Prognostic significance of delirium in frail older people

Diagnoses of psychiatric disorders in hypothetical patients by non-psychiatric physicians in Japan

OBJECTIVE

This study was undertaken to investigate non-psychiatric physicians' diagnoses of hypothetical patients in clinical scenarios with comorbid medical and psychiatric disease in Japan.

METHODS

The non-psychiatric physicians were asked to diagnose eight clinical scenarios describing several typical behavioral health problems in the medical settings.

RESULTS

A total of 155 non-psychiatric physicians participated. Many physicians had problems correctly diagnosing depression and hypoactive delirium with medically ill patients.

CONCLUSIONS

It is time to incorporate new efficient and effective approaches, such as collaborative care system and proactive delirium prevention programs, to improve overall behavioral health diagnosis and treatment, rather than relying on the rapid recognition of behavioral health problems in primary care/general medical settings.

Core symptoms not meeting criteria for delirium are associated with cognitive and functional impairment and mood and behavior problems in older long-term care residents

BACKGROUND

The immediate clinical significance of Confusion Assessment Method (CAM)-defined core symptoms of delirium not meeting criteria for delirium is unclear. This study proposed to determine if such symptoms are associated with cognitive and functional impairment, mood and behavior problems and increased Burden of Care (BOC) in older long-term care (LTC) residents.

METHODS

The study was a secondary analysis of data collected for a prospective cohort study of delirium. Two hundred and fifty-eight LTC residents aged 65 years and older in seven LTC facilities had monthly assessments (for up to six months) of CAM - defined core symptoms of delirium (fluctuation, inattention, disorganized thinking, and altered level of consciousness) and five outcome measures: Mini-Mental State Exam, Barthel Index, Cornell Scale for Depression, Nursing Home Behavioral Problems Scale, and Burden of Care. Associations between core symptoms and the five outcome measures were analyzed using generalized estimating equations.

RESULTS

Core symptoms of delirium not meeting criteria for delirium among residents with and without dementia were associated with cognitive and functional impairment and mood and behavior problems but not increased BOC. The associations appear to be intermediate between those of full delirium and no core symptoms and were greater for residents with than without dementia.

CONCLUSION

CAM-defined core symptoms of delirium not meeting criteria for delirium appear to be associated with cognitive and functional impairment and mood and behavior problems in LTC residents with or without dementia. These findings may have implications for the prevention and management of such impairments and problems in LTC settings.

Can improved intra- and inter-team communication reduce missed delirium?

To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2 % of 47 cases compared to 41.3 and 43.6 % of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.

Documentation of delirium in the VA electronic health record

Background

Delirium is a life-threatening, clinical syndrome common among the elderly and hospitalized patients. Delirium is under-recognized and misdiagnosed, complicating efforts to study the epidemiology and construct appropriate decision support to improve patient care. This study was primarily conducted to realize how providers documented confirmed cases of delirium in electronic health records as a preliminary step for using computerized methods to identify patients with delirium from electronic health records.

Methods

The Mental Health Consult (MHC) team reported cases of delirium to the study team during a 6-month study period (December 1, 2009 - May 31, 2010). A chart extraction tool was developed to abstract documentation of diagnosis, signs and symptoms and known risk factors of delirium. A nurse practitioner, and a clinical pharmacist independently reviewed clinical notes during each patients hospital stay to determine if delirium and or sign and symptoms of delirium were documented.

Results

The MHC team reported 25 cases of delirium. When excluding MHC team notes, delirium was documented for 5 of the 25 patients (one reported case in a physician’s note, four in discharge summaries). Delirium was ICD-9 Coded for 7 of the 25 cases. Signs and symptoms associated with delirium were characterized in 8 physician notes, 11 discharge summaries, and 14 nursing notes, accounting for 16 of the 25 cases with identified delirium.

Conclusions

Documentation of delirium is highly inconsistent even with a confirmed diagnosis. Hence, efforts to use existing data to precisely estimate the prevalence of delirium or to conduct epidemiological studies based on medical records will be challenging.

Delirium in elderly people

Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.

Delirium is a risk factor for institutionalization and functional decline in older hip fracture patients

OBJECTIVES

The risk of institutionalization and functional decline is substantial after a hip fracture. However, previous research has not established the extent to which delirium plays a contributory role.

