Delirium is an important predictor of incident dementia among elderly hip fracture patients

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.

Interdisciplinary intervention decreases cognitive impairment for older Taiwanese with hip fracture: 2-year follow-up

OBJECTIVES

Few studies describe the trajectories of cognitive function for hip-fracture patients following hospital discharge and the treatment effects of interdisciplinary intervention on cognitive outcomes. The purpose of this study was to explore the 2-year postoperative trajectory for cognitive function of older hip-fracture patients and cognitive effects of an interdisciplinary intervention.

METHODS

Of 160 subjects randomly assigned to groups, 29 (35.8%) in the control group (n = 81) and 30 (38.0%) in the intervention group (n = 79) were cognitively impaired at admission. The intervention group received geriatric consultation, continuous rehabilitation, and discharge planning. Subjects' cognitive function was measured using the mini mental state examination Taiwan version at admission, 6, 12, 18, and 24 months after discharge and analyzed using hierarchical generalized linear models.

RESULTS

Patients who received the intervention program had 75% less likelihood of being cognitively impaired 6 months following discharge than those who received routine care (odds ratio = 0.25, p < 0.001). The difference between the control and intervention groups was small at admission, peaked at 18 months, and decreased from 18 to 24 months following discharge.

CONCLUSIONS

Our interdisciplinary intervention improved the long-term postoperative cognitive functioning of older persons with hip fracture in Taiwan.

[Delirium in elderly patients]

BACKGROUND

Delirium, «acute confusional state», is a frequent and serious complication of acute illness, particularly in the elderly. The strain on the patient, the next of kin and the health service is considerable. The purpose of the article is to provide healthcare personnel who deal with delirium with updated information about the condition.

METHOD

The article is based on a literature search in PubMed combined with articles from the author's own archives and own clinical experience.

RESULTS

Delirium is a serious acute medical condition that is often overlooked in the elderly. The prevalence is estimated to be between 11% and 42% for elderly patients on medical wards and close to 50% in patients with hip fractures. The prevalence is probably also high in nursing homes, but this is less well surveyed. Advanced age and dementia are the most important risk factors. Traumas, infections, stroke and metabolic disturbances are the most common triggering factors. The pathophysiology is poorly surveyed and the possibilities for drug treatment are few and are little studied. Delirium is associated with increased risk of dementia, loss of function and mortality. Short-term use of low-dosage antipsychotics is the first-line choice, but is contraindicated for patients with Parkinsonian symptoms.

INTERPRETATION

Detection and treatment of triggering causes must have high priority in case of delirium. Non-drug interventions are most important to prevent and treat the condition.

The neuropsychological sequelae of delirium in elderly patients with hip fracture three months after hospital discharge

BACKGROUND

Delirium is a risk factor for long-term cognitive impairment and dementia. Yet, the nature of these cognitive deficits is unknown as is the extent to which the persistence of delirium symptoms and presence of depression at follow-up may account for the association between delirium and cognitive impairment at follow-up. We hypothesized that inattention, as an important sign of persistent delirium and/or depression, is an important feature of the cognitive profile three months after hospital discharge of patients who experienced in-hospital delirium.

METHODS

This was a prospective cohort study. Fifty-three patients aged 75 years and older were admitted for surgical repair of acute hip fracture. Before the surgery, baseline characteristics, depressive symptomatology, and global cognitive performance were documented. The presence of delirium was assessed daily during hospital admission and three months after hospital discharge when patients underwent neuropsychological assessment.

RESULTS

Of 27 patients with in-hospital delirium, 5 were still delirious after three months. Patients with in-hospital delirium (but free of delirium at follow-up) showed poorer performance than patients without in-hospital delirium on tests of global cognition and episodic memory, even after adjustment for age, gender, and baseline cognitive impairment. In contrast, no differences were found on tests of attention. Patients with in-hospital delirium showed an increase of depressive symptoms after three months. However, delirium remained associated with poor performance on a range of neuropsychological tests among patients with few or no signs of depression at follow-up.

