Using DSM-III criteria to diagnose delirium in elderly general medical patients

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Comparative Study of Delirium in Emergency and Consultation Liaison- A Tertiary Care Hospital Based Study in Northern India

INTRODUCTION

Delirium is an acute and often fluctuating disturbance in level of consciousness and thought process (cognition) that develops over a short period of time and is a significant change from previous level of functioning. Its prevalence increases with age, complexity of medical co- morbidities and number of medications prescribed.

AIM

To compare the cause and severity of delirium in patients in emergency and consultation liaison psychiatry group.

MATERIALS AND METHODS

A cross-sectional, tertiary care hospital based study was conducted on the patients who presented with delirium from emergency department (50) and consultation-liaison psychiatry groups (50), over a period of one year. The diagnosis was made on the basis of DSM- 5 criteria. The Delirium Rating Scale (DRS-R-98) was applied to know the severity of delirium, cognitive and non-cognitive symptoms of delirium in patients. The results were subjected to appropriate statistical analysis.

RESULTS

In emergency group, 42% patients had metabolic abnormalities, while in consultation-liaison, 38% patients had hyponatremia and hypokalemia and the difference was found to be statistically non-significant (p>0.05). In emergency group, 21(42%) patients were diagnosed as delirium due to other medical condition, followed by 13 (26%) and 8(16%) patients, who were diagnosed as delirium due to multiple aetiologies and substance intoxication each respectively. In only 33(66%) cases in consultation liaison group patients had delirium secondary to other medical conditions. As per DRS-R98 Scale, mean severity score was found to be statistically significant (p<0.05) in consultation liaison group as compared to emergency department group (p> 0.05).

CONCLUSION

Delirium is multifactorial aetiological disease, with variable but preventable outcome. Approach should be aimed at finding the treatable causes to reduce morbidity and mortality.

Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis

BACKGROUND

delirium affects up to 40% of older hospitalised patients, but there has been no systematic review focussing on risk factors for incident delirium in older medical inpatients. We aimed to synthesise data on risk factors for incident delirium and where possible conduct meta-analysis of these.

METHODS

PubMed and Web of Science databases were searched (January 1987-August 2013). Studies were quality rated using the Newcastle-Ottawa Scale. We used the Mantel-Haenszel and inverse variance method to estimate the pooled odds ratio (OR) or mean difference for individual risk factors.

RESULTS

eleven articles met inclusion criteria and were included for review. Total study population 2338 (411 patients with delirium/1927 controls). The commonest factors significantly associated with delirium were dementia, older age, co-morbid illness, severity of medical illness, infection, 'high-risk' medication use, diminished activities of daily living, immobility, sensory impairment, urinary catheterisation, urea and electrolyte imbalance and malnutrition. In pooled analyses, dementia (OR 6.62; 95% CI (confidence interval) 4.30, 10.19), illness severity (APACHE II) (MD (mean difference) 3.91; 95% CI 2.22, 5.59), visual impairment (OR 1.89; 95% CI 1.03, 3.47), urinary catheterisation (OR 3.16; 95% CI 1.26, 7.92), low albumin level (MD -3.14; 95% CI -5.99, -0.29) and length of hospital stay (OR 4.85; 95% CI 2.20, 7.50) were statistically significantly associated with delirium.

CONCLUSION

we identified risk factors consistently associated with incident delirium following admission. These factors help to highlight older acute medical inpatients at risk of developing delirium during their hospital stay.

The epidemiology of delirium: challenges and opportunities for population studies

Delirium is a serious and common acute neuropsychiatric syndrome that is associated with short- and long-term adverse health outcomes. However, relatively little delirium research has been conducted in unselected populations. Epidemiologic research in such populations has the potential to resolve several questions of clinical significance in delirium. Part 1 of this article explores the importance of population selection, case-ascertainment, attrition, and confounding. Part 2 examines a specific question in delirium epidemiology: What is the relationship between delirium and trajectories of cognitive decline? This section assesses previous work through two systematic reviews and proposes a design for investigating delirium in the context of longitudinal cohort studies. Such a design requires robust links between community and hospital settings. Practical considerations for case-ascertainment in the hospital, as well as the necessary quality control of these programs, are outlined. We argue that attention to these factors is important if delirium research is to benefit fully from a population perspective.

