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PubMed2004

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.

CONTEXT: In the intensive care unit (ICU), delirium is a common yet underdiagnosed form of organ dysfunction, and its contribution to patient outcomes is unclear. OBJECTIVE: To determine if delirium is an independent predictor of clinical outcomes, including 6-month mortality and length of stay among ICU patients receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study enrolling 275 consecutive mechanically ventilated patients admitted to adult medical and coronary ICUs of a US university-based medical center between February 2000 and May 2001. Patients were followed up for development of delirium over 2158 ICU days using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale. MAIN OUTCOME MEASURES: Primary outcomes included 6-month mortality, overall hospital length of stay, and length of stay in the post-ICU period. Secondary outcomes were ventilator-free days and cognitive impairment at hospital discharge. RESULTS: Of 275 patients, 51 (18.5%) had persistent coma and died in the hospital. Among the remaining 224 patients, 183 (81.7%) developed delirium at some point during the ICU stay. Baseline demographics including age, comorbidity scores, dementia scores, activities of daily living, severity of illness, and admission diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month mortality rates (34% vs 15%, P =.03) and spent 10 days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age, severity of illness, comorbid conditions, coma, and use of sedatives or analgesic medications), delirium was independently associated with higher 6-month mortality (adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P =.008), and longer hospital stay (adjusted HR, 2.0; 95% CI, 1.4-3.0; P<.001). Delirium in the ICU was also independently associated with a longer post-ICU stay (adjusted HR, 1.6; 95% CI, 1.2-2.3; P =.009), fewer median days alive and without mechanical ventilation (19 [interquartile range, 4-23] vs 24 [19-26]; adjusted P =.03), and a higher incidence of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P =.002). CONCLUSION: Delirium was an independent predictor of higher 6-month mortality and longer hospital stay even after adjusting for relevant covariates including coma, sedatives, and analgesics in patients receiving mechanical ventilation.

APACHE↗
PubMed2001

Delirium in the non-demented oldest old in the general population: risk factors and prognosis.

BACKGROUND: The oldest old are prone to develop delirium. Studies into risk factors for delirium have been carried out predominantly in younger age groups. The aim of this population-based follow-up study was to investigate the risk factors for delirium requiring medical attention and subsequent prognosis in the non-demented general population aged > or = 85 years. METHOD: The study included the non-demented subjects in the population-based Vantaa 85+ study. After the 3-year observation period, 199 subjects (91% of those surviving) were re-examined and their medical records were evaluated for episodes of delirium. The subjects were followed up with respect to mortality for another 2 years. RESULTS: During the 3-year observational period, 20 subjects (10%) had been diagnosed as having had an episode of delirium. A Mini-Mental State Examination score of < 24 (odds ratio (OR) 3.44, confidence interval (CI = 95%) 1.27-9.32) and high systolic blood pressure (OR 3.08, CI 1.08-8.79) were identified as independent risk factors for delirium. The association between the delirium episode and a new diagnosis of dementia was significant ( p = 0.001). The mortality rate was greater among those subjects who experienced delirium than among subjects without this syndrome ( p = 0.008). CONCLUSIONS: Mild cognitive impairment and high systolic blood pressure were found to be risk factors for delirium requiring medical attention in the general non-demented population aged > or = 85 years. The study also highlights the significant association between delirium and a new dementia diagnosis in this age group.

Aged↗
PubMed1997

The Memorial Delirium Assessment Scale.

We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinician's ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinician's global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.

Adult↗
PubMed2005

Atypical antipsychotics in the management of delirium: a review of the empirical literature.