METHODS

Using a prospective design, we studied 207 hip fracture patients aged 65 and older, home-dwelling before the fracture. Patients were screened daily for delirium using the Confusion Assessment Method. Proxy information on pre-fracture cognitive function and function in activities of daily living (ADL) was obtained using the Informant Questionnaire on Cognitive Decline in the Elderly, 16-item version, and the Barthel ADL Index. After 6months, the patients' functions in ADL measured by the Barthel ADL Index and place of living were registered.

RESULTS

Delirium was present in 80 patients (39%) during the hospital stay. After 6months, 33 (16%) were institutionalized. Delirium and lower Barthel ADL Index score were the main risk factors for institutionalization with an adjusted odds ratio (AOR) of 5.50 (95% CI=1.77-17.11) and 0.54 (95% CI=0.40-0.74) respectively. In patients able to return to their private home, the independent risk factors for functional decline were higher age (B=0.053, 95% CI=0.003-0.102) and delirium (B=0.768, 95% CI=0.039-1.497).

CONCLUSIONS

At 6month follow-up, delirium constitutes an independent risk factor for institutionalization and functional decline in hip fracture patients living at home prior to the fracture.

The prevalence and recognition rate of delirium in hospitalized elderly patients in Turkey

OBJECTIVE

Delirium is frequently observed, but generally under recognized in elderly hospitalized patients. The aims of this study were to determine the prevalence of delirium in elderly patients hospitalized at a university hospital, and to determine the recognition rate by hospital staff during hospitalization.

METHODS

The study included 108 consecutive patients aged ≥ 65 years that were hospitalized in the medical and surgical inpatient departments at Başkent University Hospital, Ankara, Turkey. All the patients were evaluated using the Mini Mental State Examination (MMSE) upon admission and Confusion Assessment Method (CAM) on a daily basis during hospitalization. Written documents and consultation requests from psychiatry and/or neurology departments were reviewed for recognition of delirium by hospital staff.

RESULTS

Among the 108 patients in the study, delirium was noted in 18 (16.7%) during their hospital stay. Consultation from psychiatry or neurology departments was requested for 5 of the 18 patients, only 1 with a delirium diagnosis, indicating that 17 of the cases (94.4%) were not recognized by their primary physicians.

CONCLUSIONS

The delirium non-recognition rate in elderly hospitalized patients was very high. We think that hospital staff must be trained to recognize the symptoms of delirium and identify high-risk patients.

Do stress markers and anesthetic technique predict delirium in the elderly?

BACKGROUND

Postoperative delirium (PD) is a prevalent complication of elderly surgical patients, which predisposes to worsened cognitive recovery and dementia. Risk of PD has been associated with increasing magnitude of the hypothalamic-pituitary-adrenal stress response (serum cortisol, epinephrine and norepinephrine) to surgery. Anesthetics suppress this response; however, some (total intravenous anesthesia, TIVA) more than others (anesthetic gases). Prior comparisons of anesthetics have been equivocal but have not included stress markers. We hypothesized that TIVA would decrease serum stress markers and the incidence of PD.

METHODS

We performed a prospective cohort study of 76 elderly major surgical patients. Patients received TIVA or sevoflurane gas, and blood was drawn for serum markers pre-, intra-, and postoperatively. PD was assessed with the Confusion Assessment Method. We compared stress markers and PD between patients who received TIVA versus sevoflurane, and then modeled PD including stress and anesthetic.

RESULTS

The group that received TIVA during surgery demonstrated lower levels of all stress markers compared to the gas group, but no difference in PD. However, across groups, the postoperative norepinephrine level was much higher in patients who developed PD. Other markers and other times had no effect.

CONCLUSION

The development of PD depends more on postoperative stress than intraoperative stress or anesthetic.

Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study

BACKGROUND

Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery.

METHODS

We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data.

RESULTS

Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices.

CONCLUSIONS

Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly.

STUDY REGISTRATION

ISRCTN65924234.

Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults

BACKGROUND

Current literature does not identify the significance of underlying cognitive impairment and delirium in older adults during and 30 days following acute care hospitalization.

OBJECTIVE

Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia.

DESIGN

A 24-month prospective cohort study.

SETTING

Community hospital.

PATIENTS

A total of 139 older adults (>65 years) with dementia.

METHODS

This prospective study followed patients daily during hospitalization and 1 month posthospital. Main measures included dementia (Modified Blessed Dementia Rating score, Informant Questionnaire on Cognitive Decline in the Elderly), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3, and significance was an α level of 0.05. Logistic regression, analysis of covariance, or linear regression was performed controlling for age, gender, and dementia stage.

