1
|
Instenes I, Eide LSP, Andersen H, Fålun N, Pettersen T, Ranhoff AH, Rudolph JL, Steihaug OM, Wentzel-Larsen T, Norekvål TM. Detection of delirium in older patients-A point prevalence study in surgical and non-surgical hospital wards. Scand J Caring Sci 2024. [PMID: 38702945 DOI: 10.1111/scs.13270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/13/2024] [Accepted: 04/20/2024] [Indexed: 05/06/2024]
Abstract
AIMS AND OBJECTIVES To (i) determine the prevalence of delirium and identify delirium subtypes in surgical and non-surgical patients aged ≥65 years, (ii) determine whether certain precipitating factors affect the prevalence of delirium and (iii) review patients' medical records for description of delirium symptoms and the presence of International Classification of Diseases (ICD-10) coding for delirium in discharge summaries. METHODOLOGICAL DESIGN AND JUSTIFICATIONS Despite being a robust predictor of morbidity and mortality in older adults, delirium might be inadequately recognised and under-reported in patients' medical records and discharge summaries. A point prevalence study (24-h) of patients ≥65 years from surgical and non-surgical wards was therefore conducted in a tertiary university hospital. ETHICAL ISSUES AND APPROVAL The study was approved by the Data Protection Officer at the university hospital (2018/3454). RESEARCH METHODS, INSTRUMENTS AND/OR INTERVENTIONS Patients were assessed for delirium with 4AT and delirium subtypes with the Delirium Motor Subtype Scale. Information about room transfers, need and use of sensory aids and medical equipment was collected onsite. Patients' medical records were reviewed for description of delirium symptoms and of ICD-10 codes. RESULTS Overall, 123 patients were screened (52% female). Delirium was identified in 27% of them. Prevalence was associated with advanced age (≥85 years). The uncharacterised delirium subtype was most common (36%), followed by hypoactive (30%), hyperactive (24%) and mixed (9%). There were significant associations between positive screening tests and the need and use of sensory aids. Delirium symptoms were described in 58% of the patients who tested positive for delirium and the ICD-10 code for delirium was registered in 12% of these patients' discharge summaries. CONCLUSIONS The high prevalence of delirium and limited use of discharge codes highlight the need to improve the identification of delirium in hospital settings and at discharge. Increased awareness and detection of delirium in hospital settings are vital to improve patient care.
Collapse
Affiliation(s)
- Irene Instenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Leslie S P Eide
- Faculty of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Andersen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Nina Fålun
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Faculty of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Trond Pettersen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Anette H Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - James L Rudolph
- Department of Health Services, Policy and Practice, Brown University, Providence, USA
| | - Ole Martin Steihaug
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Tore Wentzel-Larsen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Eastern and Southern Norway, Oslo, Norway
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Faculty of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
2
|
Bauernfreund Y, Launders N, Favarato G, Hayes JF, Osborn D, Sampson EL. Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study. Acta Psychiatr Scand 2023; 147:516-526. [PMID: 35869544 PMCID: PMC10952251 DOI: 10.1111/acps.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI). METHODS We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI. RESULTS The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92). CONCLUSIONS The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.
Collapse
Affiliation(s)
- Yehudit Bauernfreund
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | | | | | - Joseph F. Hayes
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - David Osborn
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - Elizabeth L. Sampson
- Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological MedicineEast London NHS Foundation Trust, Royal London HospitalLondonUK
| |
Collapse
|
3
|
van der Heijden EFM, Kooken RWJ, Zegers M, Simons KS, van den Boogaard M. Differences in long-term outcomes between ICU patients with persistent delirium, non-persistent delirium and no delirium: A longitudinal cohort study. J Crit Care 2023; 76:154277. [PMID: 36804824 DOI: 10.1016/j.jcrc.2023.154277] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/18/2023] [Accepted: 02/03/2023] [Indexed: 02/20/2023]
Abstract
PURPOSE Determine differences in physical, mental and cognitive outcomes 1-year post-ICU between patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND). MATERIALS AND METHODS A longitudinal cohort study was performed in adult ICU patients of two hospitals admitted between July 2016-February 2020. Questionnaires on physical, mental and cognitive health, frailty and QoL were completed regarding patients' pre-ICU health status and 1-year post-ICU. Delirium data were from patients' total hospital stay. Patients were divided in PD (≥14 days delirium), NPD (<14 days delirium) or ND patients. RESULTS 2400 patients completed both questionnaires, of whom 529 (22.0%) patients developed delirium; 35 (6.6%) patients had PD and 494 (93.4%) had NPD. Patients with delirium (PD or NPD) had worse outcomes in all domains compared to ND patients. Compared to NPD, more PD patients were frail (34.3% vs. 14.6%, p = 0.006) and fatigued (85.7% vs. 61.1%, p = 0.012). After adjustment, PD was significantly associated with long-term cognitive impairment only (aOR 3.90; 95%CI 1.31-11.63). CONCLUSIONS Patients with PD had a higher likelihood to develop cognitive impairment 1-year post-ICU compared to NPD or ND. Patients with PD and NPD were more likely to experience impairment on all health domains (i.e. physical, mental and cognitive), compared to ND patients.