OBJECTIVES: To review the existing literature of atypical antipsychotics in the treatment of delirium and make recommendations regarding their use in the treatment of delirium. METHODS: I conducted a literature search in Pubmed, Psychlit, and Embase for studies using atypical antipsychotics in the treatment of delirium. In the absence of studies, case reports were used. RESULTS: Overall 13 studies examined the use of risperidone, olanzapine, and quetiapine, two cases were reported about ziprasidone, and no publication was found using aripiprazole in the treatment of delirium. Among the existing studies were retrospective and prospective, open label studies in addition to one with a double blind design using risperidone. Risperidone, olanzapine, and quetiapine may be all similarly effective in the treatment of delirium, whereas there may be limited efficacy in the use of olanzapine in the hypoactive subtype of delirium in elderly populations, which may generalize to the other atypical antipsychotics. The use of atypical antipsychotics in the treatment of delirium is safe and carries a low burden of side effects. SIGNIFICANCE OF RESULTS: Although atypical antipsychotics are widely used in the treatment of delirium, well-designed studies do not exist. Among the existing studies, stronger data supports the use of risperidone and olanzapine, and also quetiapine may be considered in the treatment of delirium. Recommendations are made based on the existing data and literature. The need for well-designed studies to validate the use of atypical antipsychotics in the treatment of delirium continues.

Antipsychotic Agents↗
PubMed2004

The association between delirium and cognitive decline: a review of the empirical literature.

Delirium is a common neurobehavioral syndrome that occurs across health care settings which is associated with adverse outcomes, including death. There are limited data on long-term cognitive outcomes following delirium. This report reviews the literature regarding relationships between delirium and cognitive impairment. Psych Info and Medline searches and investigation of secondary references for all English language articles on delirium and subsequent cognitive impairment were carried out. Nine papers met inclusion criteria and documented cognitive impairment in patients following delirium. Four papers reported greater cognitive impairment among patients with delirium than matched controls. Four papers reported higher incidence of dementia in patients with a history of delirium. One study found 1 of 3 survivors of critical illness with delirium developed cognitive impairment. The evidence suggests a relationship between delirium and cognitive impairment, although significant questions remain regarding the nature of this association. Additional research on delirium-related effects on long-term cognitive outcome is needed.

Adult↗
PubMed2001

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients.

OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective before/after design (sequential design). SETTING: The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12). INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively. RESULTS: Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive. CONCLUSIONS: This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Activities of Daily Living↗
PubMedDate not supplied

Can delirium relieve psychosis?

A delirium presages a poor prognosis in hospitalized patients, but an incidental delirium is a feature of some psychiatric treatments. We report five cases in which delirium preceded the relief of affective and psychotic symptoms of a major mental illness. The experience stimulated a review of the literature on delirium in psychiatric treatments. Five inpatients (aged 53 to 69 years) with an exacerbation of chronic mental illness developed deliria from medications (n = 4) and electrolyte disturbance (n = 1). The deliria were managed with medication washout or correction of electrolyte imbalance. The progress of the patients was noted clinically and summarized. The clinical signs of delirium such as confusion, disorganized speech, sleep-wake cycle changes, and hallucinations persisted for 24 to 72 hours. As the delirium cleared, psychotic and affective symptoms improved or resolved. The improvements persisted for 1 to 5 months, with low doses of medications in two of the cases. A delirium may precede clinical improvement in affective and psychotic symptoms. Historically, some treatments for mental illness induce an incidental delirium (e.g., electroconvulsive therapy [ECT] and insulin coma). Why a delirium should presage a beneficial effect on psychosis is unclear, but the emergence of delirium may herald a beneficial pathophysiology.

Aged↗
PubMed1999

A multicomponent intervention to prevent delirium in hospitalized older patients.

BACKGROUND: Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. METHODS: We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. RESULTS: Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment. CONCLUSIONS: The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Aged↗
PubMed1997

Delirium in AIDS patients: recognition and medication factors.

