How Do Delirium and Dementia Increase Length of Stay of Elderly General Medical Inpatients?

Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial

BACKGROUND

Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.

OBJECTIVE

Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.

DESIGN

A randomized controlled clinical trial.

SETTING

A public hospital in Indianapolis.

POPULATION

A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.

INTERVENTION

A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.

MEASUREMENTS

Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.

RESULTS

Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).

CONCLUSION

A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Delirium in elderly people: a study of a psychiatric liaison service in north India

BACKGROUND

Very few studies from India have studied the phenomenology of delirium. The aim of the present study was to study the phenomenology as measured using the Delirium Rating Scale-Revised-98 (DRS-R98), the associated etiologies and the outcome of delirium among the elderly participants seen by the consultation-liaison psychiatric service in India. In addition, an attempt was made to study the factor structure of symptoms using principal components analysis.

METHODS

The case notes of 109 elderly patients referred to psychiatry liaison services were reviewed.

RESULTS

The mean age of the sample was 73.35 years (SD: 7.44; range 65-95 years) and two-thirds of the sample had hospital emergent delirium. The mean DRS-R98 severity score was 18.77 and the DRS-R98 total score was 24.81. In 15 patients the DRS-R98 scores were in the subsyndromal range. Among the various symptoms present, most patients had sleep-wake cycle disturbance, disturbance in orientation, attention and short-term memory impairments, fluctuation of symptoms, temporal onset of symptoms and a physical disorder. Principal components analysis identified three factors which explained 43.5% of variance of symptomatology and it yielded a three-factor structure. Endocrine/metabolic disturbances were the commonest associated etiological category with delirium. The mean hospital stay after being referred to psychiatry referral services was 8.89 days, after which delirium improved in 58.7% of cases. The mortality rate during the inpatient stay was 16.5%.

CONCLUSIONS

Results suggest that the symptoms of delirium as assessed by DRS-R98 separate out into a three-factor structure. Delirium is commonly associated with metabolic endocrine disturbances and about one-sixth of the patients die during the short inpatient stay.

The Hospital Dementia Services Project: age differences in hospital stays for older people with and without dementia

BACKGROUND

People with dementia may have adverse outcomes following periods of acute hospitalization. This study aimed to explore the effects of age upon hospitalization outcomes for patients with dementia in comparison to patients without dementia.

METHODS

Data extracted from the New South Wales Admitted Patient Care Database for people aged 50 years and over for the period July 2006 to June 2007 were linked to create person-based records relating to both single and multiple periods of hospitalization. This yielded nearly 409,000 multi-day periods of hospitalization relating to almost 253,000 persons. Using ICD-10-AM codes for dementia and other principal diagnoses, the relationship between age and hospitalization characteristics were examined for people with and without dementia.

RESULTS

Dementia was age-related, with 25% of patients aged 85 years and over having dementia compared with 0.9% of patients aged 50-54 years. People with dementia were more likely to be admitted for fractured femurs, lower respiratory tract infections, urinary tract infections and head injuries than people without dementia. Mean length of stay for admissions for people with dementia was 16.4 days and 8.9 days for those without dementia. People with dementia were more likely than those without to be re-admitted within three months for another multi-day stay. Mortality rates and transfers to nursing home care were higher for people with dementia than for people without dementia. These outcomes were more pronounced in younger people with dementia.

CONCLUSION

Outcomes of hospitalization vary substantially for patients with dementia compared with patients without dementia and these differences are frequently most marked among patients aged under 65 years.

Symptoms of delirium: an exploratory factor analytic study among referred patients

OBJECTIVE

Factor analytic studies of delirium symptoms among patients referred through consultation-liaison psychiatric services are rare. We examined the factor structure of delirium symptoms in referred patients and determined whether combining items from several delirium rating scales influenced the factor structure of delirium symptoms.

METHOD

Eighty-six patients with delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) referred though the consultation-liaison services were assessed with structured rating scales. Nineteen symptom items extracted from the Delirium Rating Scale-Revised-98 (DRS-R-98), the Memorial Delirium Assessment Scale and the Confusional State Evaluation Scale were subjected to an exploratory (principal component) factor analysis. A second such analysis was conducted on 15 items of the DRS-R-98 for comparison.

RESULTS

Compared with prior studies, patients were younger and the majority had hyperactive delirium. Principal components analysis identified two factors: (1) a "cognitive" factor comprising of disturbances in language, thought processes, orientation, attention, short- and long-term memory, visuospatial ability, consciousness (awareness) and perseveration accounted for 28.9% of the variance and (2) a "behavioral" factor consisting of sleep-wake cycle disturbances, delusions, perceptual disturbances, motor agitation, affect-lability, distractibility, irritability and temporal onset accounted for 18.9% of the variance. An identical factor structure was obtained with the DRS-R-98 items.

