stem cell transplantation patients.

Delirium has been associated with a high risk of mortality in medical patients. Despite the high incidence of delirium in patients who undergo hemapoietic stem cell transplantation (HSCT), delirium as a risk factor for death has not been examined in this population. Thirty adult patients undergoing HSCT who were admitted to the University of Iowa Blood and Marrow Transplantation Program inpatient unit were assessed prospectively from 1 to 2 weeks before transplantation, throughout their inpatient stay, and at 100 days after transplantation. The Delirium Rating Scale and Memorial Delirium Assessment Scale were used twice weekly during the inpatient period to assess delirium severity and occurence. Patients' self-reports of medical history, computerized medical records, and neuropsychological and psychiatric assessments were used to identify pretransplantation risk factors. The incidence of delirium (Delirium Rating Scale score >12 or Memorial Delirium Assessment Scale score >or=8) was 43% and occurred with highest frequency in the first 2 weeks after transplantion. The presence of delirium at any point during hospitalization after transplantation and transplant type (allogeneic) were highly predictive of mortality (p < .0005; odds ratios, 14.0 and 14.4). In conclusion, this study highlights the importance of monitoring for delirium during the acute recovery period after transplantation and suggests that early or even prophylactic treatment for delirium should be studied. Studies to determine the factors that connect delerium soon after transplantation to mortality are highly warranted.

Adolescent↗
PubMed2006

Reliability of a structured assessment for nonclinicians to detect delirium among new admissions to postacute care.

OBJECTIVE: To evaluate the interrater reliability of a structured delirium assessment method for nonclinician interviewers in elderly patients newly admitted for postacute care. DESIGN: Prospective assessment using dyads of nonclinician raters. SETTING: Postacute (Medicare) units at 6 skilled nursing facilities. PARTICIPANTS: Forty elderly patients newly admitted for postacute care from medical or surgical units at acute care hospitals. MEASUREMENTS: Subjects underwent dual delirium assessments within 5 days of admission. The standardized delirium assessment included the Mini-Mental Status Exam and Digit Span to assess overall cognitive function, the Delirium Symptom Interview to elicit specific delirium symptoms, the Memorial Delirium Assessment Scale to measure the severity of delirium, and the Confusion Assessment Method (CAM) to make the diagnosis of delirium. A coding protocol that linked observations to specific coding was used to improve reliability. RESULTS: The structured delirium assessment process produced very high interobserver agreement for all instruments. Kappa for agreement on delirium diagnosis was 0.95. CONCLUSIONS: Nonclinician interviewers using a structured delirium assessment achieved reliability that rivaled or exceeded that of trained clinical assessors in other studies. Nonclinicians may offer an effective alternative for the assessment of delirium among postacute patients in skilled nursing facilities.

Aged↗
PubMed2003

Delirium in the intensive care unit: occurrence and clinical course in older patients.

OBJECTIVES: To describe the occurrence of delirium in a cohort of older medical intensive care unit (ICU) patients and its short-term duration in the hospital and to determine the association between preexisting dementia and the occurrence of delirium. DESIGN: Prospective cohort study. SETTING: Fourteen-bed medical ICU of an 800-bed university teaching hospital. PARTICIPANTS: One hundred eighteen consecutive patients aged 65 and older admitted to the ICU. MEASUREMENTS: Baseline characteristics were obtained through surrogate interviews and medical chart review. Dementia was determined using two validated surrogate-rated instruments. Delirium was assessed daily in the ICU using the Confusion Assessment Method (CAM) for the ICU (CAM-ICU). After discharge from the ICU, patients were followed for up to 7 days using the CAM. RESULTS: Delirium was present in 37 of 118 (31%) patients on admission. Only 45 patients had a normal mental status on admission, of whom 14 (31%) became delirious during their hospital stay. In the post-ICU period, delirium occurred in 40% of patients. Almost half of patients with delirium in the ICU had persistent delirium in the post-ICU period. Overall, 83 of 118 (70%) had delirium during hospitalization. Stupor or coma occurred in 44% of the patients overall, and 89% of survivors of stupor/coma progressed to delirium. Patients with dementia were 40% more likely to be delirious (relative risk = 1.4, 95% confidence interval = 1.1-1.7), even after controlling for comorbidity, baseline functional status, severity of illness, and invasive procedures. CONCLUSION: Delirium is a frequent complication in older ICU patients and often persists beyond their ICU stay. Delirium in older ICU persons is a dynamic and complex process. Dementia is an important predisposing risk factor for the development of delirium in this population during and after the ICU stay.