RESULTS

The overall incidence of new delirium was 32% (44/139). Those with delirium had a 25% short-term mortality rate, increased length of stay, and poorer function at discharge. At 1 month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium, and for every 1 unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium.

CONCLUSIONS

Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital.

The triple challenge of recruiting older adults with dementia and high medical acuity in skilled nursing facilities

PURPOSE

To describe strategies, culled from experience, for responding to several recruitment challenges in an ongoing randomized clinical trial of delirium in persons with dementia.

ORGANIZING CONSTRUCT

Delirium in people with dementia is common across all cultures. Little research supports the use of specific interventions for delirium. Recruitment of an adequate sample is critical to the validity of findings from intervention studies that form the foundation for evidence-based practice.

METHODS

The trial referenced in this article tests the efficacy of cognitive stimulation for resolving delirium in people with dementia. Participants are recruited at the time of admission to one of eight community-based skilled nursing facilities (SNFs). Eligible participants are 65 years of age or older and community dwelling, and have a diagnosis of dementia and delirium. Recruitment challenges and strategies were identified during weekly team meetings over a 2-year period.

FINDINGS

Recruitment challenges include factors in the external and internal environment and the participants and their families. Strategies that address these challenges include early site evaluation and strong communication approaches with staff, participants, and families.

CONCLUSIONS

The recruitment of an adequate sample of acutely ill older adults with dementia in SNFs can pose a challenge to investigators and threaten the validity of findings. Recruitment strategies that help improve the validity of future studies are described.

CLINICAL RELEVANCE

Worldwide, over 100 million people will have dementia by 2050, placing them at increased risk for delirium. Recruitment strategies that improve the quality of nursing research and, by extension, the care and prevention of delirium in older adults with dementia during rehabilitation in SNFs are greatly needed.

Convergent validity of the Cognitive Performance Scale of the interRAI acute care and the mini-mental state examination

OBJECTIVE

The Cognitive Performance Scale (CPS) is generated from five items of the interRAI/ Minimum Data Set instruments, a comprehensive geriatric assessment method. CPS was initially designed to assess cognition in residential care, where it has shown good psychometric performance. We evaluated the performance of the interRAI Acute Care in identifying cognitive impairment among patients hospitalized on acute geriatric wards.

METHODS

An observational study was conducted on two geriatric wards. Trained raters independently completed the interRAI Acute Care and the Mini-Mental State Examination (MMSE) in 97 inpatients (85 ± 5 years; 67% female). The level of agreement between CPS and MMSE was explored using comparisons of means, agreement coefficients, and diagnostic accuracy.

RESULTS

Cognitive impairment was present in 61% of the participants. Average MMSE scores were significantly different between groups with low CPS scores compared with those with high CPS scores (p <0.05). CPS explained only 48.8% of the variability in MMSE. Agreement in defining cognitively impaired subjects was moderate (percentage observed agreement, 68%; κ = 0.41). With MMSE score less than 24 as a gold standard, diagnostic accuracy of CPS was moderate (area under curve = 0.73), with low sensitivity, but excellent specificity. When lowering the MMSE cutoff to less than 18 and focusing on patients with severe cognitive impairment, CPS agreement coefficients and sensitivity increased but specificity decreased. Using education-adjusted MMSE cutoffs did not substantially affect the results.

CONCLUSION

CPS can be used for coarse triage between intact and severe cognitive impairment. Although promising results have been obtained in residential and community settings, our results suggest that CPS fails to differentiate across different levels of cognitive impairment in hospitalized geriatric patients.

Symptoms of delirium predict incident delirium in older long-term care residents

BACKGROUND

Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium.

METHODS

The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium.

RESULTS

Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2).

CONCLUSION

The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.

Thirty-day prevalence of delirium among very old people: a population-based study of very old people living at home and in institutions

Delirium has mainly been studied in various patient samples and in people living in institutions. The present study investigates the 30-day prevalence of delirium in a population-based sample of very old people in northern Sweden and Finland. Seven hundred and eight persons aged 85 years and older from the GErontological Regional DAtabase (GERDA) were assessed. Information was also collected from relatives, carers and medical records. Assessments performed were among others the Organic Brain Syndrome (OBS) scale, the Mini Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15). Delirium, depression and dementia diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The prevalence of delirium was 17% among 85 year-olds, 21% among 90 year-olds and 39% among participants aged 95 years and older (p<0.001). Delirium prevalence among individuals without dementia was lower than among those with dementia (5% vs. 52%, p<0.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression (Odds Ratio (OR)=2.0, 95% Confidence Interval (CI)=1.2-3.3), heart failure (OR=2.1, 95% CI=1.2-3.7), institutional living (OR 4.4, 95% CI=2.4-8.2) and prescribed antipsychotics (OR=3.0, 95% CI=1.5-6.0). Delirium is highly prevalent among very old people with dementia. Depression, heart failure, institutional living and prescribed antipsychotic medication seem to be associated with delirium.