CONCLUSIONS

Similar to previous factor analytic studies, the present study supported the existence of two principal dimensions of delirium, cognitive and behavioral. Additionally, it extended the results of earlier investigations to a wider group of patients with delirium, suggesting that these dimensions might provide important clues to the neurobiology of delirium.

Improving delirium care in the intensive care unit: the design of a pragmatic study

BACKGROUND

Delirium prevalence in the intensive care unit (ICU) is high. Numerous psychotropic agents are used to manage delirium in the ICU with limited data regarding their efficacy or harms.

METHODS/DESIGN

This is a randomized controlled trial of 428 patients aged 18 and older suffering from delirium and admitted to the ICU of Wishard Memorial Hospital in Indianapolis. Subjects assigned to the intervention group will receive a multicomponent pharmacological management protocol for delirium (PMD) and those assigned to the control group will receive no change in their usual ICU care. The primary outcomes of the trial are (1) delirium severity as measured by the Delirium Rating Scale revised-98 (DRS-R-98) and (2) delirium duration as determined by the Confusion Assessment Method for the ICU (CAM-ICU). The PMD protocol targets the three neurotransmitter systems thought to be compromised in delirious patients: dopamine, acetylcholine, and gamma-aminobutyric acid. The PMD protocol will target the reduction of anticholinergic medications and benzodiazepines, and introduce a low-dose of haloperidol at 0.5-1 mg for 7 days. The protocol will be delivered by a combination of computer (artificial intelligence) and pharmacist (human intelligence) decision support system to increase adherence to the PMD protocol.

DISCUSSION

The proposed study will evaluate the content and the delivery process of a multicomponent pharmacological management program for delirium in the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00842608.

A factor analytic study of the Delirium Rating Scale-Revised-98 in untreated patients with delirium

OBJECTIVE

Existing factor analytic studies of symptoms of delirium are mostly based on small numbers of patients from specialized settings. This study thus sought to examine the factor structure of symptoms of delirium in a reasonably large sample of untreated patients referred to liaison psychiatric services of a multi-specialty hospital in north India, employing the more commonly used Delirium Rating Scale-Revised Version-1998 (DRS-R-98).

METHOD

Patients (n=151) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for delirium were assessed with the DRS-R-98 prior to starting treatment with psychotropics. A principal component analysis was carried out to determine the factor structure of the symptoms based on these ratings.

RESULTS

Unlike previous efforts, patients of this study were relatively younger (mean age 47 years), with mainly hyperactive delirium, and did not have comorbid dementia. Three factors which together explained 47.32 % of variance of symptoms were identified. A "global cognitive" factor including disturbances of orientation, attention, short- and long-term memory, and visuospatial ability accounted for 18.33% of the variance. A "sleep and motor symptoms" factor consisting of sleep-wake cycle disturbances; delusions; and perceptual disturbances including hallucinations, motor-agitation, inverse of motor-retardation, and affect-lability accounted for 16% of the variance. A "thought and language" factor comprising abnormalities in language and thought process, temporal onset, and fluctuation of symptoms explained 13% of the variance.

CONCLUSIONS

Thus, the current factor analysis not only confirmed the presence of three principal symptom dimensions of delirium (found in several previous studies) but also extended these findings to a broader group of patients usually referred to liaison psychiatric services.

Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8

BACKGROUND

Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use.

OBJECTIVES

The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools.

METHODS

In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments.

RESULTS

The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE.

CONCLUSIONS

The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.

Impact and recognition of cognitive impairment among hospitalized elders

BACKGROUND

Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized.

OBJECTIVE

To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission.

DESIGN

Observational cohort study.

SETTING

Urban public hospital in Indianapolis.

PATIENTS

997 patients age 65 and older admitted to medical services between July 2006 and March 2008.

MEASUREMENTS

Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ).

RESULTS

424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09).

CONCLUSION

Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes.

The virtual gateway: opening doors in delirium teaching and learning

Delirium is a common, serious and potentially preventable problem. It is argued here that knowledge and skills for effective assessment and treatment of delirium cannot be considered 'specialist'. Rather, delirium is a problem that requires a healthcare team approach to assessing patients, identifying risks or symptoms and reducing precipitating factors. Research from the preceding decade suggests that the clinical reality is falling short of this ideal with the result that many cases of delirium go undetected and many precipitating factors are not reduced where this is indeed possible. This presents a challenge for the education of nursing and medical students and for the development of qualified staff in practice. The current paper outlines an educational approach, e-learning, which increases access for learners, integrates knowledge and skill development and promotes active, problem-based learning.

Motor subtypes of delirium: past, present and future

Clinical subtyping of delirium according to motor-activity profile has considerable potential to account for the heterogeneity of this complex and multifactorial syndrome. Previous work has identified a range of clinically important differences between motor subtypes in relation to detection, causation, treatment experience and prognosis, but studies have been hampered by inconsistent methodology, especially in relation to definition of subtypes. This article considers research to date, including a number of recent studies that have attempted to address these issues and identify a means of achieving greater consistency in approaches to subtyping. Possibilities for future work are discussed and a research plan for the field is outlined.