Collapse
Affiliation(s)
- Emma F M van der Heijden
- Jeroen Bosch Hospital, Department of Intensive Care Medicine, Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch, the Netherlands.
| | - Rens W J Kooken
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
| | - Marieke Zegers
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
| | - Koen S Simons
- Jeroen Bosch Hospital, Department of Intensive Care Medicine, Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch, the Netherlands.
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Radboud Institute for Health Science710 - Research IC (room 24), P.O. 9101, zipcode 6500HB, Nijmegen, the Netherlands.
| |
Collapse
|
4
|
Proposing a Scientific and Technological Approach to the Summaries of Clinical Issues of Inpatient Elderly with Delirium: A Viewpoint. Healthcare (Basel) 2022; 10:healthcare10081534. [PMID: 36011191 PMCID: PMC9408148 DOI: 10.3390/healthcare10081534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/13/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background/rationale: Despite mounting evidence about delirium, this complex geriatric syndrome is still not well managed in clinical contexts. The aging population creates a very demanding area for innovation and technology in healthcare. For instance, an outline of an aging-friendly healthcare environment and clear guidance for technology-supported improvements for people at delirium risk are lacking. Objective: We aimed to foster debate about the importance of technical support in optimizing healthcare professional practice and improving the outcomes for inpatients’ at delirium risk. We focused on critical clinical points in the field of delirium worthy of being addressed by a multidisciplinary approach. Methods: Starting from a consensus workshop sponsored by the Management Perfectioning Course based at the Marco Biagi Foundation (Modena, Italy) about clinical issues related to delirium management still not addressed in our healthcare organizations, we developed a requirements’ analysis among the representatives of different disciplines and tried to formulate how technology could support the summaries of the clinical issues. We analyzed the national and international panorama by a PubMed consultation of articles with the following keywords in advanced research: “delirium”, “delirium management”, “technology in healthcare”, and “elderly population”. Results: Despite international recommendations, delirium remains underdiagnosed, underdetected, underreported, and mismanaged in the acute hospital, increasing healthcare costs, healthcare professionals’ job distress, and poor clinical outcomes. Discussion: Although all healthcare professionals recognize delirium as a severe and potentially preventable source of morbidity and mortality for hospitalized older people, it receives insufficient attention in resource allocation and multidisciplinary research. We synthesized how tech-based tools could offer potential solutions to the critical clinical points in delirium management.
Collapse
|
5
|
Beretta M, Uggeri S, Santucci C, Cattaneo M, Ermolli D, Gerosa C, Ornaghi M, Roccasalva A, Santambrogio P, Varrassi G, Corli O. Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study. Cureus 2022; 14:e25706. [PMID: 35812586 PMCID: PMC9260701 DOI: 10.7759/cureus.25706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Delirium in end-of-life patients is reported to be between 13% and 42% and up to 80% in the terminal phase. It is a serious clinical situation, often a cause of death due to the frequent ineffectiveness of treatments. This study aimed to assess whether and how much precocity of diagnosis, hitherto little considered, could affect the outcomes and prognosis of delirium in palliative care settings. Methods: Patients consecutively admitted to a palliative care unit (PCU) between October 2018 and December 2019, cared for both in hospice and home programs, were analyzed. All patients were subjected to a careful procedure aimed at recognizing the onset of delirium. The first step was the detection of prodromal "sentinel" symptoms related to incoming delirium. PCU staff and family members/caregivers were trained to observe the patients and immediately identify the appearance of even one symptom. The final diagnosis was performed with the 4AT (4 A’s test). Patients were then included in the categories of "early" or "slow" diagnosis (cut-off: four hours) depending on the time between sentinel symptom observation and the final diagnosis of delirium. Results: Among 503 admitted patients, 95 developed delirium. Confusion was the most frequent sentinel symptom (49.5%). The early diagnosis was more frequent in hospice than in home care (p-value<0.0001). Delirium was positively resolved in 43 patients, of which 25 with an early diagnosis (p-value=0.038). Time to resolution was shorter in the case of early diagnosis (7.1 vs. 13.7 hours in hospice patients; p-value=0.018). Palliative sedation was performed on 25 patients, but only 8 of them had an early diagnosis. Conclusion: Time of diagnosis was important in determining the clinical outcomes of patients in charge of PCU who experienced delirium. The early diagnosis reduced both mortality and the necessity of palliative sedation.
Collapse
|
6
|
Chuen VL, Chan ACH, Ma J, Alibhai SMH, Chau V. Assessing the Accuracy of International Classification of Diseases (ICD) Coding for Delirium. J Appl Gerontol 2022; 41:1485-1490. [PMID: 35176883 PMCID: PMC9024024 DOI: 10.1177/07334648211067526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the accuracy of the ICD-10 code for delirium (F05) and its relationship with delirium discharge summary documentation. METHODS We performed a retrospective chart review at three academic hospitals. The Chart-based Delirium Identification Instrument (CHART-DEL) was used to identify 108 hospitalized patients aged ≥65 years with delirium, and 758 patients without delirium as controls. We assessed the proportion of patients who received the F05 code and calculated the sensitivity and specificity. We compared the rates of F05 code received between patients with and without "delirium" documented in the discharge summary. RESULTS Among delirious patients, 46.3% received a F05 code, which has a sensitivity of 46.3% and specificity of 99.6% for delirium. Of charts with "delirium" in the discharge summary (n = 67), 67.2% were appropriately coded. CONCLUSIONS Current ICD-10 data inadequately capture delirium. Delirium documentation in the discharge summary is associated with improved delirium coding.