Systematic review: Health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality

OBJECTIVES

To identify the domains of health-related characteristics of older hospitalized adults and nursing home residents most strongly associated with short-term mortality.

DESIGN

Systematic review.

SETTING

Studies published in English in MEDLINE, Scopus, or Web of Science before August 1, 2010.

PARTICIPANTS

Prospective studies consisting of persons aged 65 and older that evaluated the association between at least one health-related participant characteristic and mortality within a year in multivariable analysis.

MEASUREMENTS

All health-related characteristics associated with mortality in multivariable analysis were extracted and categorized into domains. The frequency, with all studies combined, with which particular domains were associated with mortality in multivariable analysis was determined.

RESULTS

Thirty-three studies (28 in hospitalized individuals, five in nursing home residents) reported a large number of characteristics associated with mortality that could be categorized in seven domains: cognitive function, disease diagnosis, laboratory values, nutrition, physical function, pressure ulcers, and shortness of breath. Measures of physical function and nutrition were the domains most frequently associated with mortality up to 1 year from the time of evaluation for hospitalized individuals and nursing home residents; measures of physical function, cognitive function, and nutrition were the domains most frequently associated with in-hospital mortality for hospitalized individuals.

CONCLUSION

Of a large number of health-related characteristics of older persons shown to be associated with short-term mortality, measures of nutrition, physical function, and cognitive function were the domains of health most frequently associated with mortality. These domains provide easily measurable factors that may serve as helpful markers for individuals at high mortality risk.

The course of delirium in older long-term care residents

OBJECTIVE

The purpose of this study was to determine the course of delirium in older long-term care (LTC) residents.

METHODS

A prospective cohort study of 279 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. The Mini Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. Information on medical problems and medication was abstracted from resident charts. Data were analyzed using descriptive statistics, Cox proportional hazard regression, and logistic regression.

RESULTS

Of the 279 residents, 41 (14.7%) had 61 CAM-defined incident episodes of delirium: 28 (10%) had one episode and 13 (4.7%) had two or more episodes. Episode duration was 7-63 days, mean, 11.3 (SD, 10.1) days. The mean episode DI score was 11.5 (SD, 3.5). Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2% 77.1%, and 80.3%, respectively. Most episodes were preceded or followed by one or more CAM core symptoms of delirium, sometimes lasting many weeks.

CONCLUSIONS

Confusion Assessment Method-defined incident episodes of delirium in older LTC residents appear to last longer than episodes in acute care hospital patients, but rates of recovery at 4 and 24 weeks are similar. Notably, most episodes were preceded or followed by one or more CAM core symptoms of delirium. These findings have implications for clinical practice and research in LTC settings.

Epidemiology and risk factors for delirium across hospital settings

Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.

Cost-effectiveness of multi-component interventions to prevent delirium in older people admitted to medical wards

INTRODUCTION

there is evidence to suggest that delirium incidence can be reduced in older people admitted to medical services using multi-component interventions that target delirium risk factors. The cost-effectiveness of this approach is uncertain. We therefore developed a novel cost-effectiveness model for delirium prevention.

METHOD

we compared multi-component delirium prevention intervention with usual care using a model based on a decision tree analysis. The model was used to estimate the incremental net monetary benefit (INMB). The robustness of the cost-effectiveness result was explored using deterministic and probabilistic sensitivity analyses.

RESULT

the multi-component prevention intervention was cost-effective when compared with usual care. It was associated with an INMB of £2,200 using a cost-effectiveness threshold of £20,000 per quality-adjusted life year (QALY). It remained cost-effective in the majority of the deterministic sensitivity analyses and was cost-effective in 96.8% of the simulations carried out in the probabilistic sensitivity analysis.

DISCUSSION

our analysis has shown convincingly that multi-component prevention interventions for delirium should be considered as a cost-effective health-care strategy for medically ill people admitted to hospital. It is an attractive intervention for health-care planners as they strive to reconfigure their services to better meet the needs of an ageing population.

Risk of death associated with use of PPIs in three cohorts of institutionalized older people in Finland

OBJECTIVES

To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting.

DESIGN

Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality.