Delirium phenomenology: what can we learn from the symptoms of delirium?

OBJECTIVES

This review focuses on phenomenological studies of delirium, including subsyndromal and prodromal concepts, and their relevance to other elements of clinical profile.

METHODS

A Medline search using the keywords delirium, phenomenology, and symptoms for new data articles published in English between 1998 and 2008 was utilized. The search was supplemented by additional material not identified by Medline but known to the authors.

RESULTS

Understanding of prodromal and subsyndromal concepts is still in its infancy. The characteristic profile can differentiate delirium from other neuropsychiatric disorders. Clinical (motoric) subtyping holds potential but more consistent methods are needed. Studies are almost entirely cross-sectional in design and generally lack comprehensive symptom assessment. Multiple assessment tools are available but are oriented towards hyperactive features and few have demonstrated ability to distinguish delirium from dementia. There is insufficient evidence linking specific phenomenology with etiology, pathophysiology, management, course, and outcome.

CONCLUSIONS

Despite the major advancements of the past decade in many aspects of delirium research, further phenomenological work is crucial to targeting studies of causation, pathophysiology, treatment, and prognosis. We identified eight key areas for future studies.

[Opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium]

To assess the current opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium, survey administration was conducted to 2256 nurses and 982 physicians within the University Hospitals of Leuven (Belgium). Response rate was 26% with 819 respondents (600 nurses; 219 physicians) completing the questionnaire. 72% of the respondents considered delirium as a minor problem or no problem at all. Yet over half of respondents working on a palliative care unit (87%, n=15), traumatological ward (67%, n=18), cardio-thoracic surgery ward (58%, n=20), intensive care unit (55%, n=120) and geriatric ward (55%, n=42) reported it as a serious problem. Delirium was considered as an underdiagnosed (85%) but preventable (75%) syndrome. Yet patients at risk are rarely (34%) or never (52%) screened for delirium. In case of screening (48%), only 4% used a specific validated assessment tool. 97% of all respondents were convinced that delirium requires an active and immediate intervention of nurse and physician. 82% of the physicians preferred haldol to treat delirium, in case of alcohol withdrawal 69% chose tranxene. Physical restraints were considered important in the management of delirium by a greater proportion of nurses (49%) than physicians (28%). The severity of the problem is underestimated. While opinions regarding the treatment were quite correct, prevention and early detection of delirium deserve more attention.

Prävention unerwünschter Arzneimittelwirkungen bei älteren Patienten

Adverse drug reactions are among the most common adverse events and a significant cause of preventable morbidity and mortality. As multimorbidity and polypharmacy are frequent in this population, the elderly are at special risk for adverse drug events, although the calendar age has not been proved as independent risk factor in this context. In particular falls and delirium are clinically significant and typical adverse drug events in the elderly. In this review mechanisms and factors which determine adverse drug re actions are described, and possible strategies for an effective prevention are given. This covers pharmacokinetic, pharmacogenetic and pharmacodynamic aspects as well as factors influencing individual adherence to drug therapy. A significant portion of adverse drug reaction may be prevented by a thorough indication and prudent monitoring of pharmacotherapy. Also adherence to pharmacotherapy may be improved by tailored and individual means referring to the patient's needs and expectancies. In the elderly functional limitations such as reduced cognitive abilities, reduced visual acuity and impaired dexterity determine an ineffective pharmacotherapy and medication errors. Hereby these functional limitations are significant predictors of adverse drug events in the context of self-management of pharmacotherapy. Testing of functional abilities as provided in the geriatric assessment is helpful to identify these factors. Among altered pharmacokinetic factors in the elderly, reduced renal function is most important to avoid overdosage. Although a precise measurement of renal function is not possible in a bed-side manner, an estimation of actual renal function utilizing estimation-formulas should always take place.

Recovery and outcome of delirium in elderly medical inpatients

This study investigates the relationships between delirium, cognitive impairment and acute illness severity with adverse clinical outcomes; in-hospital mortality, hospital length of stay, or new entry to a care home. It is a prospective observational study of medical inpatients 70 years or older, with repeated measurements of cognition, delirium status, delirium severity, and severity of physical illness every 3 days until the 18th day and then the 28th day of hospitalization. Of 94 participants, 33 had delirium and 14 recovered during their hospitalization. Predictor variables for recovery were initial Mini Mental State Examination (MMSE) (p=0.003) and severity of delirium at second assessment (p=0.02), for mortality initial MMSE (p=0.002) and for discharge to care home were initial delirium status (p=0.008) and age (p=0.004). Delirious people newly discharged to care homes stayed longer in hospital than those discharged to their previous address (p=0.016). We conclude that delirium is not a transient disorder. The presence of delirium was not related to measures of the severity of physical illness or disability. High mortality was associated with delirium but was specifically associated with cognitive impairment. Prolonged length of stay of delirious people may depend on discharge destination.