Aged↗
PubMed1998

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.

OBJECTIVE: To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline. DESIGN: Three prospective cohort studies. SETTING: Three university-affiliated teaching hospitals. PATIENTS: Consecutive samples of 727 patients, aged 65 years and older. MEASUREMENTS AND MAIN RESULTS: Delirium was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2). CONCLUSIONS: Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline-even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.

Activities of Daily Living↗
PubMed2001

Reducing delirium after hip fracture: a randomized trial.

OBJECTIVES: Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture. DESIGN: Prospective, randomized, blinded. SETTING: Inpatient academic tertiary medical center. PARTICIPANTS: 126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm. RESULTS: The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment. CONCLUSIONS: Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients.

Activities of Daily Living↗
PubMed2005

Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study.

OBJECTIVES: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Large medical school-affiliated general hospital in Alkmaar, The Netherlands. PARTICIPANTS: A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium. INTERVENTION: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. MEASUREMENTS: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay. RESULTS: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6-1.3); the mean highest DRS-R-98 score+/-standard deviation was 14.4+/-3.4 and 18.4+/-4.3, respectively (mean difference 4.0, 95% CI=2.0-5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI=4.0-8.0; P<.001); and the mean number of days in the hospital was 17.1+/-11.1 and 22.6+/-16.7, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). No haloperidol-related side effects were noted. CONCLUSION: Low-dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated.

Aged↗
PubMed2005

Donepezil in the prevention and treatment of post-surgical delirium.

OBJECTIVE: Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery. METHODS: A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant. RESULTS: Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility. CONCLUSIONS: This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Aged↗
PubMed2003

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition.

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses ("organic psychoses"); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses.

Aged↗
PubMed2006

[Delirium in Chilean elderly inpatients: an overlooked problem].

BACKGROUND: Delirium is a common underdiagnosed and undertreated problem in elderly inpatients, associated to higher morbidity, mortality and health cost. AIM: To evaluate the prevalence of delirium at hospital admission in medically ill elderly patients and the attending physician's diagnosis and treatment of delirium. PATIENTS AND METHODS: In a prospective and descriptive study, consecutive patients aged 65 years or more, admitted to an internal medicine ward were evaluated by independent physicians, during the first 48 h of admission, to asses the presence of delirium. Diagnosis of delirium was based on the Confusion Assessment Method. Medical and nurse records were reviewed. Family was interviewed when necessary. RESULTS: One hundred eight patients (52% women, age range 65-94 years) with an APACHE II score of 11.6+/-5, were evaluated. Fifty seven patients (53%) had delirium (32% hyperactive, 72% hypoactive and 5% mixed). Delirium prevalence was significantly higher in older patients (66% among those aged 75 years or older versus 30% in younger, p <0.05) and among patients with more severe conditions (88% among those with an APACHE score over 16 versus 47% below that value, p <0.05). Medical records of patients with delirium showed that this diagnosis was present only in 32% and cognitive deficit was described in 73%. Ten percent of patients with delirium received sedative medication and 38% were physically restricted. There were no environmental interventions to prevent or control delirium. CONCLUSIONS: Delirium in elderly inpatients at this unit is an extraordinarily prevalent problem, seriously under diagnosed (68%) and under treated. This study should alerts our medical community to improve the diagnosis and management of delirium in elderly inpatients.

APACHE↗
PubMed1997

Length of hospitalization and disposition of elderly vs younger delirium patients in psychiatric hospitals.