Collapse
Affiliation(s)
- Victoria L Chuen
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, 3710McMaster University, Hamilton, ON, Canada
| | - Adrian C H Chan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jin Ma
- Biostatistics Research Unit, 7989University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Division of General Internal Medicine and Geriatrics, Department of Medicine, 7989University Health Network, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Vicky Chau
- Division of General Internal Medicine and Geriatrics, Department of Medicine, 7989University Health Network, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Toronto, ON, Canada
| |
Collapse
|
7
|
Corli O, Santucci C, Uggeri S, Bosetti C, Cattaneo M, Ermolli D, Varrassi G, Myrcik D, Paladini A, Rekatsina M, Gerosa C, Ornaghi M, Roccasalva A, Santambrogio P, Beretta M. Factors for Timely Identification of Possible Occurrence of Delirium in Palliative Care: A Prospective Observational Study. Adv Ther 2021; 38:4289-4303. [PMID: 34228345 PMCID: PMC8342371 DOI: 10.1007/s12325-021-01814-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/01/2021] [Indexed: 12/19/2022]
Abstract
Delirium occurs in 50–80% of end-of-life patients but is often misdiagnosed. Identification of clinical factors potentially associated with delirium onset can lead to a correct early diagnosis. To this aim, we conducted a prospective cohort study on patients from an Italian palliative care unit (PCU) admitted in 2018–2019. We evaluated the presence of several clinical factors at patient admission and compared their presence in patients who developed delirium and in those who did not develop it during follow-up. Among 503 enrolled patients, after a median follow-up time of 16 days (interquartile range 6–40 days), 95 (18.9%) developed delirium. Hazard ratios (HR) and corresponding 95% confidence intervals were computed using Cox proportional hazard models. In univariate analyses, factors significantly more frequent in patients with delirium were care in hospice, compromised performance status, kidney disease, fever, renal failure, hypoxia, dehydration, drowsiness, poor well-being, breathlessness, and “around the clock” therapy with psychoactive drugs, particularly haloperidol. In multivariate analyses, setting of care (HR 2.28 for hospice versus home care, 95% CI 1.45–3.60; p < 0.001), presence of breathlessness (HR 1.71, 95% CI 1.03–2.83, p = 0.037), and administration of psychoactive drugs, particularly haloperidol (HR 2.17 for haloperidol, 95% CI 1.11–4.22 and 1.53 for other drugs, 95% CI 0.94–2.48; p = 0.048) were significantly associated with the risk of developing delirium. The study indicates that some clinical factors are associated with the probability of delirium onset. Their evaluation in PC patients could help healthcare professionals to identify the development of delirium in those patients in a timely manner.
Collapse
|
8
|
Wu H, Mach J, Le Couteur DG, Hilmer SN. Nationwide mortality trends of delirium in Australia and the United States from 2006 to 2016. Australas J Ageing 2021; 40:e279-e286. [PMID: 33687139 DOI: 10.1111/ajag.12926] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 12/10/2020] [Accepted: 01/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To examine nationwide trends in delirium mortality in Australia and the United States between 2006 and 2016. METHODS Delirium mortality data for Australian and United States populations were obtained from World Health Organization Mortality Database. Mortality trends were assessed using joinpoint regression. RESULTS Age-adjusted delirium mortality increased by 16.35%/year and 4.04%/year in Australia and the United States, respectively. Average annual age-adjusted delirium mortality rate (per 1 000 000 population) was 2.90 in Australia, and 1.06 in the United States. Death rates from delirium increased with age. Mortality was consistently higher in men than women, but the rate of annual increase was greater in women. CONCLUSIONS Our study provided important population-level data on delirium and its outcomes in Australia and the United States. Reported death rates attributed to delirium increased over the 11-year period in both countries and were consistently higher in Australia than the United States. There were distinct age and sex differences in mortality trends.
