Acute delirium and functional decline in the hospitalized elderly patient

Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment

Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.

Delirium in the acute care setting: characteristics, diagnosis and treatment

Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. It is also the most common psychiatric syndrome found in the general hospital setting, its prevalence surpassing better known psychiatric disorders. This article reviews the published literature on delirium and addresses the epidemiology, known etiologic factors, presentation and characteristics of delirium, while emphasizing what is known about treatment strategies and prevention. Given increasing evidence that delirium is not always reversible and the many sequelae associated with its development, physicians must do everything possible to prevent its occurrence or shorten its duration, by recognizing its symptoms early, correcting underlying contributing causes, and using treatment strategies proven to help recover functional status.

Outcomes Associated With Delirium in Older Patients in Surgical ICUs

BACKGROUND

We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients.

METHODS

Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patients >or= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument).

RESULTS

Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p < 0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82).

CONCLUSIONS

Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home.

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.

Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients

BACKGROUND

Delirium (acute brain dysfunction) is a potentially life threatening disturbance in brain function that frequently occurs in critically ill patients. While this area of brain dysfunction in critical care is rapidly advancing, striking limitations in use of terminology related to delirium internationally are hindering cross-talk and collaborative research. In the English literature, synonyms of delirium such as the Intensive Care Unit syndrome, acute brain dysfunction, acute brain failure, psychosis, confusion, and encephalopathy are widely used. This often leads to scientific "confusion" regarding published data and methodology within studies, which is further exacerbated by organizational, cultural and language barriers.

OBJECTIVE

We undertook this multinational effort to identify conflicts in terminology and phenomenology of delirium to facilitate communication across medical disciplines and languages.

METHODS

The evaluation of the terminology used for acute brain dysfunction was determined conducting communications with 24 authors from academic communities throughout countries/regions that speak the 13 variants of the Romanic languages included into this manuscript.

RESULTS

In the 13 languages utilizing Romanic characters, included in this report, we identified the following terms used to define major types of acute brain dysfunction: coma, delirium, delirio, delirium tremens, délire, confusion mentale, delir, delier, Durchgangs-Syndrom, acute verwardheid, intensiv-psykose, IVA-psykos, IVA-syndrom, akutt konfusion/forvirring. Interestingly two terms are very consistent: 100 % of the selected languages use the term coma or koma to describe patients unresponsive to verbal and/or physical stimuli, and 100% use delirium tremens to define delirium due to alcohol withdrawal. Conversely, only 54% use the term delirium to indicate the disorder as defined by the DSM-IV as an acute change in mental status, inattention, disorganized thinking and altered level of consciousness.

CONCLUSIONS

Attempts towards standardization in terminology, or at least awareness of differences across languages and specialties, will help cross-talk among clinicians and researchers.

Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden

The high burden of cognitive impairment in hemodialysis and chronic kidney disease (CKD) patients has only recently become recognized. Up to 70% of hemodialysis patients aged 55 years and older have moderate to severe chronic cognitive impairment, yet it is largely undiagnosed. Recent studies describe the strong graded relation between estimated glomerular filtration rate and cognitive function in CKD patients. The process of conventional hemodialysis may induce recurrent episodes of acute cerebral ischemia, which, in turn, may contribute to acute decline in cognitive function during dialysis. Thus, the worst time to communicate with dialysis patients may be during the hemodialysis session. Both symptomatic and occult, subclinical ischemic cerebrovascular disease appears to play a large role in a proposed model of accelerated vascular cognitive impairment in these populations. Severe cognitive impairment or dementia among hemodialysis patients is associated with an approximately 2-fold increased risk of both mortality and dialysis withdrawal. Predialysis cognitive screening and adding dementia to the list of comorbidities on Form 2728 would provide critical information regarding the benefit versus risks of receiving dialysis. It could also improve quality of care and outcomes by raising clinicians' awareness of the potential effects of cognitive impairment on medication, fluid, and dietary compliance and the ability to make advance directive decisions among dialysis patients. Although much remains to be learned regarding the pathophysiology of cognitive impairment in kidney disease, the public health implications of this substantial burden are immediate.

Clinical utility and validation of two instruments (the Confusion Assessment Method Algorithm and the Chinese version of Nursing Delirium Screening Scale) to detect delirium in geriatric inpatients

OBJECTIVE

There is no valid instrument to aid delirium detection in Hong Kong. The objective of this study was to investigate the effectiveness of the Confusion Assessment Method Diagnostic Algorithm (CAM algorithm) and the bilingual version of Nursing Delirium Screening Scale (Nu-DESC) among geriatric inpatients in a Chinese population.