Although it is commonly accepted that delirium patients require the full facilities of general hospitals, practical experience has shown that delirium patients of all ages continue to be admitted to psychiatric institutions. The present study was designed to detect any differences in the length of hospitalization and disposition (discharge back to the community, transfer to a general hospital, death during the index hospitalization, transfer to another psychiatric hospital) between elderly (> 65 years) and younger delirium patients admitted to psychiatric hospitalization. Our hypothesis was that the prognosis (represented in this study by the above-mentioned measures) of elderly delirium patients in a psychiatric hospital would be poorer compared with younger delirium patients. We studied psychiatric case register data of 805 patients with delirium admitted to psychiatric hospitals during the period 1984-1993. Our sample was divided into four ICD-9-CM categories: delirium in dementia, delirium tremens (DT), drug-induced delirium, and acute and subacute delirium. No significant differences in the length of hospitalization were found between < 65- and > 65-year-old patients in the categories studied. There were disposal differences between the two age groups in the acute and subacute delirium parameters, but findings in the other categories were similar. Practical implementation of the results in terms of appropriate place of management of delirium patients in a psychiatric hospital is discussed.

Adult↗
PubMed2005

Delirium in elderly people: an update.

PURPOSE OF REVIEW: To review recent studies on epidemiology, diagnosis, pathophysiology, treatment and prevention of delirium in elderly people. RECENT FINDINGS: There is no evidence that the clinical picture of delirium in elderly people differs from that in younger patients, although it may run a more chronic course. Diagnosing delirium in demented patients, however, may be difficult due to overlap in symptoms of delirium and dementia. Systematic use of screening and diagnostic instruments may help to diminish the common underdiagnosis of delirium. Delirium is best understood as the result of multiple interacting predisposing and precipitating factors. In the elderly, predisposing factors that make patients more susceptible for delirium include cognitive dysfunction and older age, while important precipitating factors that directly cause delirium are any somatic events and the use of anticholinergic drugs. Delirium has a significant negative prognostic impact on functional and cognitive outcome, as well as on morbidity and mortality. Haloperidol remains the standard treatment for delirium, while there is some evidence for the efficacy of risperidone. Other atypical antipsychotics, as well as cholinesterase inhibitors, have not yet been sufficiently studied. Results of studies on the effectiveness of systematic screening of populations at risk and standardized interventions to prevent delirium have been inconclusive. SUMMARY: In recent years, the emphasis in the approach to delirium has shifted from ad hoc treatment to systematic screening and prevention. Interest has been raised in treatment options other than haloperidol, such as atypical antipsychotics and procholinergic drugs.

Journal Article↗
PubMedDate not supplied

Preoperative risk factors for postoperative delirium.

The objective of this article was to estimate the incidence of delirium in a sample of patients undergoing elective surgery and to identify the preoperative factors most closely associated with developing this complication. Consecutive patients (n=500) underwent a full preoperative medical evaluation including assessment of cognitive and functional status. Daily evaluation on postoperative days 1 through 4 included medical record review and direct standardized patient interviews. Logistic regression was used to explore the associations between preoperative factors and postoperative delirium. Delirium was detected in 57 (11.4%) patients. Univariate factors associated with delirium included age> or =70 years (RR=3.1 [1.75,5.55]), preexisting cognitive impairment (RR=3.1 [1.73, 5.43]), greater preoperative functional limitations (RR=1.57 [1.27, 1.94]), and a history of prior delirium (RR 4.1 [1.98 to 8.27]. Adjusting for other factors, previous delirium (OR=4.08 [1.85, 9.0]), age> or =70 years (OR=3.2 [1.6, 6.0], and preexisting cognitive impairment (OR=2.16 [1.15, 4.0] remained predictive of delirium. Patients' perceptions that alcohol had affected their health (OR=6.53 [1.58 to 28.1]) and use of narcotic analgesics just prior to admission (OR=2.7 [1.37 to 5.3]) were also significantly associated with delirium postoperatively. Several easily obtained preoperative clinical factors can be used to identify patients at risk for postoperative delirium. This approach, when combined with specialized delirium teams using established guidelines, may be more effective in targeting patients at risk, thus reducing the number of episodes and days of delirium.

Age Factors↗
PubMed2006

Delirium in a sub-intensive care unit for the elderly: occurrence and risk factors.