Collapse
Affiliation(s)
- Harry Wu
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, NSW, Australia.,Laboratory of Ageing and Pharmacology, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - John Mach
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, NSW, Australia.,Laboratory of Ageing and Pharmacology, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - David G Le Couteur
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Ageing and Alzheimer's Institute (AAAI), Centre for Education and Research on Ageing (CERA) and ANZAC Research Institute, Concord Hospital, Concord, NSW, Australia.,Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, NSW, Australia.,Laboratory of Ageing and Pharmacology, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
9
|
Bowman K, Jones L, Masoli J, Mujica-Mota R, Strain D, Butchart J, Valderas JM, Fortinsky RH, Melzer D, Delgado J. Predicting incident delirium diagnoses using data from primary-care electronic health records. Age Ageing 2020; 49:374-381. [PMID: 32239180 PMCID: PMC7297278 DOI: 10.1093/ageing/afaa006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE risk factors for delirium in hospital inpatients are well established, but less is known about whether delirium occurring in the community or during an emergency admission to hospital care might be predicted from routine primary-care records. OBJECTIVES identify risk factors in primary-care electronic health records (PC-EHR) predictive of delirium occurring in the community or recorded in the initial episode in emergency hospitalisation. Test predictive performance against the cumulative frailty index. DESIGN Stage 1: case-control; Stages 2 and 3: retrospective cohort. SETTING clinical practice research datalink: PC-EHR linked to hospital discharge data from England. SUBJECTS Stage 1: 17,286 patients with delirium aged ≥60 years plus 85,607 controls. Stages 2 and 3: patients ≥ 60 years (n = 429,548 in 2015), split into calibration and validation groups. METHODS Stage 1: logistic regression to identify associations of 110 candidate risk measures with delirium. Stage 2: calibrating risk factor weights. Stage 3: validation in independent sample using area under the curve (AUC) receiver operating characteristic. RESULTS fifty-five risk factors were predictive, in domains including: cognitive impairment or mental illness, psychoactive drugs, frailty, infection, hyponatraemia and anticholinergic drugs. The derived model predicted 1-year incident delirium (AUC = 0.867, 0.852:0.881) and mortality (AUC = 0.846, 0.842:0.853), outperforming the frailty index (AUC = 0.761, 0.740:0.782). Individuals with the highest 10% of predicted delirium risk accounted for 55% of incident delirium over 1 year. CONCLUSIONS a risk factor model for delirium using data in PC-EHR performed well, identifying individuals at risk of new onsets of delirium. This model has potential for supporting preventive interventions.
Collapse
Affiliation(s)
- Kirsty Bowman
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Lindsay Jones
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Jane Masoli
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Ruben Mujica-Mota
- The Health Economics Group, Institute of Health Research, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - David Strain
- Diabetes, Cardiovascular Risk and Ageing, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Joe Butchart
- Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, RD&E, Exeter EX2 5DW, UK
| | - José M Valderas
- The Health Services and Policy Research Group, Institute of Health Research, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - Richard H Fortinsky
- University of Connecticut, School of Medicine, Center on Aging, Mansfield, CT 06030-5215, USA
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - João Delgado
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| |
Collapse
|
10
|
Grealish L, Todd JA, Krug M, Teodorczuk A. Education for delirium prevention: Knowing, meaning and doing. Nurse Educ Pract 2019; 40:102622. [DOI: 10.1016/j.nepr.2019.102622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 05/28/2019] [Accepted: 08/31/2019] [Indexed: 11/27/2022]
|
11
|
Selecting a Bedside Cognitive Vital Sign to Monitor Cognition in Hospital: Feasibility, Reliability, and Responsiveness of Logical Memory. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193545. [PMID: 31546698 PMCID: PMC6801972 DOI: 10.3390/ijerph16193545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/15/2019] [Accepted: 09/19/2019] [Indexed: 11/17/2022]
Abstract
Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside “cognitive vital sign” (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3–5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p < 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these.
Collapse
|
12
|
Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia. Geriatrics (Basel) 2019; 4:geriatrics4030052. [PMID: 31514465 PMCID: PMC6787739 DOI: 10.3390/geriatrics4030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022] Open
Abstract
The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.
Collapse
|
13
|
Davis D, Searle SD, Tsui A. The Scottish Intercollegiate Guidelines Network: risk reduction and management of delirium. Age Ageing 2019; 48:485-488. [PMID: 30927352 DOI: 10.1093/ageing/afz036] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 01/09/2023] Open
Abstract
Clinical and research interest in delirium has been rising over the last 15 years. The Scottish Intercollegiate Guidelines Network (SIGN) publication on delirium is a state-of-the-art synthesis of the field, and the first UK guideline since 2010. There is new guidance around delirium detection, particularly in recommending the 4 'A's Test (4AT). The 4AT has the advantage of being brief, embeds and operationalises cognitive testing, and is scalable with little training. The guidelines highlight the importance of non-pharmacological management for all hospital presentations involving the spectrum of cognitive disorders (delirium, dementia but at risk of delirium, delirium superimposed on dementia). Pharmacotherapy has a minimal role, but specific indications (e.g. intractable distress) are discussed. Advances in delirium research, education and policy, have come together with steady changes in the sociocultural context in which healthcare systems look after older people with cognitive impairment. However, there remains a gap between desired and actual clinical practice, one which might be bridged by re-engaging with compassionate, patient-centred care. In this respect, these SIGN guidelines offer a key resource.