METHODS

Between January and March 2007, 100 newly admitted geriatric patients were assessed by physician and bedside nurses, using the CAM algorithm and bilingual version of Nu-DESC, respectively. The two instruments were compared with a gold standard, the psychiatrist's DSM-IV-based diagnosis. Receiver operating characteristic curve (ROC) was used in conjunction with sensitivity and specificity measures to assess the performance of the tools.

RESULTS

The prevalence of delirium was 25%. The ROC curve of Nu-DESC showed at the optimal cutoff of >0 a sensitivity of 0.96 and specificity of 0.79. CAM had a sensitivity of 0.76 and specificity of 1. Underlying dementia did not affect the validity of both instruments. Average time of Nu-DESC administration was 1 min/shift and CAM was 10 min.

CONCLUSIONS

The bilingual version of Nu-DESC is a sensitive screening tool and the CAM algorithm is an accurate diagnostic instrument for detection of delirium in geriatric inpatient population.

The 6 and 12 month outcomes of older medical inpatients who recover from delirium

OBJECTIVE

To compare the 6 and 12 month outcomes of patients who recovered from delirium by 8 weeks with those who did not have an index episode.

METHODS

Older medical inpatients were assessed for delirium using the Confusion Assessment Method. All patients with delirium and a sample of patients without delirium were enrolled. Recovery from delirium at 8 weeks was determined using the Delirium Index and an algorithm based on DSM-III-R criteria. The primary composite outcome was cognitive or functional decline, institutional residence or death at 6 and 12 months. We fitted two logistic regression models to predict outcome odds ratio (OR) of delirium-recovered vs no delirium groups, adjusting for co-morbidity, severity of physical illness and demographic variables. In secondary analyses, we examined each component of the primary outcome separately.

RESULTS

Of 361 patients enrolled, 59 died, 33 withdrew and one was lost to follow-up before 8 weeks. Of 268 patients assessed at 8 weeks, 115 and 95 were in delirium-recovered and no delirium groups, respectively. The 6 month OR for the primary composite outcome was 0.89 (95% CI 0.46, 1.70); the 12 month OR was 1.5 (95% CI 0.77, 2.90). Secondary analyses revealed a clinically important increase in mortality at 6 and 12 months.

CONCLUSION

Among patients who survived, there were no significant differences in cognition, function or institutional status between delirium-recovered and no delirium groups at 6 and 12 months. If replicated, these findings have potentially important implications for clinical practice and research.

One-year health care costs associated with delirium in the elderly population

BACKGROUND

While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium.

METHODS

Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics.

RESULTS

During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year.

CONCLUSIONS

The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.

Preliminary derivation of a Nursing Home Confusion Assessment Method based on data from the Minimum Data Set

OBJECTIVES

To develop a Nursing Home Confusion Assessment Method (NH-CAM) for diagnosing delirium using items found on the Minimum Data Set (MDS) and to compare its performance with that of the delirium Resident Assessment Protocol (RAP) trigger and to an additive score of six of the RAP items.

DESIGN

Retrospective cohort study using MDS and Medicare claims data.

SETTING

Free-standing NHs in urban markets in the 48 contiguous U.S. states.

PARTICIPANTS

Long-stay residents who returned to their NHs after acute hospitalizations between April and September 2000 (N=35,721).

MEASUREMENTS

Mortality and rehospitalization rates within 90 days of readmission to the NH from the hospital.

RESULTS

Almost one-third (31.8%) of the residents were identified as having delirium according to the RAP; 1.4% had full delirium, 13.2% had Subsyndromal II delirium, and 17.2% had Subsyndromal I delirium. More-severe NH-CAM scores were associated with greater risks of mortality and rehospitalization. NH-CAM levels were strong independent risk factors for survival and rehospitalization in a Cox model (hazard ratios ranging from 1.5 to 1.9 for mortality and 1.1 to 1.3 for rehospitalization) adjusting for cognitive and physical function, diagnoses, inpatient care parameters, care preferences, and sociodemographic factors.

CONCLUSION

The NH-CAM successfully stratified NH residents' risk of mortality and rehospitalization. If validated clinically, the NH-CAM may be useful in care planning and in further research on the determinants and consequences of delirium in the NH.

Acute variation in cognitive function in hemodialysis patients: a cohort study with repeated measures

BACKGROUND

Although cognitive function in hemodialysis patients is believed to be best 24 hours after the dialysis session, the extent of variation during the dialysis cycle is unknown.

STUDY DESIGN

Cohort study with repeated measures.