A quality assurance study to assess the one-day prevalence of delirium in elderly hospitalized patients

BACKGROUND

Research indicates that 40% of hospital-acquired delirium cases may be preventable. However, despite its clinical significance, delirium often goes unrecognized or is misdiagnosed. The purpose of this study was to assess the need for delirium education in acute care hospitals in Hamilton, Ontario.

METHODS

Approximately 100 health professionals were trained as delirium screeners. On 'Delirium Day', all patients ≥ 65 years of age in non-critical care areas in all acute care sites in Hamilton were identified. Those willing to take part in the prevalence study were assessed for delirium using the Standardized Mini-Mental State Examination and the Confusion Assessment Method. The Research Ethics Boards at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton approved this quality assurance project.

RESULTS

Of the 562 patients eligible for screening, eight were excluded and six did not have sufficient data collected to assess for delirium. Of the 548 individuals screened for delirium, 10.6% screened positive. Prevalence estimates ranged by site from 0% to 21% and type of unit from 3.8% to 16%. Recognition of delirium by nursing staff was fair; but, documentation was usually absent.

CONCLUSION

While the prevalence rates were somewhat lower than in other studies, the results support the need for education among health-care providers in the prevention, identification, and management of delirium.

Postoperative delirium and functional decline after noncardiac surgery

OBJECTIVES

To determine whether delirium after noncardiac surgery is associated with functional decline 3 months postoperatively.

DESIGN

Secondary analysis of a prospective study.

SETTING

Thirteen hospitals in eight countries.

PARTICIPANTS

One thousand two hundred eighteen individuals aged 60 and older undergoing noncardiac surgery.

MEASUREMENTS

Participants were interviewed before surgery and 3 months postoperatively using six items pertaining to social and independent function. Functional decline was determined according to a loss in function in at least one item at the 3-month assessment from baseline. Postoperatively, a trained interviewer assessed delirium daily using a standardized battery. The primary outcome of this analysis was an examination of the risk of functional decline with delirium.

RESULTS

Of the 948 participants who completed functional assessment at 3 months, 20% (n = 189) had a decline in function. In unadjusted analysis, postoperative delirium increased the odds of functional decline (odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.4-4.2). After adjustment for age, sex, education, cognition, and surgery duration, delirium remained associated with functional decline (OR = 2.1, 95% CI = 1.2-3.8).

CONCLUSION

Although considered an acute event, delirium can have lasting functional consequences. Clinicians should give strong consideration to preoperative delirium risk assessment, delirium prevention strategies, and delirium surveillance programs after noncardiac surgery.

Damage accrual, cumulative glucocorticoid dose and depression predict anxiety in patients with systemic lupus erythematosus

The burden of anxiety in patients with systemic lupus erythematosus (SLE) compared to those with other inflammatory rheumatological conditions is unclear. We aimed to compare the frequency and level of anxiety between patients with SLE, rheumatoid arthritis (RA), and gout and healthy individuals and explore independent predictors for anxiety in SLE patients. Consecutive patients with SLE, RA and gout and healthy individuals who were age and sex matched with the SLE group were evaluated for anxiety using the Hospital Anxiety and Depression Scale (HADS). Sociodemographic and disease-related variables were compared between all groups. Predictors for anxiety were studied by regression models, with construction of a prediction model for the presence of anxiety in SLE patients by the receiver operating characteristic (ROC) analysis. Amongst 271 subjects studied, 60 had lupus, 50 had gout, 100 had RA and 61 were healthy controls. The frequency and level of anxiety were significantly higher in SLE patients than patients with gout, RA and healthy controls. SLE per se was independently associated with higher HADS-anxiety score after controlling for potential confounders. Logistic regression model showed that higher damage accrual, higher cumulative glucocorticoid dose, depression and fewer regular medications predicted anxiety in SLE patients, with an accuracy of 90% by the ROC analysis.