SETTING AND PARTICIPANTS

A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort).

MEASUREMENTS

Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality.

RESULTS

In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04-1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23-2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs.

CONCLUSION

PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

The overlap of delirium with neuropsychiatric symptoms among patients with dementia

OBJECTIVES

To study the frequency of overlapping of delirium with neuropsychiatric symptoms (NPS) among patients with dementia, and to investigate the prognostic value of delirium, multiple NPS without delirium, or neither during a 2-year follow-up.

METHODS

We assessed 425 consecutive patients in acute geriatric wards and in seven nursing homes in Helsinki. Those 255 suffering from dementia were examined for NPS of dementia described in the Neuropsychiatric Inventory (delusions, hallucinations, agitation/aggression, depression/low mood, anxiety, euphoria/elation, apathy, disinhibition, irritability/mood changes, and aberrant motor behavior) and for delirium criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Patients were categorized into three groups: delirium with or without multiple NPS (delirium group), multiple NPS without delirium (multiple NPS group), or having neither delirium nor multiple NPS (zero or only one NPS group).

RESULTS

A total of 66 patients suffered from delirium according to the DSM-IV, 127 had multiple NPS without delirium, and 62 had neither multiple NPS nor delirium. In the delirium group 61 individuals (92.4%) were deceased or residing in permanent institutional care at the end of the 2-year follow up period, compared to 100 individuals (78.7%) in the multiple NPS group and 48 (77.4%) in the zero or one NPS group (Pearson χ² = 6.64, df 2, p = 0.036). In logistic regression analysis adjusted for age, sex, and comorbidities, delirium was an independent predictor of this composite outcome (OR: 4.3, 95% CI: 1.4-13.6).

CONCLUSIONS

Patient groups with symptoms of delirium and multiple NPS are highly overlapping. The presence of delirium indicates poor prognosis.

Delirium superimposed on dementia: accuracy of nurse documentation

Delirium is an acute, fluctuating confusional state that results in poor outcomes for older adults. Dementia causes a more convoluted course when coexisting with delirium. This study examined 128 days of documentation to describe what nurses document when caring for patients with dementia who experience delirium. Nurses did not document that they recognized delirium. Common descriptive terms included words and phrases indicating fluctuating mental status, lethargy, confusion, negative behavior, delusions, and restlessness. Delirium is a medical emergency. Nurses are in need of education coupled with clinical and decisional support to facilitate recognition and treatment of underlying causes of delirium in individuals with dementia.

How nurses understand and care for older people with delirium in the acute hospital: a Critical Discourse Analysis

Delirium is a common presentation of deteriorating health in older people. It is potentially deleterious in terms of patient experience and clinical outcomes. Much of what is known about delirium is through positivist research, which forms the evidence base for disease-based classification systems and clinical guidelines. There is little systematic study of nurses' day-to-day practice of nursing patients with delirium. The aim was to uncover the kinds of knowledge that informs nurses' care and to explicate the basis of that knowledge. Critical Discourse Analysis is underpinned by the premise that powerful interests within society mediate how social practices are constructed. Links were made between the grammatical and lexical features of nurses' language about care in interviews and naturalistic settings, and the healthcare context. Care focused on the continuous surveillance of patients with delirium by nurses themselves or vicariously through other patients, and containment. Nurses influenced by major discourses of risk reduction and safety, constructed patients with delirium as risk objects. The philosophy of person-centred and dignified care advocated in nursing literature and government policy is an emerging discourse, though little evident in the data. The current dominant discourses on safety must give space to discourses of dignity and compassion.

Association of anticholinergic drugs with hospitalization and mortality among older cardiovascular patients: A prospective study

BACKGROUND

Many potentially inappropriate drugs prescribed to older people have anticholinergic properties as adverse effects and are therefore potentially harmful. These effects typically include constipation, dry mouth, blurred vision, dizziness and slowing of urination. It has been shown that drugs with anticholinergic properties (DAPs) are associated with cognitive decline and dementia, may contribute to events such as falls, delirium and impulsive behaviour, are associated with self-reported adverse effects and physical impairment, and may even be associated with mortality. However, studies of the prognostic implications of DAPs remain scarce.

OBJECTIVE

To evaluate the impact of DAPs on hospitalization and mortality in older patients with stable cardiovascular disease (CVD).