Collapse
Affiliation(s)
- Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Samuel D Searle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- Division of Geriatric Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| |
Collapse
|
14
|
Casey P, Cross W, Mart MW, Baldwin C, Riddell K, Dārziņš P. Hospital discharge data under‐reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service. Intern Med J 2019; 49:338-344. [DOI: 10.1111/imj.14066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/18/2018] [Accepted: 07/31/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Penelope Casey
- Faculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
- Eastern Health Melbourne Victoria Australia
| | - Wendy Cross
- Federation University Melbourne Victoria Australia
| | | | | | | | - Pēteris Dārziņš
- Faculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
- Eastern Health Melbourne Victoria Australia
| |
Collapse
|
15
|
Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
Collapse
Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| |
Collapse
|
16
|
Abstract
OBJECTIVE To assess if ongoing delirium research activity within an acute admissions unit impacts on prevalent delirium recognition. DESIGN Prospective cohort study. SETTING Single-site tertiary university teaching hospital. PARTICIPANTS 125 patients with delirium, as diagnosed by an expert using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition reference criteria, were recruited to a prospective cohort study investigating use of informant tools to detect unrecognised dementia. This study evaluated recognition of delirium and documentation of delirium by medical staff. INTERVENTIONS The main study followed an observational design; the intervention discussed was the implementation of this study itself. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was recognition of delirium by the admitting medical team prior to study diagnosis. Secondary outcomes included recording of or description of delirium in discharge summaries, and factors which may be associated with unrecognised delirium. RESULTS Delirium recognition improved between the first half (48%) and second half (71%) of recruitment (p=0.01). There was no difference in recording of delirium or description of delirium in the text of discharge summaries. CONCLUSION Delirium research activity can improve recognition of delirium. This has the potential to improve patient outcomes.
Collapse
Affiliation(s)
- Carly Welch
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thomas A Jackson
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
17
|
Halladay CW, Sillner AY, Rudolph JL. Performance of Electronic Prediction Rules for Prevalent Delirium at Hospital Admission. JAMA Netw Open 2018; 1:e181405. [PMID: 30646122 PMCID: PMC6324279 DOI: 10.1001/jamanetworkopen.2018.1405] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Delirium at admission is associated with increased hospital morbidity and mortality, but it may be missed in up to 70% of cases. Use of a predictive algorithm in an electronic medical record (EMR) system could provide critical information to target assessment of those with delirium at admission. OBJECTIVES To develop and assess a prediction rule for delirium using 2 populations of veterans and compare this rule with previously confirmed rules. DESIGN, SETTING, AND PARTICIPANTS In a diagnostic study, randomly selected EMRs of hospitalized veterans from the Veterans Affairs (VA) External Peer Review Program at 118 VA medical centers with inpatient facilities were reviewed for delirium risk factors associated with the National Institute for Health and Clinical Excellence (NICE) delirium rule in a derivation cohort (October 1, 2012, to September 30, 2013) and a confirmation cohort (October 1, 2013, to March 31, 2014). Delirium within 24 hours of admission was identified using key word terms. A total of 39 377 veterans 65 years or older who were admitted to a VA medical center for congestive heart failure, acute coronary syndrome, community-acquired pneumonia, and chronic obstructive pulmonary disease were included in the study. EXPOSURE The EMR calculated delirium risk. MAIN OUTCOMES AND MEASURES Delirium at admission as identified by trained nurse reviewers was the main outcome measure. Random forest methods were used to identify accurate risk factors for prevalent delirium. A prediction rule for prevalent delirium was developed, and its diagnostic accuracy was tested in the confirmation cohort. This consolidated NICE rule was compared with previously confirmed scoring algorithms (electronic NICE and Pendlebury NICE). RESULTS A total of 27 625 patients were included in the derivation cohort (28 118 [92.2%] male; mean [SD] age, 75.95 [8.61] years) and 11 752 in the confirmation cohort (11 536 [98.2%] male; mean [SD] age, 75.43 [8.55] years). Delirium at admission was identified in 2343 patients (8.5%) in the derivation cohort and 882 patients (7.0%) in the confirmation cohort. Modeling techniques identified cognitive impairment, infection, sodium level, and age of 80 years or older as the dominant risk factors. The consolidated NICE rule (area under the receiver operating characteristic [AUROC] curve, 0.91; 95% CI, 0.91-0.92; P < .001) had significantly higher discriminatory function than the eNICE rule (AUROC curve, 0.81; 95% CI, 0.80-0.82; P < .001) or Pendlebury NICE rule (AUROC curve, 0.87; 95% CI, 0.86-0.88; P < .001). These findings were confirmed in the confirmation cohort. CONCLUSIONS AND RELEVANCE This analysis identified preexisting cognitive impairment, infection, sodium level, and age of 80 years or older as delirium screening targets. Use of this algorithm in an EMR system could direct clinical assessment efforts to patients with delirium at admission.