Insomnia among hospitalized older persons

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

WITHDRAWN: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus* . The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

AUTHORS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Distinguishing delirium and dementia

Delirium and dementia are syndromes with multiple cognitive impairments common to the elderly and to medically ill patients. While strides have been made in recognition of both delirium and dementia, underdiagnosis is common. Delirium and dementia cause great suffering in patients, families and caregivers. Both necessitate further advancement in assessment methods and treatment, especially when they overlap. Differentiating delirium and dementia requires recognizing that both may present with cognitive, behavioral and neuropsychiatric symptoms, but attentional disturbance and acute onset are cardinal discriminators in delirium. Superimposed delirium on dementia presents a particularly vexing problem in terms of recognition, treatment and prognosis. The pathophysiology of delirium results from diffuse cortical dysfunction or impairment in susceptible areas of the cortex and the reticular activating system. The pathophysiology of dementia is varied across dementias although several share histolological features. Treatment for both delirium and dementia includes antipsychotic medications and cholinesterase inhibitors, among others, although the disadvantages of pharmacological treatment are becoming better understood and demand caution. Nevertheless, there is an array of treatments and preventive strategies being explored for dementia, and to a lesser degree for delirium, that hold promise for the future.

Occurrence and outcome of delirium in medical in-patients: a systematic literature review

BACKGROUND

Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting.

OBJECTIVE

To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature.

METHOD

We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols.

RESULTS

Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months.

CONCLUSION

Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.

Delirium in older patients admitted to general internal medicine

Delirium on the day of admission to general internal medicine wards was studied in 400 consecutive patients aged 70 years and above regarding occurrence, associated factors, clinical profile, length of hospital stay, and mortality. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination, and delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day of admission occurred in 31.3% of the patients and was independently associated with old age, fever on the day of admission (> or = 38 degrees C), treatment with neuroleptics, impaired vision, male sex, and previous stroke. Delirious patients had longer hospital stay (15.4 vs 9.5 days, P < .001), a higher mortality rate during hospitalization (11/125 vs 5/275, P < .001), and a higher 1-year mortality rate (45/125 vs 55/275, P = .001). Delirium is a common complication with often easily identified causes, and it has a serious impact on outcome for older medical patients.

A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients

OBJECTIVES

To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients.

DESIGN

Prospective intervention study.

SETTING

Department of General Internal Medicine, Sundsvall Hospital, Sweden.

PARTICIPANTS

Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward.

INTERVENTION

The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care.

MEASUREMENTS

The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

RESULTS

Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03).

CONCLUSION

This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus*. The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

REVIEWERS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up

OBJECTIVES

To examine the prevalence, incidence, persistence, predictors, and outcomes of cognitive impairment after hip fracture.

DESIGN

Longitudinal cohort study.

SETTING

Eight hospitals in Baltimore, Maryland.

PARTICIPANTS

Six hundred seventy-four hip fracture patients aged 65 and older living in the community before fracture.

MEASUREMENT

Delirium at admission and postsurgery, Mini-Mental State Examination (MMSE) scores postsurgery, and prefracture proxy ratings of MMSE and dementia. Follow-up measures at 2 and 12 months postfracture included mortality, MMSE, physical activities of daily living (PADLs), instrumental activities of daily living (IADLs), social functioning, and the Center for Epidemiologic Studies-Depression Scale.

RESULTS

Overall, 28% had prefracture dementia or MMSE impairment, 8% had cognitive impairment first detected presurgery, 14% had impairment first detected postsurgery, and 50% were not impaired before or during hospitalization. Incident cognitive impairment was more likely in patients who were older, male, and less educated and had more prefracture PADL impairment, intertrochanteric fractures, and higher anesthesia risk ratings. Presurgery incident cases did not differ significantly from those detected postsurgery in functional outcomes or in persistence of cognitive impairment. Cognitive impairment first noted in the hospital persisted through 2 and 12 months in more than 40% of patients. Those with cognitive impairment persisting through 2 months had poorer 12-month PADLs and social functioning.

CONCLUSION

Prefracture cognitive impairment and incident cognitive impairment during hospitalization are risk factors for poor functional outcomes. Many incident cognitive problems persisted over 2 to 12 months, and per-sistence predicted later functional and social impairment.

