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Tsui A, Yeo N, Searle SD, Bowden H, Hoffmann K, Hornby J, Goslett A, Weston-Clarke M, Lanham D, Hogan P, Seeley A, Rawle M, Chaturvedi N, Sampson EL, Rockwood K, Cunningham C, Ely EW, Richardson SJ, Brayne C, Terrera GM, Tieges Z, MacLullich AMJ, Davis D. Extremes of baseline cognitive function determine the severity of delirium: a population study. Brain 2023; 146:2132-2141. [PMID: 36856697 PMCID: PMC10151184 DOI: 10.1093/brain/awad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 03/02/2023] Open
Abstract
Although delirium is a significant clinical and public health problem, little is understood about how specific vulnerabilities underlie the severity of its presentation. Our objective was to quantify the relationship between baseline cognition and subsequent delirium severity. We prospectively investigated a population-representative sample of 1510 individuals aged ≥70 years, of whom 209 (13.6%) were hospitalized across 371 episodes (1999 person-days assessment). Baseline cognitive function was assessed using the modified Telephone Interview for Cognitive Status, supplemented by verbal fluency measures. We estimated the relationship between baseline cognition and delirium severity [Memorial Delirium Assessment Scale (MDAS)] and abnormal arousal (Observational Scale of Level of Arousal), adjusted by age, sex, frailty and illness severity. We conducted further analyses examining presentations to specific hospital settings and common precipitating aetiologies. The median time from baseline cognitive assessment to admission was 289 days (interquartile range 130 to 47 days). In admitted patients, delirium was present on at least 1 day in 45% of admission episodes. The average number of days with delirium (consecutively positive assessments) was 3.9 days. Elective admissions accounted for 88 bed days (4.4%). In emergency (but not elective) admissions, we found a non-linear U-shaped relationship between baseline global cognition and delirium severity using restricted cubic splines. Participants with baseline cognition 2 standard deviations below average (z-score = -2) had a mean MDAS score of 14 points (95% CI 10 to 19). Similarly, those with baseline cognition z-score = + 2 had a mean MDAS score of 7.9 points (95% CI 4.9 to 11). Individuals with average baseline cognition had the lowest MDAS scores. The association between baseline cognition and abnormal arousal followed a comparable pattern. C-reactive protein ≥20 mg/l and serum sodium <125 mM/l were associated with more severe delirium. Baseline cognition is a critical determinant of the severity of delirium and associated changes in arousal. Emergency admissions with lowest and highest baseline cognition who develop delirium should receive enhanced clinical attention.
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Affiliation(s)
- Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Natalie Yeo
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Samuel D Searle
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS B3H 2E1, Canada
| | - Helen Bowden
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Katrin Hoffmann
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Joanne Hornby
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Arley Goslett
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | | | - David Lanham
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Patrick Hogan
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Anna Seeley
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Nuffield Department of Primary Care, University of Oxford, Oxford, OX2 6GG, UK
| | - Mark Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | - Nish Chaturvedi
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
| | | | - Kenneth Rockwood
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS B3H 2E1, Canada
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute, Dublin 2, Republic of Ireland
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah J Richardson
- AGE Research Group, Translational and Clinical Research Institute, Newcastle University, UK
| | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, UK
- SMART Technology Centre, Glasgow Caledonian University, Glasgow, UK
| | - Alasdair M J MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 7HB, UK
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Tsui A, Searle SD, Bowden H, Hoffmann K, Hornby J, Goslett A, Weston-Clarke M, Hamill Howes L, Street R, Perera R, Taee K, Kustermann C, Chitalu P, Razavi B, Magni F, Das D, Kim S, Chaturvedi N, Sampson EL, Rockwood K, Cunningham C, Ely EW, Richardson SJ, Brayne C, Muniz Terrera G, Tieges Z, MacLullich A, Davis D. The effect of baseline cognition and delirium on long-term cognitive impairment and mortality: a prospective population-based study. Lancet Healthy Longev 2022; 3:e232-e241. [PMID: 35382093 PMCID: PMC7612581 DOI: 10.1016/s2666-7568(22)00013-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background There is an unmet public health need to understand better the relationship between baseline cognitive function, the occurrence and severity of delirium, and subsequent cognitive decline. Our aim was to quantify the relationship between baseline cognition and delirium and follow-up cognitive impairment. Methods We did a prospective longitudinal study in a stable representative community sample of adults aged 70 years or older who were registered with a Camden-based general practitioner in the London Borough of Camden (London, UK). Participants were recruited by invitation letters from general practice lists or by direct recruitment of patients from memory clinics or patients recently discharged from secondary care. We quantified baseline cognitive function with the modified Telephone Interview for Cognitive Status. In patients who were admitted to hospital, we undertook daily assessments of delirium using the Memorial Delirium Assessment Scale (MDAS). We estimated the association of pre-admission baseline cognitive function with delirium prevalence, severity, and duration. We assessed subsequent cognitive function 2 years after baseline recruitment using the Telephone Interview for Cognitive Status. Regression models were adjusted by age, sex, education, illness severity, and frailty. Findings We recruited 1510 participants (median age 77 [IQR 73-82], 57% women) between March, 2017, and October, 2018. 