The purpose of this study is to determine the frequency of delirium in AIDS patients residing at a skilled nursing facility and to identify factors and outcomes associated with delirium episodes. Medical records were reviewed for 137 patients discharged from or dying at the facility in 1994. Presence or absence of delirium was determined using the Confusion Assessment Method. Patients with delirium were compared to those without delirium regarding demographics, medical conditions, and medication exposure using Mann-Whitney U, chi-square, and two-tailed t-tests. A model for delirium based on medication exposure was determined using multiple logistic regression. Forty-six percent of patients (n = 63) were determined to have at least one delirium episode; only one episode was diagnosed at the time of occurrence. Associated medical conditions included medication changes (44%), fever (38%), and infection (26%). Narcotics, benzodiazepines, anticholinergic/antihistaminic, and steroid medications each contributed significantly to the model for delirium (chi 2 = 60.19; df = 4; p = 0.0000). The authors concluded that delirium is a common yet underidentified condition in AIDS patients, and that patterns of medication use contribute to a large number of delirium episodes.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?

BACKGROUND: Delirium is common in older surgical patients and predicts negative health outcomes. Whether depressive symptoms are prevalent and predict the development of postoperative delirium in elderly surgical patients has not been investigated. Our study aimed to examine the prevalence and prognostic importance of preoperative depressive symptoms in older surgical patients. METHODS: Patients at least 65 years of age who were scheduled for major noncardiac surgery were recruited. Preoperatively, patients were screened for symptoms of depression using the 15-point Geriatric Depression Scale (GDS). Postoperative delirium was measured using the Confusion Assessment Method. The associations between covariates and preoperative depression, and postoperative delirium were determined by multivariate logistic regression. RESULTS: In the 219 patients studied, the mean age was 73.6 +/- 6 years, 12% of patients reported six or more depressive symptoms, and 32% reported three to five depressive symptoms. By multivariate logistic regression, patient characteristics associated with six or more symptoms of depression included <12 years of education, moderate to severe limitation in functional status, and drinking more than two alcoholic beverages per day. Postoperatively, 46% of patients developed delirium. Patients with a greater number of preoperative depressive symptoms were more likely to develop postoperative delirium (p =.048) and experience a longer duration of postoperative delirium (p =.027). Even after adjusting for covariates associated with depression and postoperative delirium--including age, educational level, functional status, and preoperative alcohol use--patients with more than six preoperative depressive symptoms were still significantly more likely to have a longer duration of postoperative delirium than did those patients with fewer than two depressive symptoms (odds ratio = 2.69, confidence interval = 1.04-6.93). CONCLUSION: Preoperative screening for the presence of depressive symptoms can be performed easily in elderly patients, and yields useful prognostic information relating to postoperative delirium.

Aged↗
PubMed1997

Delirium in Alzheimer disease.

Advanced age and dementia are well-known risk factors for delirium, and most studies of delirium have concentrated on hospitalized populations. We reviewed the records of 199 community-dwelling Alzheimer disease (AD) patients and identified 43 (22%) who had had episodes of delirium during their dementing illness. These patients were matched for age, gender, and disease duration to AD patients without previous episodes of delirium. Variables examined included causes of delirium, Mini-Mental State Examination scores, Clinical Dementia Rating scores. Blessed Activities of Daily Living (ADL) scores, years of education, neuropsychological performance, and incidence of behavioral symptoms on the Brief Psychiatric Rating Scale. In six of 198 (3%) patients delirium was an initial symptom of AD. Conditions associated with onset of delirium were urinary tract infections, stressful events, surgery, medical illnesses, and medications. No significant differences were found between groups on neuropsychological testing. Patients with previous episodes of delirium had worse ADL scores and higher disease-course incidences of hallucinations and paranoid delusions, mostly occurring during the delirious episode. We conclude that delirium is common in AD, but it is an unusual initial symptom and it occurs in diverse clinical settings. Measures of behavioral symptoms and ADLs are more likely to reflect the impact of delirium on clinical status than measures of cognition or stage of dementia.

Aged↗
PubMed2006

Assessing neurocognitive outcomes after critical illness: are delirium and long-term cognitive impairments related?