METHODS

This was a prospective study with a mean follow-up of 3.3 years involving two study groups: users (n = 295) and non-users (n = 105) of DAPs. The participants were 400 community-dwelling older people (aged 75-90 years) with stable CVD participating in a secondary prevention study of CVD (DEBATE) in Helsinki, Finland. The use of DAPs was estimated using definitions from the previous scientific literature. The Charlson Comorbidity Index (CCI) was used to estimate the burden of co-morbidity and the Mini-Mental State Examination test was used to assess cognitive function. The risks in the two study groups for hospital visits, number of days spent in hospital care and mortality were measured from 2000 to the end of 2003.

RESULTS

The unadjusted follow-up mortality was 20.7% and 9.5% among the users and non-users of DAPs, respectively (p = 0.010). However, the use of DAPs was not a significant predictor of mortality in multivariate analysis after adjustment for age, sex and CCI score (hazard ratio 1.57; 95% CI 0.78, 3.15). The mean ± SD number of hospital days per person-year was higher in the DAP user group (14.9 ± 32.5) than in the non-user group (5.2 ± 12.3) [p < 0.001]. In a bootstrap-type analysis of covariance adjusted for age, sex and CCI score, the use of DAPs predicted the number of days spent in hospital (p = 0.011).

CONCLUSIONS

The use of DAPs in older patients with stable CVD was associated with an increased number of hospital days but not with mortality.

Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial

BACKGROUND

Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD).

METHODS/DESIGN

This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD.

DISCUSSION

Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01267682

Emergency orthogeriatrics: concepts and therapeutic alternatives

Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery.

Delirium in the older emergency department patient: a quiet epidemic

Delirium is defined as an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. This form of organ dysfunction commonly occurs in older patients in the emergency department (ED) and is associated with a multitude of adverse patient outcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus on searching for the underlying cause. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.

Systemic inflammation induces acute working memory deficits in the primed brain: relevance for delirium

Delirium is an acute, severe neuropsychiatric syndrome, characterized by cognitive deficits, that is highly prevalent in aging and dementia and is frequently precipitated by peripheral infections. Delirium is poorly understood and the lack of biologically relevant animal models has limited basic research. Here we hypothesized that synaptic loss and accompanying microglial priming during chronic neurodegeneration in the ME7 mouse model of prion disease predisposes these animals to acute dysfunction in the region of prior pathology upon systemic inflammatory activation. Lipopolysaccharide (LPS; 100 μg/kg) induced acute and transient working memory deficits in ME7 animals on a novel T-maze task, but did not do so in normal animals. LPS-treated ME7 animals showed heightened and prolonged transcription of inflammatory mediators in the central nervous system (CNS), compared with LPS-treated normal animals, despite having equivalent levels of circulating cytokines. The demonstration that prior synaptic loss and microglial priming are predisposing factors for acute cognitive impairments induced by systemic inflammation suggests an important animal model with which to study aspects of delirium during dementia.

Factors associated with prolonged delirium: a systematic review

BACKGROUND

Delirium frequently accompanies acute illness. With treatment of the illness, some individuals recover from delirium while for others the symptoms persist. It is not understood why some individuals improve but others do not. The purpose of this paper is to review systematically what is known about the factors associated with the persistence of delirium.

METHODS

A medical literature search was conducted using several bibliographic databases, supplemented by manual searches of the references. English or French studies were included if they compared two groups of delirious individuals in delirium duration or persistence up to six months after the onset of delirium, diagnosed prospectively with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (or a scale derived and validated against the DSM). Information was collected on the association between possible non-therapeutic prognostic variables and delirium persistence.

RESULTS

Twenty-one observational studies were included, in various settings (e.g. mixed medical-surgical, medical or geriatric, surgical, psychiatric, cancer or palliative care units). Variables assessed included patient characteristics (e.g. age, dementia, medical comorbidity, functional status), delirium characteristics (e.g. presence of hypoactive symptoms, delirium severity) and illness characteristics (e.g. severity of illness, and underlying acute illness). Overall, studies suggested that delirium is often persistent at discharge or beyond. Persistence was associated with dementia, increasing numbers of medical conditions, increasing severity of delirium, hypoactive symptoms and hypoxic illnesses.

CONCLUSIONS

Preliminary findings suggest that some factors may identify those at risk for persistent delirium; however, more research is needed.

Delirium in care homes

Delirium is a distressing but preventable condition associated with increased morbidity and mortality, and significant financial costs. Most research on delirium has focused on high-risk patients in hospitals. Another group also at high risk are residents in care homes for older people. This report reviews the literature on the occurrence, aetiology, outcomes, prevention and treatment of delirium in long-term care. Delirium appears to be common in this setting, with a median point prevalence estimate of 14.2% in studies comparable to the UK. However, there is a paucity of high-quality studies, likely to reflect the difficulty in conducting research in this population and the particular challenges of investigating delirium. Addressing delirium successfully in care homes presents an opportunity to improve care standards and to reduce inequalities in health and social care. Well-designed prospective cohort studies and robust evaluations of interventions to prevent and treat delirium are needed.

Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study

BACKGROUND

Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes.

METHODS

The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design).

RESULTS

332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001).

CONCLUSIONS

The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study

BACKGROUND

Delirium is an important problem especially in older medical inpatients.

OBJECTIVE

The authors asked whether delirium and its duration are associated with higher mortality in a 3-month follow-up period.

METHOD

In this prospective cohort study, inpatients age 65 and older were assessed every 48 hours with the Confusion Assessment Method.

RESULTS

Of 542 patients enrolled, 192 (35.4%) developed delirium. After 3 months, mortality in the delirium cohort was 25.9%, and in the nondelirium cohort was 5.8%. Delirium was independently associated with mortality, and increased by 11% for every 48 hours of delirium.

CONCLUSION

Delirium and increased delirium durations are significantly associated with higher mortality.

Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture

OBJECTIVES

To evaluate risk factors for preoperative and postoperative delirium.

DESIGN

Prospective cohort study.

SETTING

Departments of orthopedic surgery in two Norwegian hospitals.

PARTICIPANTS

Three hundred sixty-four patients with and without cognitive impairment, aged 65 and older.

MEASUREMENTS

Patients were screened daily for delirium using the Confusion Assessment Method. Established risk factors and risk factors regarded as clinically important according to expert opinion were explored in univariate analyses. Variables associated with the outcomes (P<.05) were entered into multivariate logistic regression models.

RESULTS

Delirium was present in 50 of 237 (21.1%) assessable patients preoperatively, whereas 68 of 187 (36.4%) patients developed delirium postoperatively (incident delirium). Multivariate logistic regression identified four risk factors for preoperative delirium: cognitive impairment (adjusted odds ratio (AOR)=4.7, 95% confidence interval (CI)=1.9-11.3), indoor injury (AOR=3.6, 95% CI=1.1-12.2), fever (AOR=3.4, 95% CI=1.5-7.7), and preoperative waiting time (AOR=1.05, 95% CI=1.0-1.1 per hour). Cognitive impairment (AOR=2.9, 95% CI=1.4-6.2), indoor injury (AOR=2.9, 95% CI=1.1-6.3), and body mass index (BMI) less than 20.0 (AOR=2.9, 95% CI=1.3-6.7) were independent and statistically significant risk factors for postoperative delirium.

CONCLUSION

Time from admission to operation is a risk factor for preoperative delirium, whereas low BMI is an important risk factor for postoperative delirium in hip fracture patients. Cognitive impairment and indoor injury are independent risk factors for preoperative and postoperative delirium.

Systemic inflammation induces acute behavioral and cognitive changes and accelerates neurodegenerative disease

BACKGROUND

Chronic neurodegeneration results in microglial activation, but the contribution of inflammation to the progress of neurodegeneration remains unclear. We have shown that microglia express low levels of proinflammatory cytokines during chronic neurodegeneration but are "primed" to produce a more proinflammatory profile after systemic challenge with bacterial endotoxin (lipopolysaccharide [LPS]).

METHODS

Here, we investigated whether intraperitoneal (IP) challenge with LPS, to mimic systemic infection, in the early stages of prion disease can 1) produce exaggerated acute behavioral (n = 9) and central nervous system (CNS) inflammatory (n = 4) responses in diseased animals compared with control animals, and 2) whether a single LPS challenge can accelerate disease progression (n = 34-35).

RESULTS

Injection of LPS (100 microg/kg), at 12 weeks postinoculation (PI), resulted in heightened CNS interleukin-1 beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), and interferon-beta (IFN-beta) transcription and microglial IL-1beta translation in prion-diseased animals relative to control animals. This inflammation caused exaggerated impairments in burrowing and locomotor activity, and induced hypothermia and cognitive changes in prion-diseased animals that were absent in LPS-treated control animals. At 15 weeks PI, LPS (500 microg/kg) acutely impaired motor coordination and muscle strength in prion-diseased but not in control animals. After recovery, these animals also showed earlier onset of disease-associated impairments on these parameters.