SETTING & PARTICIPANTS

Hemodialysis centers; patients aged 55 years or older.

PREDICTOR

Time of assessment related to the dialysis session. Time 1 (T1) occurred approximately 1 hour before the dialysis session; T2, 1 hour into the session; T3, 1 hour after; and T4, the next day.

OUTCOMES

Measures of cognitive function using a 45-minute cognitive battery. An average composite score was calculated to measure global cognitive function, equal to the average of subjects' standardized scores on all tests given at each test time. Times were classified as best and worst according to composite scores.

MEASUREMENTS

Testing was conducted on average over 2 dialysis sessions to avoid test fatigue. The cognitive battery included tests of verbal fluency, immediate and delayed verbal and visual memory, and executive function, administered at 4 times.

RESULTS

In the 28 subjects who completed testing at 3 or 4 testing times, mean age was 66.7 +/- 9.5 years and mean dialysis vintage was 44.7 +/- 33.3 months. Using a general linear model for correlated data, the composite score was significantly lower (poorer) during dialysis (T2) than shortly before the session (T1) or on the next day (T4; P < 0.001 for both).

LIMITATIONS

Relatively small sample size, testing delays, results may not be generalizable.

CONCLUSION

Global cognitive function varies significantly during the dialysis cycle, being worst during dialysis and best shortly before the session or on the day after. Clinician visits may be most effective at these times.

Delirium in Older Patients in Surgical Intensive Care Units

PURPOSE

To examine the frequency and course of delirium in older adults admitted to a surgical intensive care unit (SICU).

DESIGN AND METHODS

Prospective, observational cohort study of 114 English-speaking participants and their surrogates, aged 65 and older, admitted to an SICU, and managed by a surgical critical care service. Chart reviews and surrogate interviews were conducted within 24 hours of SICU admission to collect information regarding evidence of dementia using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly. Participants were also screened for delirium daily throughout their hospitalization with either the Confusion Assessment Method-ICU (CAM-ICU) while in the SICU or the CAM while on medical/surgical units.

RESULTS

In this population of older adults, 18.4% had evidence of dementia on admission to the SICU. Few older adults (2.6%) were admitted to the hospital with evidence of preexisting delirium, but 28.3% developed delirium in the SICU and 22.7% during the post-SICU period. A total of 52 of 114 (45.6%) participants were delirious sometime during their hospital stay or 24 hours before hospital admission. Episodes of deep sedation and nonarousal were uncommon, occurring in only 9.7% of the sample.

CONCLUSIONS

Older adults admitted to SICUs were at high risk for developing delirium during hospitalization. Further research is needed to elucidate the risk factors for, and outcomes of, delirium in this uniquely vulnerable population.

Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients

BACKGROUND

Delirium is common among hospitalized elders and may persist for months. Therefore, the adverse impact of delirium on independence often occurs in the post acute care (PAC) setting. The effect of psychomotor subtypes on delirium remains uncertain. The purpose of this study is to examine the association between psychomotor activity delirium subtypes and 1-year mortality among 457 newly admitted delirious PAC patients.

METHODS

Patients were screened for delirium on admission to PAC facilities after an acute hospitalization, and patients with "Confusion Assessment Method"-defined delirium were enrolled. Psychomotor activity was assessed using the Memorial Delirium Assessment Scale, and patients were classified as to their delirium subtype (hyperactive, hypoactive, mixed, or normal). One-year mortality data were obtained from the National Death Index. A Kaplan-Meier survival analysis and a proportional hazards analysis using indicator (dummy) variables with normal psychomotor activity as the referent were performed.

RESULTS

The normal psychomotor activity group had the lowest 1-year mortality rate, followed by the hyperactive, mixed, then hypoactive groups in increasing order. Independent of age, gender, comorbidity, dementia, and delirium severity, hypoactive patients were 1.60 (95% confidence interval [CI], 1.09-2.35) times more likely to die during the 1-year follow-up period than were patients with normal psychomotor activity. The hyperactive (hazard ratio = 1.30; 95% CI, 0.73-2.31) and mixed (hazard ratio = 1.25; 95% CI, 0.72-2.17) psychomotor groups had nonsignificant elevated risks relative to the normal psychomotor behavior group.

CONCLUSIONS

All three psychomotor disturbance subtypes had an elevated risk of dying during the 1-year follow-up relative to the normal psychomotor group, though the hypoactive group had the highest mortality risk and was the only group with a statistically significantly elevated risk relative to the normal group.