PURPOSE OF REVIEW: Critically ill patients have a high risk of developing neurologic dysfunction including delirium and long-term cognitive impairment. In this paper we examine possible relationships between delirium and long-term cognitive impairments and explore this in the context of critical illness. RECENT FINDINGS: Critical illness and its treatment can lead to neurologic morbidity including neuropathological abnormalities, delirium, and cognitive impairments. The association between delirium and long-term cognitive impairments has been shown in a number of populations. Among intensive care unit cohorts, delirium appears to be one of many possible causes of cognitive impairments and may be a leading modifiable cause. The mechanisms of both delirium and intensive care unit related cognitive impairment remain unclear, although a variety of common mechanisms have been proposed. SUMMARY: Potential neurologic consequences of critical illness include delirium and long-term cognitive impairments. Defining the extent of their association in intensive care unit cohorts is an important research priority due to the high prevalence of delirium and persistent cognitive impairments in critically ill patients. Future research should focus on strategies for the early identification of delirium and cognitive impairments, elucidating mechanisms of brain injury, and the development and implementation of therapeutic modalities designed to prevent or decrease delirium and cognitive morbidity.

Cognition Disorders↗
PubMed2003

Predicting delirium after vascular surgery: a model based on pre- and intraoperative data.

OBJECTIVE: The aim of the study was to determine pre- and intraoperative risk factors for the development of postoperative delirium among patients undergoing aortic, carotid, and peripheral vascular surgery to predict the risk for postoperative delirium. SUMMARY BACKGROUND DATA: Although postoperative delirium after vascular surgery is a frequent complication and is associated with the need for more inpatient hospital care and longer length of hospital stay, little is known about risk factors for delirium in patients undergoing vascular surgery. METHODS: Pre-, intra-, and postoperative data were prospectively collected, including the first 7 postoperative days with daily follow-up by a surgeon and a psychiatrist of 153 patients undergoing elective vascular surgery. Delirium (Diagnostic and statistical Manual of Mental Disorders IV) was diagnosed by the psychiatrist. Multivariate linear logistic regression and a cross validation analysis were performed to find a set of parameters to predict postoperative delirium. RESULTS: Sixty patients (39.2%) developed postoperative delirium. The best set of predictors included the absence of supraaortic occlusive disease and hypercholesterinemia, history of a major amputation, age over 65 years, a body size of less than 170 cm, preoperative psychiatric parameters and intraoperative parameters correlated to increased blood loss. The combination of these parameters allows the estimation of an individual patients' risk for postoperative delirium already at the end of vascular surgery with an overall accuracy of 69.9%. CONCLUSIONS: Postoperative delirium after vascular surgery is a frequent complication. A model based on pre- and intraoperative somatic and psychiatric risk factors allows prediction of the patient's risk for developing postoperative delirium.

Aged↗
PubMed2004

Delirium: behavioural changes before and during the prodromal phase.

BACKGROUND: Delirium is an important form of psychopathology in older people and is associated with increased morbidity and functional decline. In the prodromal phase of delirium early symptoms occur, before all criteria have been met. AIM: The aim of this study was to delineate behavioural changes before and during the prodromal phase of delirium. That was considered to include the time from the first behavioural change up to the point when all DSM-IV criteria for delirium were met. DESIGN: Prospective and descriptive observation study. METHODS: One hundred and three hip surgery patients (hip fracture and hip replacement) aged > or = 80 years participated in this study. On admission none of them was delirious or had severe cognitive decline, but 32 patients met the DSM-IV criteria for delirium during the hospital stay. Frequent observations were performed up to delirium onset or 48 hours postoperatively. The observations included 37 items on the patient's state of mind, cognition, activity and behaviour. The first observation on admission was used as a reference and behavioural changes were defined as deviations from this first observation. RESULTS: Twenty-one patients out of the 32 who met the DSM-IV criteria (62%, D group) demonstrated behavioural changes before delirium onset, as did 34 (48%, R group) out of the remaining 71 patients. The D group had different and more numerous behavioural changes than the R group. Anxiety was common in both groups. Disorientation and urgent calls for attention were the most frequent changes in the D group. The D group presented a pattern of behavioural changes and early symptoms of the approaching delirium. Six hours immediately before the onset of delirium, the behavioural changes were more numerous and evident. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: It is necessary to pay attention to each behavioural change in the patients and to be aware of the prodromal phase of delirium in order to prevent its onset and to maintain the patient's well-being.