The Delirium Observation Screening Scale: a screening instrument for delirium

The Delirium Observation Screening (DOS) scale, a 25-item scale, was developed to facilitate early recognition of delirium, according to the Diagnostic and Statistical Manual-IV criteria, based on nurses' observations during regular care. The scale was tested for content validity by a group of seven experts in the field of delirium. Internal consistency, predictive validity, and concurrent and construct validity were tested in two prospective studies with high risk groups of patients: geriatric medicine patients and elderly hip fracture patients. Among the patients admitted to a geriatric department (N = 82), 4 became delirious; among the elderly hip fracture patients (N = 92), 18 became delirious. The DOS scale was determined to be content valid and showed high internal consistency, alpha = 0.93 and alpha = 0.96. Predictive validity against the Diagnostic and Statistical Manual-IV diagnosis of delirium made by a geriatrician was good in both studies. Correlations of the DOS scale with the Mini Mental State Examination (MMSE) were Rs -0.79 (p < or = 0.001) in the hip fracture patients and Rs -0.66 (p < or = 0.001) in the geriatric medicine patients. Concurrent validity, as tested by comparison of the research nurse's ratings of the DOS scale and the Confusion Assessment Method (CAM), for the group of hip fracture patients was 0.63 (p < or = 0.001). Construct validity of the DOS was tested against the Informant Questionnaire of Cognitive Decline in Elderly (IQCODE), a preexisting psychiatric diagnosis and the Barthel Index. Correlation with the IQCODE was 0.74 (p < or = 0.001) in the study with the hip fracture patients and 0.33 (p < or = 0.05) in the study with the geriatric medicine patients. Correlation with the Barthel Index was -0.26 (p < or = 0.05) in the geriatric medicine patients and -0.55 (p < or = 0.001) in the hip fracture patients. The overall conclusion of these studies is that the DOS scale shows satisfactory validity and reliability, to guide early recognition of delirium by nurses' observation.

Confusion assessment method in the diagnostics of delirium among aged hospital patients: would it serve better in screening than as a diagnostic instrument?

BACKGROUND

The Confusion Assessment Method (CAM) is an easy, four-step algorithmic diagnostic test developed to detect delirium.

OBJECTIVE

To determine how sensitive and specific the CAM is in diagnosing delirium when compared with fully operationalized criteria of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) editions III, III revised, and IV, and the International Classification of Diseases (ICD) 10th edition.

METHODS

A cross-sectional study with blinded assessments was performed on consecutive elderly patients (>70 years) (n=81) in two acute geriatric hospitals in Helsinki, Finland. The sensitivity, specificity, likelihood ratios, and positive and negative predictive values of CAM were assessed with the DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria of delirium used as reference standards.

RESULTS

Sensitivity rates of the CAM were proved to be only moderate (0.81-0.86) against all formal criteria of delirium. The specificity rates were lower (0.63-0.84), and far less than reported in previous studies using global assessment of the reference standard. Instead of the DSM-III-R, from which it is derived, the CAM seems more concordant with the DSM-IV criteria of delirium. The likelihood ratio for a positive CAM test was 5.06 and for a negative test 0.23, when compared with the DSM-IV.

CONCLUSION

The CAM seems to be an acceptable screening instrument for delirium, but the diagnosis should be ensured according to the formal criteria of delirium, preferably by the DSM-IV.

Risk for acute confusion on hospital admission

Elderly individuals are at risk for acute confusion (AC) during hospitalization. Using a prospective design, this study assessed the relationship between admission risk factors and subsequent development of AC in 117 elderly hospitalized patients. AC was ascertained using the NEECHAM Confusion Scale. Other measures included demographic data, cognitive status, physical function, laboratory data, medications, infections, activity, pain, and nursing acuity. The cumulative incidence estimate was 14%. Patients who developed AC were more likely to be admitted to the hospital from somewhere other than home, to have lower admission NEECHAM and MMSE scores, and to have restricted activity levels, an infection, and abnormal lab values. These patients were more cognitively and physically frail and may have been chronically undernourished and dehydrated on admission to the hospital. Nurses can be trained to routinely assess for acute confusion using easily implemented instruments incorporated into a research-based protocol.