A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline

AIMS AND OBJECTIVES

To determine a valid, reliable and clinical user-friendly instrument, based on predictors of functional decline, to identify older patients at risk for functional decline. The predictors of functional decline are initially considered and, subsequently, the characteristics and psychometric qualities of existing screening instruments are investigated.

BACKGROUND

Functional decline is a common and serious problem in older hospitalized patients, resulting in a change in quality of life and lifestyle. Studies have shown that 30-60% of older people develop new dependencies in activities of daily living (ADL) during their hospital stay. Adverse health outcomes such as mortality, a prolonged hospital stay, nursing home placement and increased dependency of older people at home are the results. Not only are the personal costs high but also, in a rapidly growing older population, the impact on health-care costs is also high.

RESULTS

Age, lower functional status, cognitive impairment, preadmission disability in instrumental activities of daily life (IADL), depression and length of hospital stay were identified as predictors of functional decline. Three screening instruments to identify hospitalized patients at risk for functional decline were found in the literature: the Hospital Admission Risk Profile, the Identification of Seniors at Risk and the Care Complexity Prediction Instrument. The reported validity was moderate. Reliability and the ease of use in the clinical setting were not well described.

CONCLUSION

These three instruments should be further tested in a hospitalized older population.

RELEVANCE TO CLINICAL PRACTICE

Screening is a first step to identify patients at risk for functional decline and this will make it possible to treat patients who are identified so as to prevent functional decline. Because of their ability to observe and to guide the patients and the overall view they have, nurses play a key role in this process.

The effects of postoperative pain and its management on postoperative cognitive dysfunction

To determine risks for postoperative cognitive dysfunction (POCD), the authors conducted a prospective cohort study of 225 patients > or = 65 years of age undergoing noncardiac surgery. Cognitive testing using the Word List, Verbal Fluency, and Digit Symbol tests was conducted for each patient preoperatively and 1 and 2 days postoperatively in patients without postoperative delirium. POCD was defined as meeting statistical criteria for decline from the patient's preoperative performance levels on at least two of the three cognitive tests. Multivariate logistic regression analysis determined the association between pain and postoperative analgesia with POCD after controlling for demographics, comorbidities, preoperative level of cognitive and daily functioning, preoperative medications, duration and type of anesthesia, and adverse events. Patients were on average 72 years old and 13% of patients experienced POCD on day 1, 7% on day 2, and 15% had POCD on either day 1 or day 2 after the surgery. Multivariate regression analyses revealed that only postoperative analgesia was associated with the development of POCD. Compared with those receiving postoperative analgesia through a patient-controlled analgesia device that administered opioids intravenously, those who received postoperative analgesia orally were at significantly lower risk for the development of POCD (odds ratio: 0.22; 95% confidence interval: 0.06-0.80; Wald chi-square = 5.36, df = 1, p = 0.02). Older patients undergoing noncardiac surgery who are not delirious can experience significant declines in cognitive functioning postoperatively. Those at least risk of experiencing POCD were those who received postoperative analgesia orally.

Is Depth of Anesthesia, as Assessed by the Bispectral Index, Related to Postoperative Cognitive Dysfunction and Recovery?

We randomized 74 patients to either a lower Bispectral Index (BIS) regimen (median BIS, 38.9) or a higher BIS regimen (mean BIS, 50.7) during the surgical procedure. Preoperatively and 4-6 wk after surgery, the patients' cognitive status was assessed with a cognitive test battery consisting of processing speed index, working memory index, and verbal memory index. Processing speed index was 113.7 +/- 1.5 (mean +/- se) in the lower BIS group versus 107.9 +/- 1.4 in the higher BIS group (P = 0.006). No difference was observed in the other two test battery components. Somewhat deeper levels of anesthesia were therefore associated with better cognitive function 4-6 wk postoperatively, particularly with respect to the ability to process information.

The influence of latent viral infection on rate of cognitive decline over 4 years

OBJECTIVES

To examine whether cytomegalovirus (CMV) and herpes simplex virus type-1 (HSV-1) are associated with cognitive decline over a 4-year period and to assess whether C-reactive protein (CRP) modifies these relationships.

DESIGN

Prospective cohort study over a 4-year period.

SETTING

Community-dwelling elderly population.

PARTICIPANTS

The sample was a subset (1,204/1,789) of participants in the Sacramento Area Latino Study on Aging (SALSA) aged 60 to 100.

MEASUREMENTS

Participants were screened annually over a 4-year period for cognitive function and episodic memory. Cognitive function was assessed using the modified Mini-Mental State Examination, and episodic memory was assessed using a word list-learning test of delayed recall. Baseline serum samples were assayed for levels of immunoglobulin G antibodies to CMV and HSV-1 and for levels of CRP.