BACKGROUND AND AIMS: The objective was to study occurrence and risk factors of delirium in a new model of care, the Sub-Intensive Care Unit for the elderly (SICU), which is a level of care between that offered by ordinary wards and intensive care. METHODS: A prospective observational study of 401 consecutively admitted patients, 60+ years, in a four-bed SICU in the geriatric ward of a general hospital. Delirium was detected by the Confusion Assessment Method (CAM) at admission (prevalent) and during SICU stay (incident). Impaired function (Barthel Index) and/or IADL two weeks prior to admission identified disability, and additional Mini-Mental State Examination (MMSE) <18 at discharge identified probable dementia. RESULTS: Delirium was detected in 117 patients (29.2%). Of these 62 (15.5%) had delirium at admission and a further 55 developed delirium during their time in the SICU. Delirium occurred in 19 (11.4%) of the "robust" (no dementia or disability), 28 (24.1%) of the disabled and 70 (58.4%) of the demented patients (p<0.001). Prevalent delirium was found in 8 (4.8%), 11 (9.5%) and 43 (36.1%) (p<0.001) and incident in 11 (6.6%), 17 (14.7%) and 27 (22.7%) (p<0.001) of the robust, disabled, and demented patients respectively. Heavy alcohol use, maximum intake of 7 or more drugs, and the use of a bladder catheter were independently associated with delirium. CONCLUSIONS: Delirium was common in the SICU, and patients with probable dementia had the highest risk. They tended to have delirium at admission, whereas patients without dementia, although less at risk, were more prone to developing delirium during their stay in the SICU.

Aged↗
PubMed2001

The impact of delirium in the intensive care unit on hospital length of stay.

STUDY OBJECTIVE: To determine the relationship between delirium in the intensive care unit (ICU) and outcomes including length of stay in the hospital. DESIGN: A prospective cohort study. SETTING: The adult medical ICU of a tertiary care, university-based medical center. PARTICIPANTS: The study population consisted of 48 patients admitted to the ICU, 24 of whom received mechanical ventilation. MEASUREMENTS: All patients were evaluated for the development and persistence of delirium on a daily basis by a geriatric or psychiatric specialist with expertise in delirium assessment using the Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric Association, the reference standard for delirium ratings. Primary outcomes measured were length of stay in the ICU and hospital. RESULTS: The mean onset of delirium was 2.6 days (S.D.+/-1.7), and the mean duration was 3.4+/-1.9 days. Of the 48 patients, 39 (81.3%) developed delirium, and of these 29 (60.4%) developed the complication while still in the ICU. The duration of delirium was associated with length of stay in the ICU ( r=0.65, P=0.0001) and in the hospital ( r=0.68, P<0.0001). Using multivariate analysis, delirium was the strongest predictor of length of stay in the hospital ( P=0.006) even after adjusting for severity of illness, age, gender, race, and days of benzodiazepine and narcotic drug administration. CONCLUSIONS: In this patient cohort, the majority of patients developed delirium in the ICU, and delirium was the strongest independent determinant of length of stay in the hospital. Further study and monitoring of delirium in the ICU and the risk factors for its development are warranted.

Delirium↗
PubMedDate not supplied

Impact on delirium detection of using a sensitive instrument integrated into clinical practice.

Early symptoms of delirium often go unnoticed. The Nursing Delirium Screening Scale (Nu-DESC) is a recently developed short, accurate and sensitive 24-h screening instrument. The Nu-DESC is more sensitive than the instrument from which it was derived, the Confusion Rating Scale (CRS). This study examined the impact on delirium detection of using the Nu-DESC over the CRS in 134 consecutive oncology patients. Expected false-negative rate (FNR) reductions at different delirium prevalence rates when using the Nu-DESC compared to the CRS and the number needed to screen (NNS) by the Nu-DESC were calculated. Kaplan-Meier survival analyses were used to study Nu-DESC-CRS divergences in delirium status and length of delirium-free survival. Ninety-nine patients were negative for delirium according to both tests. Of the remaining 35 patients, 16 had identical Nu-DESC-CRS delirium status and delirium-free survival, whereas 19 were detected later by the CRS (mean, 4.8 days). Among the 19 patients, 6 were still CRS negative upon hospital discharge. Integrating a continuous and sensitive delirium assessment instrument into usual care can facilitate its recognition, since more cases of delirium are diagnosed and patients are detected earlier.