Early recognition of delirium: review of the literature

This review focuses on delirium and early recognition of symptoms by nurses. Delirium is a transient organic mental syndrome characterized by disturbances in consciousness, thinking and memory. The incidence in older hospitalized patients is about 25%. The causes of delirium are multi-factorial; risk factors include high age, cognitive impairment and severity of illness. The consequences of delirium include high morbidity and mortality, lengthened hospital stay and nursing home placement. Delirium develops in a short period and symptoms fluctuate, therefore nurses are in a key position to recognize symptoms. Delirium is often overlooked or misdiagnosed due to lack of knowledge and awareness in nurses and doctors. To improve early recognition of delirium, emphasis should be given to terminology, vision and knowledge regarding health in ageing and delirium as a potential medical emergency, and to instruments for systematic screening of symptoms.

Acute confusional state in patients with and without dementia

Among 1029 geriatric consultations in a comprehensive geriatric hospital unit, 69 had an acute confusional state (6.7%) of whom 32 had dementia. Acute confusional state was the initial presentation in 17 (53%) of those with dementia There were no differences between these two dementia subgroups in any of the baseline variables. The two subgroups were combined for further analysis against the non-dementia group. The mean age in the dementia group was lower (79 years+/-6.8) than in the non-dementia group (84 years+/-8.5) but this was not significant (P<0.32) and 78% of the patients in latter group were males (P<0.03). The aetiological factors were not significantly different in the two groups. There were six deaths, five from the non-dementia group with a mean age of 80 years (range 74-89). There was no difference between groups in the final disposition (P<0.21) and more than half in each group required placement in a long term nursing care facility. The functional disability following acute confusional state had an important impact on caregivers in both groups perhaps even exceeding that of cognitive decline and was a significant factor for institutionalisation.

Delirium phenomenology illuminates pathophysiology, management, and course

The phenomenology of delirium has received little standardized longitudinal study but offers the prospect of valuable insights regarding clinical subtypes, differentiation from other neuropsychiatric disorders, identification of underlying pathophysiologies, management, and course. This review examines current approaches to the investigation of delirium phenomenology and how the findings to date illuminate our understanding of delirium. It concludes with recommendations for future investigations.

Delirium in hospital: does it increase length of stay?

OBJECTIVE

To determine the effect of delirium, as a comorbid diagnosis in hospitalised patients, on patient length of stay (LOS).

METHOD

Prospective study comparing LOS of delirious patients with controls matched by age, gender, principal diagnosis and date of admission. Medical and surgical inpatients of Westmead Hospital with delirium were identified from a Consultation Liaison (CL) psychiatry database and were matched with controls from the hospital medical records.

RESULTS

Delirious patient LOS was found to be significantly longer (2.2-fold; 95% confidence interval 1.5-3.3) than matched controls.

CONCLUSIONS

Delirium, as a comorbid diagnosis in general hospital patients, is associated with an increased use of resources. Its early diagnosis may limit this and morbidity.

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

OBJECTIVE

To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline.

DESIGN

Three prospective cohort studies.

SETTING

Three university-affiliated teaching hospitals.

PATIENTS

Consecutive samples of 727 patients, aged 65 years and older.

MEASUREMENTS AND MAIN RESULTS

Delirium was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2).

CONCLUSIONS

Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline-even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.

Cognitive side effects of medications

Iatrogenically induced cognitive deficits are common with pharmacological therapy. The deficits may range from gross encephalopathy with delirium to subtle subjective alterations (e.g., mood and perception of well being). The risks are increased for certain drug types, polypharmacy, the elderly, and patients with dementia or metabolic abnormalities. This review examines methodological concerns and the neuropsychological data on cognitive side effects across a variety of commonly used medicines in clinical practice.

Focal neurocognitive dysfunctions in abstinence delirium: a case report

Due to abrupt interruption of hidden benzodiazepine-use, a 68-year-old woman developed a full-blown abstinence delirium characterized by epileptic seizures and progressive focal neurocognitive symptoms. The evolution of such rare neuro-linguistic phenomena as an echoism, palilalia and glossomania associated with a progressive visuo-perceptive syndrome and a visual hallucinosis are for the first time reported within the context of withdrawal. Notwithstanding the lack of any neuroradiological evidence for a morphological lesion in the clinically expected brain regions, the anatomo-clinical hypothesis of a focal frontal and parieto-occipital dysfunction was explicitly corroborated by repeated 99mTc-HMPAO SPECT findings.