RESULTS

There was a significantly higher rate of cognitive decline over the 4-year period in subjects with the highest CMV antibody levels at baseline than in individuals with the lowest levels (beta=-0.053, standard error =0.018; P=.003), after controlling for age, sex, education, income, and chronic health conditions. There was no association between HSV-1 antibody levels and cognitive decline. CRP did not modify the relationship between viral antibody levels and cognitive decline.

CONCLUSION

This is the first study to show that individuals with higher levels of antibody to CMV experience a more-rapid rate of cognitive decline than those with lower levels. Understanding the mechanisms by which CMV influences cognition may aid development of intervention strategies targeting infection, viral reactivation, and immune response over the life course.

Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology

OBJECTIVES

To evaluate a replication of the Hospital Elder Life Program (HELP), a quality-improvement model, in a community hospital without a research infrastructure, using administrative data.

DESIGN

A pretest/posttest quality-improvement study.

SETTING

A 500-bed community teaching hospital in western Pennsylvania.

PARTICIPANTS

Four thousand seven hundred sixty-three hospitalized patients aged 70 and older admitted to one nursing unit over 3.5 years.

INTERVENTION

Application of the HELP multicomponent intervention targeting patients at risk for delirium.

MEASUREMENTS

A proxy measure for delirium was developed using administrative data to calculate delirium rate and differences in variable costs of care and length of stay for patients before and after the intervention. Similar calculations were used in delirious patients for variable costs and length of stay before and after the intervention. Satisfaction surveys were administered to nursing staff and patient families before and after the intervention.

RESULTS

The intervention reduced the absolute rate of delirium according to proxy report 14.4% from baseline, which represented a relative reduction in risk of 35.3% (P=.002). Total costs on this 40-bed nursing unit were reduced $626,261 over 6 months. Satisfaction of nursing staff and families was high in the intervention group. In addition, the intervention showed sustained benefits over time and remains funded by the hospital.

CONCLUSION

HELP can be successfully replicated in a community hospital, yielding clinical and financial benefits.

Association between delirium resolution and functional recovery among newly admitted postacute facility patients

BACKGROUND

Delirium is common among hospitalized elders and may persist for months. The adverse impact of delirium on independence may increasingly occur in the postacute care (PAC) setting. The purpose of this study is to examine the association between delirium resolution and functional recovery in skilled nursing facilities specializing in PAC.

METHODS

Patients were screened for delirium on admission after an acute hospitalization at PAC facilities. Only patients with "Confusion Assessment Method"-defined delirium were enrolled. Delirium and activities of daily living were assessed prehospital, at PAC admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments to measure functional ability. Four distinct delirium resolution groups were created ranging from resolution within 2 weeks without recurrence to no resolution over 6 months. Repeated-measures analysis of covariance was used to determine if functional performance differed over time by delirium resolution status.

RESULTS

Among the 393 PAC patients, functional recovery differed significantly (p <.0001) by delirium resolution status. Patients who resolved their delirium by 2 weeks without recurrence regained 100% of their prehospital functional level, whereas patients who never resolved their delirium retained less than 50% of their prehospital functional level. Patients with slower resolving delirium and recurrent delirium had intermediate functional outcomes.

CONCLUSIONS

Resolution of delirium among PAC patients appears to be a prerequisite for functional recovery. Delirium resolution within 2 weeks without recurrence is associated with excellent functional recovery. Effective strategies to resolve delirium promptly and prevent its recurrence in the PAC setting will likely benefit patient rehabilitation and functional recovery.

The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review

Postoperative delirium and cognitive decline are adverse events that occur frequently in elderly patients. Preexisting patient factors, medications, and various intraoperative and postoperative causes have been implicated in the development of postoperative delirium and cognitive decline. Despite previous studies identifying postoperative pain as a risk factor, relatively few clinical studies have compared the effect of common postoperative pain management techniques (IV and epidural) or opioid analgesics on postoperative cognitive status. A systematic search of the PubMed and CINAHL databases identified six studies comparing different opioid analgesics on postoperative delirium and cognitive decline and five studies comparing IV and epidural routes of administering analgesia. Meperidine was consistently associated with an increased risk of delirium in elderly surgical patients, but the current evidence has not shown a significant difference in postoperative delirium or cognitive decline among other more frequently used postoperative opioids such as morphine, fentanyl, or hydromorphone. The available studies also suggest that IV or epidural techniques do not influence cognitive function differently. However, future investigations of sufficient study size and more standardized methods of defining outcomes are necessary to confirm the current findings.

Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures

OBJECTIVE

To describe the incidence, risk factors and clinical features (subtypes) of delirium during the postoperative period after hip fracture surgery in elderly patients.

DESIGN

Prospective study.

METHODS

Thirty-four consecutive patients (9 men and 25 women) were included in this study between June 16 to July 14, 2003. All patients underwent surgery for a fractured neck of femur and were pre- and postoperatively cared for at a combined geriatric/orthopedic ward.

ASSESSMENT

The diagnosis of delirium was based on the criteria of the DSM-IV and the Confusion Assessment Method Scale. Subtypes of delirium were classified according to the criteria proposed by Lipowski: hyperactive-hyperalert (or agitated), hypoactive-hypoalert (somnolent) and mixed delirium.

RESULTS

Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The development of delirium was associated with the medication midazolam taken perioperatively. Nine (47%) of the delirious patients had a hyperactive type of delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed type. We did not find any association among subtypes of delirium and clinical features.

CONCLUSIONS

Delirium is a common complication in the postoperative period of elderly patients treated for hip fractures. The use of midazolam in the perioperative period increased the risk of developing postoperative delirium. The hyperactive type of delirium was the most common subtype of delirium.

Central and systemic endotoxin challenges exacerbate the local inflammatory response and increase neuronal death during chronic neurodegeneration

The contribution of inflammation to the progression of neurodegenerative diseases such as Alzheimer's, Parkinson's, and prion diseases is poorly understood. Brain inflammation in animal models of these diseases is dominated by chronic microglial activation with minimal proinflammatory cytokine expression. However, these inflammatory cells are "primed" to produce exaggerated inflammatory responses to subsequent lipopolysaccharide (LPS) challenges. We show that, using the ME7 model of prion disease, intracerebral challenge with LPS results in dramatic interleukin-1beta (IL-1beta) expression, neutrophil infiltration, and inducible nitric oxide synthase expression in the brain parenchyma of prion-diseased mice compared with the same challenge in normal mice. Systemic inflammation evoked by LPS also produced greater increases in proinflammatory cytokines, pentraxin 3, and inducible nitric oxide synthase transcription in prion-diseased mice than in control mice and induced microglial expression of IL-1beta. These systemic challenges also increased neuronal apoptosis in the brains of ME7 animals. Thus, both central and peripheral inflammation can exacerbate local brain inflammation and neuronal death. The finding that a single acute systemic inflammatory event can induce neuronal death in the CNS has implications for therapy in neurodegenerative diseases.

Amyloid beta peptide 1-40 enhances the action of Toll-like receptor-2 and -4 agonists but antagonizes Toll-like receptor-9-induced inflammation in primary mouse microglial cell cultures

The interaction of endogenous and exogenous stimulators of innate immunity was examined in primary cultures of mouse microglial cells and macrophages after application of defined Toll-like receptor (TLR) agonists [lipopolysaccharide (LPS) (TLR4), the synthetic lipopeptide Pam3Cys-Ser-Lys4 (Pam3Cys) (TLR2) and single-stranded unmethylated CpG-DNA (CpG) (TLR9)] alone and in combination with amyloid beta peptide (Abeta) 1-40. Abeta1-40 stimulated microglial cells and macrophages primed by interferon-gamma in a dose-dependent manner. Co-administration of Abeta1-40 with LPS or Pam3Cys led to an additive release of nitric oxide (NO) and tumour necrosis factor alpha (TNF-alpha). This may be one reason for the clinical deterioration frequently observed in patients with Alzheimer's disease during infections. In contrast, co-application of Abeta1-40 with CpG led to a substantial decrease of NO and TNF-alpha release compared with stimulation with CpG alone. Abeta1-40 and CpG did not co-localize within the same subcellular compartment, making a direct physicochemical interaction as the cause of the observed antagonism very unlikely. This suggests that not all TLR agonists enhance the stimulatory effect of A beta on innate immunity.

A comparison of anesthetic quality in propofol-spinal anesthesia and propofol-fentanyl anesthesia for total knee arthroplasty in elderly patients

STUDY OBJECTIVE

To compare propofol plus spinal anesthesia during spontaneous ventilation using the Laryngeal Mask Airway and propofol plus fentanyl anesthesia during mechanical ventilation with an endotracheal tube on quality of recovery after anesthesia.

DESIGN

Prospective, randomized study.

SETTING

Hirosaki National Hospital.

PATIENTS

150 patients (aged > 70 years) undergoing total knee arthroplasty.