Collapse
Affiliation(s)
- Christopher W. Halladay
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | | | - James L. Rudolph
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- Brown University, Warren Alpert Medical School and School of Public Health, Providence, Rhode Island
| |
Collapse
|
18
|
Morandi A, Di Santo SG, Cherubini A, Mossello E, Meagher D, Mazzone A, Bianchetti A, Ferrara N, Ferrari A, Musicco M, Trabucchi M, Bellelli G. Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study. Am J Geriatr Psychiatry 2017; 25:1064-1071. [PMID: 28579352 DOI: 10.1016/j.jagp.2017.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To date motor subtypes of delirium have been evaluated in single-center studies with a limited examination of the relationship between predisposing factors and motor profile of delirium. We sought to report the prevalence and clinical profile of subtypes of delirium in a multicenter study. METHODS This is a point prevalence study nested in the "Delirium Day 2015", which included 108 acute and 12 rehabilitation wards in Italy. Delirium was detected using the 4-AT and motor subtypes were measured with the Delirium Motor Subtype Scale (DMSS). A multinomial logistic regression was used to determine the factors associated with delirium subtypes. RESULTS Of 429 patients with delirium, the DMSS was completed in 275 (64%), classifying 21.5% of the patients with hyperactive delirium, 38.5% with hypoactive, 27.3% with mixed and 12.7% with the non-motor subtype. The 4-AT score was higher in the hyperactive subtype, similar in the hypoactive, mixed subtypes, while it was lowest in the non-motor subtype. Dementia was associated with all three delirium motor subtypes (hyperactive, OR 3.3, 95% CI: 1.2-8.7; hypoactive, OR 2.8, 95% CI: 1.2-6.5; mixed OR 2.6, 95% CI: 1.1-6.2). Atypical antipsychotics were associated with hypoactive delirium (OR 0.23, 95% CI: 0.1-0.7), while intravenous lines were associated with mixed delirium (OR 2.9, 95% CI: 1.2-6.9). CONCLUSIONS The study shows that hypoactive delirium is the most common subtype among hospitalized older patients. Specific clinical features were associated with different delirium subtypes. The use of standardized instruments can help to characterize the phenomenology of different motor subtypes of delirium.
Collapse
Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care, "Fondazione Camplani" Hospital, Cremona, Italy; Geriatric Research Group, Italy.
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - David Meagher
- Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Andrea Mazzone
- Department of Rehabilitation, Istituto Redaelli, Milano, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | | | | | - Massimo Musicco
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Geriatric Unit, S. Gerardo Hospital, Monza, Italy
| | | |
Collapse
|
19
|
Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
Collapse
Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| |
Collapse
|
20
|
|
21
|
A Retrospective Analysis of Neurocognitive Impairment in Older Patients With Burn Injuries. PSYCHOSOMATICS 2017; 58:386-394. [DOI: 10.1016/j.psym.2017.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 12/13/2022]
|
22
|
Abstract
BACKGROUND Delirium may be more prevalent in elderly outpatients than has long been assumed. However, it may be easily missed due to overlap with dementia. Our aim was to study delirium symptoms and underlying somatic disorders in psycho-geriatric outpatients. METHODS We performed a case-control study among outpatients that were referred to a psychiatric institution between January 1st and July 1st 2010 for cognitive evaluation. We compared 44 cases with DSM-IV delirium (24 with and 20 without dementia) to 44 controls with dementia only. All participants were aged 70 years or older. We extracted from the medical files (1) referral characteristics including demographics, medical history, medication use, and referral reasons, (2) delirium symptoms, scored with the Delirium Rating Scale-Revised-98, and (3) underlying disorders categorized as: drugs/intoxication, infection, metabolic/endocrine disturbances, cardiovascular disorders, central nervous system disorders, and other health problems. RESULTS At referral, delirium patients had significantly higher numbers of chronic diseases and medications, and more often a history of delirium and a recent hospital admission than controls. Most study participants, including those with delirium, were referred for evaluation of (suspected) dementia. The symptoms that occurred more frequently in cases were: sleep disturbances, perceptual abnormalities, delusions, affect lability, agitation, attention deficits, acute onset, and fluctuations. Drug related (68%), infectious (61%), and metabolic-endocrine (50%) disturbances were often involved. CONCLUSIONS Detection of delirium and distinction from dementia in older outpatients was feasible but required detailed caregiver information about the presence, onset, and course of symptoms. Most underlying disorders could be managed at home.
Collapse
|
23
|
Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
Collapse
Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy. .,Geriatric Unit, San Gerardo University Hospital, Monza, Italy. .,Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy.,Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy.,Tor Vergata, Rome University, Rome, Italy.,Italian Psychogeriatric Association (AIP), Brescia, Italy
| | | |
Collapse
|
24
|
Verloo H, Goulet C, Morin D, von Gunten A. Association between frailty and delirium in older adult patients discharged from hospital. Clin Interv Aging 2016; 11:55-63. [PMID: 26848261 PMCID: PMC4723030 DOI: 10.2147/cia.s100576] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Delirium and frailty – both potentially reversible geriatric syndromes – are seldom studied together, although they often occur jointly in older patients discharged from hospitals. This study aimed to explore the relationship between delirium and frailty in older adults discharged from hospitals. Methods Of the 221 patients aged >65 years, who were invited to participate, only 114 gave their consent to participate in this study. Delirium was assessed using the confusion assessment method, in which patients were classified dichotomously as delirious or nondelirious according to its algorithm. Frailty was assessed using the Edmonton Frailty Scale, which classifies patients dichotomously as frail or nonfrail. In addition to the sociodemographic characteristics, covariates such as scores from the Mini-Mental State Examination, Instrumental Activities of Daily Living scale, and Cumulative Illness Rating Scale for Geriatrics and details regarding polymedication were collected. A multidimensional linear regression model was used for analysis. Results Almost 20% of participants had delirium (n=22), and 76.3% were classified as frail (n=87); 31.5% of the variance in the delirium score was explained by frailty (R2=0.315). Age; polymedication; scores of the Confusion Assessment Method (CAM), instrumental activities of daily living, and Cumulative Illness Rating Scale for Geriatrics; and frailty increased the predictability of the variance of delirium by 32% to 64% (R2=0.64). Conclusion Frailty is strongly related to delirium in older patients after discharge from the hospital.