Assessing attentiveness in older hospital patients: global assessment versus tests of attention

OBJECTIVES

Impairment of attentiveness is a cardinal symptom of delirium. We examined the relationship between bedside tests of attention and a global rating of attentiveness in older hospital patients and sought to identify cut-off points on the tests of attention that might be helpful in the diagnosis of delirium.

SETTING AND PARTICIPANTS

Subjects were 110 patients admitted to an acute geriatric unit.

MEASUREMENTS

Subjects were assessed by two physicians. One physician rated global attentiveness on a 10-cm visual analog scale following general conversation with the patient. The second physician determined whether patients met DSM-3 criteria for delirium or dementia and administered four tests of attentiveness: Digit Span Forwards (DSF), Digit Span Backwards (DSB), Vigilance "A' test (VAT), and a timed Digit Cancellation Test (DCT).

MAIN RESULTS

Of the 87 patients who completed the study, 18 were delirious and 17 demented. There was no difference between demented and delirious patients on the VAT, DSF, or MMSE tests; other comparisons between demented and delirious patients and between delirious patients and those with neither delirium nor dementia were significant. All tests of attention except DSF were significantly correlated with the global rating.

CONCLUSION

Simple bedside tests of attention can aid identification of delirium.

The prognostic significance of delirium in older hospital patients

OBJECTIVES

To determine whether delirium is an independent predictor of adverse outcomes of hospitalization in older patients.

DESIGN

Cohort study.

PATIENTS

A total of 225 people admitted as an emergency to an acute geriatric unit in a university teaching hospital.

METHODS

Subjects were screened for delirium, defined by Diagnostic and Statistical Manual, 3rd Edition criteria, every 48 hours. Outcome measures included mortality, duration of hospital stay, hospital-acquired complications, and institutional placement. The influence of delirium on these outcomes was calculated after adjusting for age, illness severity on admission, burden of comorbidity, prior cognitive impairment, and level of disability.

RESULTS

Delirium was present on admission in 41 patients (18%) and developed after admission in a further 53 patients (24%). Patients with delirium were more likely than non-delirious patients to have chronic cognitive impairment, severe acute illness, multiple comorbid conditions, and functional disability. Nevertheless, in multivariate analyses adjusting for these factors, delirium was independently associated with prolonged hospital stay, functional decline during hospitalization, increased risk of developing a hospital-acquired complication, and with increased admission to long-term care.

CONCLUSION

Delirium is an independent predictor of adverse outcomes in older hospital patients.

Further analyses of the Delirium Rating Scale

The Delirium Rating Scale is a clinician-rated, 10-item symptom rating scale for assessment of delirium severity. In order to better understand the relationship between items of the scale and whether they reflect one or more underlying groupings or dimensions, further analyses of the originally published scale data were performed. Factor analysis revealed a strong single underlying dimension that could be further divided into two components: one comprising delusions, psychomotor behavior, cognition, sleep-wake cycle disturbance, and mood lability; the other comprising temporal onset of symptoms, perceptual disturbances, hallucinations, and fluctuation of symptoms. Implications for improved phenomenological understanding of delirium are discussed.

A critique of instruments and methods to detect, diagnose, and rate delirium

This document reviews existing instruments for evaluation of delirium. Instruments have been grouped into four categories: tests that screen for cognitive impairment, delirium diagnostic instruments, delirium-specific numerical rating scales, and laboratory and paraclinical exams. Analysis of instruments was based on comparison of their psychometric properties as well as subjective judgment. Guidelines are suggested for choosing the appropriate instrument according to the type of clinical evaluation or delirium research envisaged. Important factors in choosing an instrument, besides the appropriateness of its psychometric characteristics, include administration time constraints, level of rater expertise, and patient capabilities. By familiarizing investigators with the variety of evaluation instruments available, this work should permit more appropriate instrument selection in future studies on delirium.