INTERVENTIONS

Patients were divided randomly into two groups, to receive spontaneous ventilation with a Laryngeal Mask Airway during propofol-spinal anesthesia, or to receive propofol-fentanyl anesthesia with mechanical ventilation via endotracheal tube.

MEASUREMENTS

Quality of anesthesia recovery such as nausea, vomiting, headache, pain throat, hoarse voice, back pain, dizziness, feeling comfortable, dreaming, recovery times in recovery of anesthesia, recovery times, postoperative pain, confusion, was assessed.

MAIN RESULTS

The frequency of postoperative pain throat, hoarse voice, and nausea was significantly lower in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The time to extubation, emergence, response to commands, and orientation were significantly faster (p < 0.001) in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The frequency of postoperative confusion occurring in the propofol-spinal anesthesia group during the first 24 hours was significantly lower than that of the propofol-fentanyl anesthesia group (p = 0.03).

CONCLUSIONS

Propofol-spinal anesthesia provided better and faster recovery than did propofol-fentanyl anesthesia for elderly patients undergoing total knee arthroplasty.

Prognostic significance of delirium in frail older people

Our aim was to investigate the long-term prognosis of delirium in the frailest elderly, and to clarify whether delirium is just a marker of the underlying severe disease. We used logistic regression analysis to determine the independent prognostic significance of delirium. A representative sample of 425 patients (> or = 70 years) in acute geriatric wards and nursing homes were assessed at baseline and followed up for 2 years. DSM-IV was used for classification. The prevalence of delirium at baseline was 24.9% (106/425). The prognosis of delirium was poor: mortality at 1 year was 34.9 vs. 21.6% in nondelirious subjects (p = 0.006), and at 2 years 58.5 vs. 42.6% (p = 0.005). Among home-dwelling people at baseline, 54.4% of the delirious vs. 27.9% of others were permanently institutionalized within 2 years (p < 0.001). In logistic regression analysis, delirium was an independent predictor for mortality at 1 year (OR 1.86, 95% CI 1.1-3.1), at 2 years (OR 1.76, 95% CI 1.1-2.8), and for permanent institutionalization (OR 2.45, 95% CI 1.2-4.9). Delirious patients with prior dementia tended to have a better prognosis than those without.

Predictors and outcomes of delirium

OBJECTIVES

To determine factors associated with the occurrence of delirium among patients undergoing surgical repair of abdominal aortic aneurysm (AAA).

METHODS

The sample included all consenting patients who underwent AAA repair during a 12-month period. Before surgery, daily while in hospital, and at 1 and 6 months after surgery, we assessed patients' mood, mental status and functional status. We compared delirious and nondelirious patients for severity of preoperative depressive symptoms, length of hospital stay and mortality. The effects of delirium on postoperative functional status were assessed in conjunction with postoperative depressive symptoms using regression models.

RESULTS

The sample of 35 patients was primarily male and elderly; one-quarter had three or more medical conditions; and eight (23%) developed delirium after surgery. Postoperative delirium was significantly associated with preoperative depressive symptoms, alcohol use and cognitive impairment as well as with longer lengths of stay and poorer functional status at 1 and 6 months after surgery.

CONCLUSION

Identification and treatment of patients with depressive symptoms, alcohol use and cognitive impairment prior to AAA surgery could reduce the incidence of postoperative delirium and the prolonged hospital stays and impaired functional status associated with it. Surgeons should consider using simple screening instruments before surgery to identify patients at risk and referring them for psychiatric evaluation and treatment. They should also consider including psychiatrists early in the care of high-risk patients to improve detection of and early intervention for delirium.

Psychometric properties of the Flemish translation of the NEECHAM Confusion Scale

BACKGROUND

Determination of a patient's cognitive status by use of a valid and reliable screening instrument is of major importance as early recognition and accurate diagnosis of delirium is necessary for effective management. This study determined the reliability, validity and diagnostic value of the Flemish translation of the NEECHAM Confusion Scale.

METHODS

A sample of 54 elderly hip fracture patients with a mean age of 80.9 years (SD = 7.85) were included. To test the psychometric properties of the NEECHAM Confusion Scale, performance on the NEECHAM was compared to the Confusion Assessment Method (CAM) and the Mini-Mental State Examination (MMSE), by using aggregated data based on 5 data collection measurement points (repeated measures). The CAM and MMSE served as gold standards.

RESULTS

The alpha coefficient for the total NEECHAM score was high (0.88). Principal components analysis yielded a two-component solution accounting for 70.8% of the total variance. High correlations were found between the total NEECHAM scores and total MMSE (0.75) and total CAM severity scores (-0.73), respectively. Diagnostic values using the CAM algorithm as gold standard showed 76.9% sensitivity, 64.6% specificity, 13.5% positive and 97.5% negative predictive values, respectively.