Collapse
Affiliation(s)
- Henk Verloo
- Department Nursing Sciences, University of Applied Sciences, Lausanne, Switzerland
| | - Céline Goulet
- Faculty of Nursing Science, University of Montreal, Montreal, QC, Canada
| | - Diane Morin
- Institut Universitaire de Formation et Recherche en Soins (IUFRS), Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland; Faculty of Nursing Science, Université Laval, Québec, Canada
| | - Armin von Gunten
- Department of Psychiatry, Service Universitaire de Psychiatrie de l'Age Avancé (SUPAA), Lausanne University Hospital, Prilly, Switzerland
| |
Collapse
|
25
|
Luijendijk HJ, de Bruin NC, Hulshof TA, Koolman X. Terminal illness and the increased mortality risk of conventional antipsychotics in observational studies: a systematic review. Pharmacoepidemiol Drug Saf 2015; 25:113-22. [PMID: 26601922 DOI: 10.1002/pds.3912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Numerous large observational studies have shown an increased risk of mortality in elderly users of conventional antipsychotics. Health authorities have warned against use of these drugs. However, terminal illness is a potentially strong confounder of the observational findings. So, the objective of this study was to systematically assess whether terminal illness may have biased the observational association between conventional antipsychotics and risk of mortality in elderly patients. METHODS Studies were searched in PubMed, CINAHL, Embase, the references of selected studies and articles referring to selected studies (Web of Science). Inclusion criteria were (i) observational studies that estimated (ii) the risk of all-cause mortality in (iii) new elderly users of (iv) conventional antipsychotics compared with atypical antipsychotics or no use. Two investigators assessed the characteristics of the exposure and reference groups, main results, measured confounders and methods used to adjust for unmeasured confounders. RESULTS We identified 21 studies. All studies were based on administrative medical and pharmaceutical databases. Sicker and older patients received conventional antipsychotics more often than new antipsychotics. The risk of dying was especially high in the first month of use, and when haloperidol was administered per injection or in high doses. Terminal illness was not measured in any study. Instrumental variables that were used were also confounded by terminal illness. CONCLUSIONS We conclude that terminal illness has not been adjusted for in observational studies that reported an increased risk of mortality risk in elderly users of conventional antipsychotics. As the validity of the evidence is questionable, so is the warning based on it.
Collapse
Affiliation(s)
- Hendrika J Luijendijk
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Geriatric Psychiatry, BAVO Europoort, Rotterdam, The Netherlands
| | - Niels C de Bruin
- Laurens Alzheimer's Care Research Center, Rotterdam, The Netherlands.,Novicare Geriatric Care Inc, Best, The Netherlands
| | - Tessa A Hulshof
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| |
Collapse
|
26
|
Bellelli G, Nobili A, Annoni G, Morandi A, Djade CD, Meagher DJ, Maclullich AMJ, Davis D, Mazzone A, Tettamanti M, Mannucci PM. Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards. Eur J Intern Med 2015; 26:696-704. [PMID: 26333532 DOI: 10.1016/j.ejim.2015.08.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/05/2015] [Accepted: 08/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric disorder, triggered by medical precipitants causes. Study aims were to describe the prevalence and impact on in-hospital mortality of delirium identified through ICD-9 codes as well as evidence of neurocognitive deficits demonstrated in a population of older patients admitted to acute medical wards. METHODS This was a prospective cohort multicenter study of 2521 older patients enrolled in the "Registro Politerapie SIMI (REPOSI)" during the years 2010 and 2012. The diagnosis of delirium was obtained by ICD-9 codes. Cognitive function was evaluated with the Short Blessed Test (SBT) and single SBT items were used as measures of deficits in attention, orientation and memory. Combination of deficits in SBT items was used as a proxy for delirium. Logistic regression was used to evaluate the association with in-hospital mortality of delirium and combined deficits in SBT items. RESULTS Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates. CONCLUSIONS The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.
Collapse
Affiliation(s)
- G Bellelli
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy.