Delirium and physical restraint in the hospitalized elderly

Delirium or acute confusion increase the likelihood of physical restraint use and subsequent harmful physical and psychological effects. Assessment for delirium is presented as a conceptual framework to guide researchers, administrators, and clinicians in developing strategies to decrease the use of physical restraint and to support quality of life for hospitalized older adults.

The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients

Delirium, with occurrence rates from 14% to 56%, associated mortality rates from 10% to 65%, and excess annual health care expenditures from $1 to $2 billion, poses a common and serious problem for hospitalized elderly patients. Delirium is often unrecognized or misdiagnosed by physicians caring for elderly patients. Cognitive testing is rarely done as part of the admission evaluation of elderly hospitalized patients. Specific diagnosis has been difficult, since diagnostic criteria and instruments are still being developed. The etiology of delirium is complex and multifactorial, and both predisposing (host vulnerability) and precipitating factors must be considered. The recommended approach to the evaluation of delirium is empiric, in the absence of objective efficacy data. The cornerstone of evaluation includes a careful history, physical examination, and review of the medication list--since medications are the most common reversible cause of delirium. Research is needed to establish a cost-effective approach and to clarify the role of further testing, such as cerebrospinal fluid examination, brain imaging, and electroencephalography. This article is intended to heighten the awareness of clinicians as well as to stimulate research to address this important, neglected problem for elderly hospitalized patients.

Delirium in hospitalized older persons: outcomes and predictors

OBJECTIVE

The purpose of this study was fourfold; to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

DESIGN

Two prospective cohort studies

SETTING

Medical and surgical wards of 2 university teaching hospitals.

PATIENTS

In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale-New Haven Hospital were studied.

MEASUREMENTS

Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM-III-R criteria. Duration of hospitalization was adjusted for diagnosis-related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Sociodemographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium.

MAIN RESULTS

The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in-hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%.

CONCLUSIONS

This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized older persons.

Increasing the recognition of delirium in elderly patients

OBJECTIVE

To determine if an educational intervention aimed at house staff will increase knowledge about and recognition of delirium.

DESIGN

Before/after study, with blinding of participants to the intent of the study.

SETTING

University hospital in Halifax, Nova Scotia.

PATIENTS

One hundred eighty-seven control patients, seen as consecutive admissions of elderly patients (65 + years) to the General Medicine services of the Victoria General Hospital prior to the educational intervention, and 247 patients seen thereafter.

INTERVENTION

Educational intervention at grand rounds, housestaff rounds, sign-in rounds, and bedside teaching.

MEASUREMENTS

Recognition of delirium in the admitting history or progress notes, Confusion Assessment Method (CAM) as recorded by nurses, diagnosis of delirium by independent study physicians using DSM-IIIR criteria and the Trzepacz Delirium Symptom Rating Scale.

RESULTS

Prior to the intervention, delirium or acute confusion was diagnosed in 3% of patients; after the intervention, delirium or acute confusion was diagnosed in 9% of patients (P < 0.01). Other abnormalities in mental state were noted in 8.5% of admissions prior to the intervention, and 15.6% of admissions after the intervention. After the intervention there was a significant difference in the proportion of patients in whom a mental status questionnaire had been carried out and in whom there was formal comment on various aspects of the mental state. The nursing CAM had a sensitivity of 0.68 and a specificity of 0.97.

CONCLUSIONS

A simple educational intervention aimed at house staff appears to be effective in changing house staff behavior. Improved recognition of delirium may lead to better patient outcomes.

Cognitive Change After Elective Surgery in Nondemented Older Adults

The authors report the results of repeated cognitive function tests administered over 10 months to 82 patients between the ages of 55 and 82 who underwent elective surgery. The Mini-Mental State Exam (MMSE) score, 10 months after surgery, was modeled by a multivariate linear regression that included the baseline demographics, baseline cognitive functions, and immediate postoperative MMSE scores. Immediate postoperative MMSE scores were highly significant to 10-month postoperative MMSE scores not explained by baseline variables. The results suggest that immediate postoperative cognitive change may predict later postoperative cognitive decline.