CONCLUSION

Elderly hip fracture patients with in-hospital delirium experience impairments in global cognition and episodic memory three months after hospital discharge. Our results suggest that inattention, as a cardinal sign of persistent delirium or depressive symptomatology at follow-up, cannot fully account for the poor cognitive outcome associated with delirium.

Different functional outcomes in patients with delirium and subsyndromal delirium one month after hospital discharge

BACKGROUND

Subsyndromal delirium has an increasing relevance in the medical literature. There are only three studies in hospitalized elderly patients. Our goal is to demonstrate the importance of this syndrome in a population with more complexity and cognitive impairment than in previous studies.

METHODS

Prospective multicentre study in three tertiary hospitals. The health outcomes recorded in the follow-up at 1 month were the persistence of delirium, hospital readmission, discharge destination, death, Barthel index and the Delirium Rating Scale Revised 98. To assess the impact of delirium in the Barthel index at 30 days, we adjusted univariate and multivariate linear regression models.

RESULTS

85 patients were enrolled; 75.3% of the patients had at least 1 positive item in the Confusion Assessment Method; 45 patients (53%) were diagnosed with delirium and 19 (22.3%) with subsyndromal delirium (SSD). The 30-day risk of death was associated with lower levels of albumin (p = 0.021) and the Cumulative Illness Rating Scale in Geriatrics (CIRS-G; p = 0.003). Adjusting for CIRS-G and the initial Barthel index, the diagnosis of delirium appears to be related to a lower Barthel index at 30 days (p = 0.019), showing a significant linear gradient (p < 0.005).

CONCLUSION

SSD could help get more accurate diagnoses as well as improve patient management.

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.

Cognitive dysfunction in hip fracture patients

Hip fractures represent a widespread morbidity among the geriatric population. In North America, more than 320,000 hip fractures are sustained annually, a number that is expected to increase dramatically as the population continues to age. Disorders of cognition, primarily dementia and delirium, also have a higher-than-average incidence and prevalence among the geriatric population. The co-occurrence of cognitive dysfunction and hip fracture is an important entity for orthopedic surgeons and other clinicians involved in hip fracture care to recognize. This article provides an overview of the currently available evidence regarding cognitive dysfunction, specifically dementia and delirium, in patients with hip fractures.

Novel risk markers and long-term outcomes of delirium: the successful aging after elective surgery (SAGES) study design and methods

OBJECTIVES

Delirium, a costly, life-threatening, and potentially preventable condition, is a common complication for older adults following major surgery. Although the basic epidemiology of delirium after surgery has been defined, the contribution of delirium to long term outcomes remains uncertain, and novel biomarkers from plasma and neuroimaging have yet to be examined. This program project was designed to contribute to our understanding of the complex multifactorial syndrome of delirium.

DESIGN

Long term prospective cohort study.

SETTING

Three academic medical centers (2 hospitals and 1 coordinating center).

PARTICIPANTS

Patients without recognized dementia (targeted cohort= 550 patients) age 70 and older scheduled to undergo elective major surgery are assessed at baseline before surgery, daily during their hospital stay, and for 18 to 36 months after discharge.

MEASUREMENTS

The Successful Aging after Elective Surgery (SAGES) study is an innovative, interdisciplinary study that includes biomarkers, neuroimaging, cognitive reserve markers, and serial neuropsychological testing to examine the contribution of delirium to long term cognitive and functional decline. The primary goal is to examine the contribution of delirium to long term cognitive and functional decline. In addition, novel risk markers for delirium are being examined, including plasma biomarkers (eg, cytokines, proteomics), advanced neuroimaging markers (eg, volumetric, white matter hyperintensity, noncontrast blood flow, and diffusion tensor measures), and cognitive reserve markers (eg, education, occupation, lifetime activities).

CONCLUSION

Results from this study will contribute to a fuller understanding of the etiology and prognosis of delirium. Ultimately, we hope this project will provide the groundwork for future development of prevention and treatment strategies for delirium, designed to minimize the long term negative impact of delirium in older adults.

Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture

BACKGROUND

The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture.

METHODS

The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling.

RESULTS

In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results.

CONCLUSIONS

Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

The effect of a pre- and post-operative orthogeriatric service on cognitive function in patients with hip fracture. The protocol of the Oslo Orthogeriatrics Trial

BACKGROUND

Hip fractures mainly affect older people. It is associated with high morbidity and mortality, and in particular a high frequency of delirium. Incident delirium following hip fracture is associated with an increased risk of dementia in the following months, but it is still not firmly established whether this is an association or a causal relationship. Orthogeriatric units vary with respect to content and timing of the intervention. One main effect of orthogeriatric care may be the prevention of delirium, especially if preoperative and postoperative care are provided. Thus, the aim of Oslo Orthogeriatric Trial, is to assess whether combined preoperative and postoperative orthogeriatric care can reduce the incidence of delirium and improve cognition following hip fracture.

METHODS/DESIGN

Inclusion and randomisation will take place in the Emergency Department, as soon as possible after admission. All patients with proximal femur fractures are eligible, irrespective of age, pre-fracture function and accommodation, except if the fracture is caused by a high energy trauma or the patient is terminally ill. The intervention is pre-and post-operative orthogeriatric care delivered on a dedicated acute geriatric ward. The primary outcome measure is a composite endpoint combining the Clinical Dementia Rating Scale (CDR) and the 10 word memory task at four months after surgery. Secondary outcomes comprise incident delirium, length of stay, cognition, mobility, place of residence, activities of daily living and mortality, measured at 4 and 12 months after surgery. We have included 332 patients in the period 17th September 2009 to 5th January 2012.

DISCUSSION

Our choice of outcome measures and our emphasis of orthogeriatric care in the preoperative as well as the postoperative phase will enable us to provide new knowledge on the impact of orthogeriatric care on cognition.

TRIALS REGISTRATION

ClinicalTrials.gov NCT01009268.

Whether, when and how chronic inflammation increases the risk of developing late-onset Alzheimer's disease

Neuropathological studies have revealed the presence of a broad variety of inflammation-related proteins (complement factors, acute-phase proteins, pro-inflammatory cytokines) in Alzheimer's disease (AD) brains. These constituents of innate immunity are involved in several crucial pathogenic events of the underlying pathological cascade in AD, and recent studies have shown that innate immunity is involved in the etiology of late-onset AD. Genome-wide association studies have demonstrated gene loci that are linked to the complement system. Neuropathological and experimental studies indicate that fibrillar amyloid-β (Aβ) can activate the innate immunity-related CD14 and Toll-like receptor signaling pathways of glial cells for pro-inflammatory cytokine production. The production capacity of this pathway is under genetic control and offspring with a parental history of late-onset AD have a higher production capacity for pro-inflammatory cytokines. The activation of microglia by fibrillar Aβ deposits in the early preclinical stages of AD can make the brain susceptible later on for a second immune challenge leading to enhanced production of pro-inflammatory cytokines. An example of a second immune challenge could be systemic inflammation in patients with preclinical AD. Prospective epidemiological studies show that elevated serum levels of acute phase reactants can be considered as a risk factor for AD. Clinical studies suggest that peripheral inflammation increases the risk of dementia, especially in patients with preexistent cognitive impairment, and accelerates further deterioration in demented patients. The view that peripheral inflammation can increase the risk of dementia in older people provides scope for prevention.

[Acute postoperative confusional syndrome in the elderly patient]

With the progressive aging of the population surgical candidates have more comorbidities resulting in a higher risk to develop postoperative complications. One of the most frequent postoperative complications in the elderly is acute confusional state or delirium, which may have devastating consequences: higher mortality, and risk of medical complications during admission and, a higher risk of functional decline, institutionalization, and cognitive impairment at discharge. For all these reasons and with the aim of optimising surgical procedures, it is essential to identify patients at risk of delirium in order to take appropriate preventive action and provide early treatment. In the present article we review the current evidence on the management of postoperative delirium in the elderly.