| | - A Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - G Annoni
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | - A Morandi
- Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - C D Djade
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - D J Meagher
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - A M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom; Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, United Kingdom
| | - D Davis
- MRC Unit for Lifelong Health and Ageing, University College London, United Kingdom
| | - A Mazzone
- Department of Health Sciences, University of Milano Bicocca, Italy
| | - M Tettamanti
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - P M Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
| |
Collapse
|
27
|
Park Y, Franklin JM, Schneeweiss S, Levin R, Crystal S, Gerhard T, Huybrechts KF. Antipsychotics and mortality: adjusting for mortality risk scores to address confounding by terminal illness. J Am Geriatr Soc 2015; 63:516-23. [PMID: 25752911 DOI: 10.1111/jgs.13326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether adjustment for prognostic indices specifically developed for nursing home (NH) populations affect the magnitude of previously observed associations between mortality and conventional and atypical antipsychotics. DESIGN Cohort study. SETTING A merged data set of Medicaid, Medicare, Minimum Data Set (MDS), Online Survey Certification and Reporting system, and National Death Index for 2001 to 2005. PARTICIPANTS Dual-eligible individuals aged 65 and older who initiated antipsychotic treatment in a NH (N=75,445). MEASUREMENTS Three mortality risk scores (Mortality Risk Index Score, Revised MDS Mortality Risk Index, Advanced Dementia Prognostic Tool) were derived for each participant using baseline MDS data, and their performance was assessed using c-statistics and goodness-of-fit tests. The effect of adjusting for these indices in addition to propensity scores (PSs) on the association between antipsychotic medication and mortality was evaluated using Cox models with and without adjustment for risk scores. RESULTS Each risk score showed moderate discrimination for 6-month mortality, with c-statistics ranging from 0.61 to 0.63. There was no evidence of lack of fit. Imbalances in risk scores between conventional and atypical antipsychotic users, suggesting potential confounding, were much lower within PS deciles than the imbalances in the full cohort. Accounting for each score in the Cox model did not change the relative risk estimates: 2.24 with PS-only adjustment versus 2.20, 2.20, and 2.22 after further adjustment for the three risk scores. CONCLUSION Although causality cannot be proven based on nonrandomized studies, this study adds to the body of evidence rejecting explanations other than causality for the greater mortality risk associated with conventional antipsychotics than with atypical antipsychotics.
Collapse
Affiliation(s)
- Yoonyoung Park
- Department of Epidemiology, School of Public Health, Harvard University, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
28
|
Fleet J, Chen S, Martin FC, Ernst T. A multifaceted intervention package to improve the diagnosis and management of delirium. Int Psychogeriatr 2014; 27:1-6. [PMID: 25273153 DOI: 10.1017/s1041610214001938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT Background: Delirium is a major cause of morbidity and mortality amongst hospital patients. Previous studies have shown that it is often poorly recognized and managed. We wanted to assess the impact of a multifaceted intervention on delirium management. Methods: A pre/post-intervention design was used. The local hospital delirium guideline was adapted into A7 sized cards and A3/A2 posters. Cards were distributed to junior doctors and teaching sessions were held. Computer screen savers were displayed and delirium promotion days held. The pre/post-intervention data were used to audit the following: delirium knowledge through questionnaires, documented use of the confusion assessment method (CAM) and identification and management of eight common precipitating factors. Re-audit was four months post baseline with interventions within this period. χ2 tests were used for statistical analysis. Results: A convenience sample of randomly selected doctors in postgraduate training posts completed 100 questionnaires and 25 clinical notes were selected via retrospective identification of delirium. Results from questionnaires demonstrated significant improvements in: recognizing CAM as the diagnostic tool for delirium (24% vs. 71%, p < 0.01); identifying haloperidol as first line in pharmacological management (55% vs. 98%, p <0.01) and its correct dose (40% vs. 67%, p <0.01). In clinical practice, there was significant improvement in documentation of CAM for inpatient delirium assessments (0% vs. 77%, p <0.01). Trainees found the delirium card "very helpful" (82%) and carried it with them at all times (70%). Conclusion: This multifaceted intervention increased CAM use in delirium recognition and improved the knowledge of pharmacological management. The delirium card was highly popular.
Collapse
Affiliation(s)
- J Fleet
- Department of Ageing and Health,Guy's and St. Thomas' Hospital Foundation Trust,Westminster Bridge Road,London,SE1 7EH,UK
| | - S Chen
- Department of Ageing and Health,Guy's and St. Thomas' Hospital Foundation Trust,Westminster Bridge Road,London,SE1 7EH,UK
| | - F C Martin
- Department of Ageing and Health,Guy's and St. Thomas' Hospital Foundation Trust,Westminster Bridge Road,London,SE1 7EH,UK
| | - T Ernst
- Department of Ageing and Health,Guy's and St. Thomas' Hospital Foundation Trust,Westminster Bridge Road,London,SE1 7EH,UK
| |
Collapse
|
29
|
Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
30
|
O'Hanlon S, O'Regan N, Maclullich AMJ, Cullen W, Dunne C, Exton C, Meagher D. Improving delirium care through early intervention: from bench to bedside to boardroom. J Neurol Neurosurg Psychiatry 2014; 85:207-13. [PMID: 23355807 DOI: 10.1136/jnnp-2012-304334] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.
Collapse
Affiliation(s)
- Shane O'Hanlon
- Graduate Entry Medical School, , University of Limerick, Ireland
| | | | | | | | | | | | | |
Collapse
|
31
|
Current world literature. Curr Opin Psychiatry 2012; 25:251-9. [PMID: 22456191 DOI: 10.1097/yco.0b013e328352dd8d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Clegg A, Young J. In-hospital delirium risk assessment, diagnosis and management; medications to avoid. ITALIAN JOURNAL OF MEDICINE 2011. [DOI: 10.1016/j.itjm.2011.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|