Suitable screening tests for cognitive impairment and depression in the terminally ill--a prospective prevalence study

Although confusional states and depression are common accompaniments of advanced cancer, few objective data are available concerning the prevalence of these clinical states or what methods are most suitable for their accurate detection. We decided that a 10-question Abbreviated Mental Test Score (AMTS) and a semistructured application of modified DSMIII-R (Diagnostic and Statistical Manual of Mental Disorder, third edition-revised) criteria for a major depressive illness were the most suitable screening tests for a terminally ill population. Thirty of 87 patients (34%) displayed significant cognitive impairment. The AMTS rating declined with approaching death and also correlated negatively with age. Of 81 patients, 21 (26%) were depressed when screened using DSMIII-R criteria for depression. One-third of patients with impaired AMTS scores also satisfied DSMIII-R criteria for depression. Of cognitively impaired patients, 90% had at least two possible causes for their confused state. We have found that both the AMTS and semistructured interview using DSMIII-R criteria for depression are useful routine screening tests in the terminally ill.

Functional status outcomes of a nursing intervention in hospitalized elderly

This paper examines the effectiveness of a nursing intervention for elderly hospitalized patients (N = 235) as measured by functional outcomes. A nursing intervention targeted at factors which influence acute confusion or delirium employed strategies to educate nursing staff, mobilize patients, monitor medication and make environmental and sensory modifications. Subjects who received the intervention were more likely to improve in functional status from admission to discharge than subjects who did not receive the intervention.

Prognosis after hospital discharge of older medical patients with delirium

OBJECTIVE

To determine survival, functional independence, and cognitive performance of older patients 2 years after an episode of delirium.

DESIGN

Descriptive cohort study.

SETTING

General medical wards of a teaching hospital.

PATIENTS

Two hundred twenty-nine consecutive patients aged 70 years or older who had been community-dwelling prior to admission. Fifty patients met criteria for delirium (cases); these were compared to patients without delirium (controls). Two-hundred twenty-three patients survived hospitalization (46 cases, 177 controls) Of these, 92% were followed greater than or equal to 2 years.

MAIN OUTCOME MEASURES

Vital status, place of residence, activities of daily living (ADL), and cognitive performance were determined by telephone interview of patients or care-givers 2 years after discharge. Independent community living was defined as survivorship outside of an institution and without dependence in any of four basic ADL (bathing, dressing, transfers, eating).

RESULTS

Two-year mortality in the entire population was 39% for cases and 23% for controls (relative risk 1.82, 95% confidence interval 1.04-3.19). Delirium identified those patients at risk for loss of independent community living, even after adjustment for potential confounding variables (adjusted odds ratio 2.56, 95% confidence interval 1.10-5.91). Follow-up cognitive testing in a subset of patients with high baseline performance revealed a greater decline in performance among cases of delirium than controls (P = 0.023).

CONCLUSIONS

Delirium identifies older patients at risk for mortality or loss of independence. Delirium may also identify patients at risk for future cognitive decline.

Prospective versus retrospective methods of identifying patients with delirium

OBJECTIVE

To determine if DSM-III criteria or clinical or discharge diagnoses, reviewed retrospectively, are as accurate an indicator of the presence of delirium as prospective evaluation by a psychiatrist.

DESIGN

Selection of delirious patients prospectively by a psychiatrist, followed by retrospective record review of the same patients.

SETTING

A referral-based university hospital.

PATIENTS

From a sample of 235 consecutive medical patients over age 70, 47 delirious patients were identified prospectively by a research psychiatrist using DSM-III criteria. The medical record of these delirious patients was reviewed after discharge for evidence of delirium.

RESULTS

Four patients were assigned ICD-9 codes suggestive of delirium (sensitivity 0.09). Review of physicians' diagnoses correctly identified 8 of 47 (sensitivity 0.17) patients as being delirious or acutely confused. The specific diagnostic criteria necessary to meet a DSM-III diagnosis of delirium could be ascertained from 10 of 47 records (sensitivity 0.21).

CONCLUSION

The retrospective medical record review is very imprecise in establishing the diagnosis of delirium. As research in this field moves from descriptive epidemiology to studies of pathogenesis and treatment, prospective designs will be needed.