Adult↗
PubMed2000

Delirium in elderly people without severe predisposing disorders: etiology and 1-year prognosis after discharge.

BACKGROUND: The etiologic factors of delirium have been frequently studied in hospitalized elderly patients who usually have an underlying disorder, i.e., hip fracture or dementia predisposing to delirium. The etiologic factors of delirium and prognosis in healthy elderly remain unstudied. The aim of our study was to detect the primary and additional etiologic factors contributing to delirium among community-dwelling healthy elderly people without predisposing disorders to delirium and to evaluate 1-year prognosis after discharge to home. METHOD: The study subjects consisted of 51 community-dwelling people over 65 years of age, without severe underlying disorders predisposing to delirium, admitted consecutively to the hospital because of a delirious state. The diagnosis of delirium was based on the DSM-III-R criteria. After discharge to home, the subjects were followed up for 1 year. RESULTS: The most important primary causes of delirium were infections in 22 cases (43%) and cerebrovascular attacks in 13 cases (25%). After the 1-year follow-up period, 10 patients (20%) had been taken into long-term care and 5 patients (10%) had died. DISCUSSION: The plausible etiologic factor of delirium was detected in all cases. Among healthy elderly people, infections and cerebrovascular attacks were the most important etiologic factors for delirium. After discharge to home, 30% of the patients had to be taken into long-term care or had died within 1 year of the delirium.

Acute Disease↗
PubMed1999

The risk of dementia and death after delirium.

BACKGROUND: delirium is common and is associated with many adverse short-term consequences. OBJECTIVES: to examine the relationship between an episode of delirium and subsequent dementia and death over 3 years. DESIGN: prospective cohort study. SETTING: patients (n = 203) were aged 65 years or older at baseline and survivors of the index admission. METHODS: Using a standard assessment of cognitive function, we followed 38 inpatients diagnosed with delirium (22 with delirium and dementia, 16 with delirium only) and 148 patients with no delirium or dementia, for a median of 32.5 months. Follow-up was by personal interviews, supplemented by standardized clinical examinations. We calculated the incidence and odds of dementia and the incidence and hazard ratio for death, with adjustment for potential confounders. RESULTS: The incidence of dementia was 5.6% per year over 3 years for those without delirium and 18.1% per year for those with delirium. The unadjusted relative risk of dementia for those with delirium was 3.23 (95% confidence interval 1.86-5.63). The adjusted relative risk of death also increased (1.80; 1.11-2.92), while the median survival time was significantly shorter in those with (510 days; 433-587) than in those without delirium (1122 days; 922-1322). CONCLUSION: delirium appears to be an important marker of risk for dementia and death, even in older people without prior cognitive or functional impairment.

Aged↗
PubMed2005

Enzymes of drug metabolism during delirium.

BACKGROUND: Delirium is common in ill medical patients. Several drugs and polypharmacy are recognised risk factors, yet little is known about drug metabolism in people with delirium. OBJECTIVE: The aim of this study was to investigate the activities of plasma esterases (drug metabolising enzymes) in delirium. DESIGN: This was a prospective study of delirium present at time of hospital admission (community acquired) or developing later (hospital acquired) in patients admitted as a medical emergency and aged 75 years or over. METHODS: Following informed consent or assent cognitive screening was completed on all patients on admission and every 48 hours subsequently. Delirium was diagnosed by Confusion Assessment Method and DSM IV criteria. Blood samples were taken on admission and at onset of delirium if this was later. Four plasma esterase assays were performed spectrophotometrically: acetylcholinesterase, aspirin esterase, benzoylcholinesterase, butyrylcholinesterase. RESULTS: 283 patients (71% of eligible) were recruited, with mean age 82.4 years and 59% female. 27% had community acquired delirium, 10% developed hospital acquired delirium, 63% never developed delirium. On admission the mean activities of all four esterase assays were statistically significantly lower in delirious than non delirious patients. There were no significant differences on admission in any plasma esterase activity between patients with hospital and community acquired delirium. In-hospital mortality was associated with low plasma esterase activities on admission. CONCLUSION: Plasma esterase activities are suppressed during delirium. These data reinforce the need for extreme caution with drugs in this vulnerable population.

Acetylcholinesterase↗