Aged↗
PubMed2006

Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model.

OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model. DESIGN: Prospective cohort study. SETTING: Medical school-affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: Six hundred three hip-surgery patients aged 70 and older screened for risk factors for postoperative delirium. MEASUREMENTS: Predefined risk factors for delirium were assessed on admission. One point was assigned for each of four risk factors present, resulting in three groups: low, intermediate, and high risk. Baseline screening and assessment included the Mini-Mental State Examination, the standardized Snellen test for visual impairment, chart review to determine Acute Physiological and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine ratio. The primary outcome was postoperative delirium, as defined using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria. All patients were screened daily for delirium. RESULTS: Incidence of delirium was 3.8% in the low-risk group (P<.001), 11.1% in the intermediate-risk group (P=.27, relative risk (RR)=3.0), and 37.1% in the high-risk group (P<.001, RR=9.8). Cognitive impairment at admission had the highest predictive value for postoperative delirium (coefficient of determination=0.15). Contrary to previous findings, age was an independent predictive factor for delirium. Moreover, postoperative delirium was four times as frequent in acute patients as in elective hip-replacement patients. CONCLUSION: The medical risk factor model is valid for elderly hip-surgery patients. Cognitive impairment, age, and type of admission are important risk factors for delirium in this surgical population.

Age Factors↗
PubMed2006

Impaired executive function is associated with delirium after coronary artery bypass graft surgery.

OBJECTIVES: To determine the extent to which preoperative performance on tests of executive function and memory was associated with delirium after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective observational cohort study. SETTING: Two academic medical centers and one Department of Veterans Affairs medical center in Massachusetts. PARTICIPANTS: Eighty subjects without preoperative delirium undergoing CABG or CABG-valve surgery completed baseline neuropsychological assessments with validated measures of memory and executive function. MEASUREMENTS: Beginning on postoperative Day 2, a battery to diagnose delirium was administered daily. Confirmatory factor analysis (CFA) was used to define two cognitive domain composites (memory and executive function). The loading pattern of neuropsychological measures onto the latent cognitive domains was determined a priori. Poisson regression was used to model the association between neuropsychological performance and cognitive domain composite scores and risk of postoperative delirium. The association was expressed as the difference between impaired (0.5 standard deviations (SDs) below mean) and nonimpaired (0.5 SDs above mean) performers. RESULTS: Forty subjects (50%) developed delirium. Measures of memory function were not significantly related to delirium. Of the executive function measures, verbal fluency, category fluency, Hopkins Verbal Learning Test learning, and backward recounting of days and months were significantly related to delirium. Preoperative mental status was a strong predictor of postoperative delirium. After controlling for age, sex, education, medical comorbidity, mental status, and the other cognitive domain, CFA cognitive domain composites suggest that risk for delirium is specific for executive functioning impairment (relative risk (RR) = 2.77, 95% confidence interval (CI) = 1.12-6.87) but not for memory impairment (RR = 0.49, 95% CI = 0.19-1.25). CONCLUSION: Worse preoperative performance in executive function was independently associated with greater risk of developing delirium after CABG.

Aged↗
PubMed2006

Older adults discharged from the hospital with delirium: 1-year outcomes.

OBJECTIVES: To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital. DESIGN: Secondary analysis of prospective cohort data from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000. PARTICIPANTS: Four hundred thirty-three patients aged 70 and older who were not delirious at admission. MEASUREMENTS: Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1-year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60-4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43). CONCLUSION: Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1-year follow-up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.

Aged↗
PubMed1998

Delirium in hospitalized older patients: recognition and risk factors.

Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.

Aged↗