CONCLUSIONS

These data demonstrate that transient systemic inflammation superimposed on neurodegenerative disease acutely exacerbates cognitive and motor symptoms of disease and accelerates disease progression. These deleterious effects of systemic inflammation have implications for the treatment of chronic neurodegeneration and associated delirium.

High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study

BACKGROUND/AIMS

The aim of the study was to investigate the association of postoperative delirium with the outcomes of cognitive impairment, functional disability and death.

METHODS

Hip surgery patients aged 60 years or over (n = 200) underwent preoperative and daily postoperative assessment of their cognitive status during hospital stay. Outcome variables were determined at an average of 8 and 38 months after discharge from hospital.

RESULTS

Fourty-one patients developed postoperative delirium. Delirium was a strong independent predictor of cognitive impairment and the occurrence of severe dependency in activities of daily living. The associations were more marked for the long- than for the short-term outcome. Thirty-eight months after discharge from hospital, 53.8% of the surviving patients with postoperative delirium suffered from cognitive impairment, as compared to only 4.4% of the nondelirious participants. Logistic regression analysis adjusted for age, sex, medical comorbidity and preoperative cognitive performance revealed highly significant associations between delirium and cognitive impairment (OR = 41.2; 95% CI = 4.3-396.2), subjective memory decline (OR = 6.2; 95% CI = 1.5-25.8) and incident need for long-term care (OR = 5.6; 95% CI = 1.6-19.7).

CONCLUSION

The present study confirms a poor prognosis after delirium in elderly patients. The findings suggest that delirium does not simply persist for a certain time but also predicts a future cognitive decline with an increased risk of dementia.

Educating staff working in long-term care about delirium: the Trojan horse for improving quality of care?

OBJECTIVE

This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice.

METHODS

The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes. Our intervention incorporated the following features: targeting risk factors for delirium, a 'delirium practitioner' functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback. The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation.

RESULTS

We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems.

CONCLUSION

We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.

Differing management of people with advanced cancer and delirium by four sub-specialties

INTRODUCTION

Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer.

METHODS

A questionnaire was designed to identify investigations and treatment used, in relation to two cases.

RESULTS

Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists.

INVESTIGATIONS

85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium.

TREATMENT

Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium.

DISCUSSION

The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

Multicomponent geriatric intervention for elderly inpatients with delirium: effects on costs and health-related quality of life

BACKGROUND

The detrimental effects of delirium on functioning and mortality are well known, but health-related quality of life (HRQoL) and costs of care have rarely been investigated among patients with delirium. We studied the effects of multicomponent geriatric treatment on costs of care and HRQoL in delirious inpatients.

METHODS

A randomized, controlled trial of 174 inpatients with delirium was performed in an acute geriatric hospital. The intervention was individually tailored geriatric treatment. The HRQoL was measured by the 15D instrument and subjective health by a four-level ordinal scale. Health care costs including intervention costs were calculated for 1 year after the delirium episode.

RESULTS

Mean age of the patients was 83 years; 31% had prior dementia. After the index hospitalization for delirium, a greater proportion in the intervention group than in the control group stated that they felt healthy (71% vs 49%, p =.050). HRQoL deteriorated in both groups as a consequence of delirium. Deterioration was, however, slower in the intervention group (-0.026, 95% confidence interval [CI], -0.051 to -0.001) than in the control group (-0.065, 95% CI, -0.09 to -0.040; p =.034). Counting all costs of hospital care, long-term care, skilled home nursing visits, and costs related to intervention, the intervention group used, on average, 19,737 euro during the follow-up year, whereas the respective figure for the control group was 19,557 euro. The difference between the groups was nonsignificant (180 euro [95% CI, -5,006 to 5,064 euro]).

CONCLUSIONS

Comprehensive geriatric intervention improved HRQoL without increasing overall costs of care.

Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation

OBJECTIVE

This study evaluates patient characteristics that might predict a missed diagnosis of delirium prior to being seen by a psychiatric consultant.

METHOD

Study participants were assessed using quantitative standardized scales of cognitive function, delirium and physical impairment.

RESULTS

Referring service personnel missed the diagnosis of delirium in 46% of psychiatric consultations. Two factors were associated with their failure to identify delirium accurately: use of a past psychiatric diagnosis to explain delirium symptoms and the presence of pain. Symptoms of delirium and quantitative scale scores did not distinguish between patients with whom diagnosis had been missed and those with accurate diagnoses.

CONCLUSION

The consulting physicians of patients with delirium often incorrectly turn to past psychiatric diagnoses and/or are distracted by the presence of pain and, thus, fail to accurately diagnose delirium.