209 participants were admitted to hospital across 371 episodes (1999 person-days of assessment). Better baseline cognition was associated with a lower risk of delirium (odds ratio 0·63, 95% CI 0·45 to 0·89) and with less severe delirium (-1·6 MDAS point, 95% CI -2·6 to -0·7). Individuals with high baseline cognition (baseline Z score +2·0 SD) had demonstrable decline even without delirium (follow-up Z score +1·2 SD). However, those with a high delirium burden had an even larger absolute decline of 2·2 SD in Z score (follow-up Z score -0·2). Once individuals had more than 2 days of moderate delirium, the rates of death over 2 years were similar regardless of baseline cognition; a better baseline cognition no longer conferred any mortality benefit. Interpretation A higher baseline cognitive function is associated with a good prognosis with regard to likelihood and severity of delirium. However, those with a high baseline cognition and with delirium had the highest degree of cognitive decline, a change similar to the decline observed in individuals with a high amyloid burden in other cohorts. Older people with a healthy baseline cognitive function who develop delirium stand to lose the most after delirium. This group could benefit from targeted cognitive rehabilitation interventions after delirium.
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Affiliation(s)
- Alex Tsui
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Samuel D Searle
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Helen Bowden
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Katrin Hoffmann
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Joanne Hornby
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Arley Goslett
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Maryse Weston-Clarke
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Lee Hamill Howes
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Rebecca Street
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Rachel Perera
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Kayvon Taee
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Christoph Kustermann
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Petronella Chitalu
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Benjamin Razavi
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Francesco Magni
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Devajit Das
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Sung Kim
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | - Nish Chaturvedi
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
| | | | - Kenneth Rockwood
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
- Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah J Richardson
- AGE Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
- SMART Technology Centre, Glasgow Caledonian University, Glasgow, UK
| | - Alasdair MacLullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel Davis
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, UK
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Davis D, Richardson S, Hornby J, Bowden H, Hoffmann K, Weston-Clarke M, Green F, Chaturvedi N, Hughes A, Kuh D, Sampson E, Mizoguchi R, Cheah KL, Romain M, Sinha A, Jenkin R, Brayne C, MacLullich A. The delirium and population health informatics cohort study protocol: ascertaining the determinants and outcomes from delirium in a whole population. BMC Geriatr 2018; 18:45. [PMID: 29426299 PMCID: PMC5807842 DOI: 10.1186/s12877-018-0742-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/05/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Delirium affects 25% of older inpatients and is associated with long-term cognitive impairment and future dementia. However, no population studies have systematically ascertained cognitive function before, cognitive deficits during, and cognitive impairment after delirium. Therefore, there is a need to address the following question: does delirium, and its features (including severity, duration, and presumed aetiologies), predict long-term cognitive impairment, independent of cognitive impairment at baseline? METHODS The Delirium and Population Health Informatics Cohort (DELPHIC) study is an observational population-based cohort study based in the London Borough of Camden. It is recruiting 2000 individuals aged ≥70 years and prospectively following them for two years, including daily ascertainment of all inpatient episodes for delirium. Daily inpatient assessments include the Memorial Delirium Assessment Scale, the Observational Scale for Level of Arousal, and the Hierarchical Assessment of Balance and Mobility. Data on delirium aetiology is also collected. The primary outcome is the change in the modified Telephone Interview for Cognitive Status at two years. DISCUSSION DELPHIC is the first population sample to assess older persons before, during and after hospitalisation. The cumulative incidence of delirium in the general population aged ≥70 will be described. DELPHIC offers the opportunity to quantify the impact of delirium on cognitive and functional outcomes. Overall, DELPHIC will provide a real-time public health observatory whereby information from primary, secondary, intermediate and social care can be integrated to understand how acute illness is linked to health and social care outcomes.
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Affiliation(s)
- Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Joanne Hornby
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Helen Bowden
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | - Fenella Green
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Alun Hughes
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | | | | | | | - Abhi Sinha
- Royal Free London NHS Foundation Trust, London, UK
- Central and North West London NHS Foundation Trust, London, UK
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