CONCLUSION

This validation of the Flemish version of the NEECHAM Confusion Scale adds to previous evidence suggesting that this scale holds promise as a valuable screening instrument for delirium in clinical practice. Further validation studies in diverse clinical populations; however, are needed.

Promethazine adverse events after implementation of a medication shortage interchange

BACKGROUND

Prochlorperazine and droperidol were commonly used antiemetics at the University of Pittsburgh Medical Center-Presbyterian Hospital until a shortage of prochlorperazine occurred and a black box warning was added to droperidol prescribing information. Subsequently, promethazine was selected as the approved intravenous antiemetic for therapeutic interchange in December 2001. Promethazine use and adverse drug events (ADEs) were investigated following review of a serious ADE that identified promethazine use as a probable contributing factor.

OBJECTIVE

To illustrate ADEs associated with promethazine and characterize high-risk patients.

METHODS

An ADE database analysis identified promethazine ADEs reported from 2000 to 2003. Promethazine utilization and ADEs were compared with those of other antiemetics during the pre- and post-interchange periods.

RESULTS

Promethazine utilization increased significantly during the post-interchange period compared with all other antiemetics (p < 0.001). Promethazine ADEs increased from one event during the pre-interchange period to 13 events during the post-interchange period. Causality assessment using the Naranjo algorithm ranged from possible to probable. The promethazine ADE rate per 10 000 doses was significantly higher than the combined ADE rate for all other antiemetics (p < 0.001; incident rate ratio [IRR] 4.32). Elderly patients (aged > or =65 y) experienced more promethazine ADEs than younger patients (p = 0.005; IRR 4.68). Concurrent use of opioids and/or sedating drugs contributed to promethazine ADEs in 11 of 14 (78.6%) patients.

CONCLUSIONS

Geriatric status is a significant risk factor for promethazine ADEs. Concomitant use of sedating drugs may further increase the risk for ADEs. Therapeutic interchange programs should be monitored for both ADEs and utilization.

Postoperative interleukin-6 and cortisol concentrations in elderly patients with postoperative confusion

OBJECTIVE

To investigate changes in plasma interleukin (IL)-6, cortisol or noradrenaline concentrations after surgery in elderly patients with postoperative confusion.

METHODS

We studied 80 patients aged 70-90 years undergoing abdominal surgery and measured plasma IL-6, cortisol or noradrenaline concentrations before surgery, at the end of surgery, and 24 and 48 h after surgery.

RESULTS

Plasma IL-6 concentrations in elderly patients with postoperative confusion were 83.2 +/- 30.5, 49.3 +/- 14.1 and 42.9 +/- 19.4 pg.ml(-1) at the end of surgery, and 24 and 48 h after surgery, respectively, being significantly higher than in elderly patients without postoperative confusion (58.0 +/- 37.5, 36.1 +/- 20.0 and 28.2 +/- 16.7 pg.ml(-1)). Plasma cortisol concentrations in elderly patients with postoperative confusion (42.2 +/- 7.8, 38.3 +/- 8.3 and 33.1 +/- 8.4 microg.dl(-1) at the end of surgery, and 24 and 48 h after surgery, respectively) were significantly higher than in elderly patients without postoperative confusion (32.9 +/- 6.7, 30.4 +/- 8.6 and 25.6 +/- 6.5 microg.dl(-1), respectively). There were no significant differences in plasma norepinephrine concentrations at all sampling points between elderly patients with and without postoperative confusion. However, plasma IL-6 and cortisol concentrations were related in elderly patients with postoperative confusion (at the end of surgery and 24 and 48 h after surgery). However, there was no relationship between plasma IL-6 and cortisol concentrations 24 and 48 h after surgery in elderly patients without postoperative confusion.

CONCLUSION

Elderly patients with postoperative confusion had increased plasma IL-6 and cortisol concentrations. The interaction between IL-6 and cortisol after surgery is associated with developing postoperative confusion in the elderly patients.

Facteurs de qualité de la prise en charge des sujets âgés opérés d’une fracture de l’extrémité supérieure du fémur

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

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

The purpose of this study was to identify the proximate causes through which dementia and delirium extend length of stay (LOS) in elderly general hospital patients. Among 93 patients age >/=65 years admitted to a tertiary-care teaching hospital through the emergency department, admission ratings of cognitive impairment, delirium, and dementia predicted the emergence of mental and behavioral manifestations of delirium and dementia in the hospital and greater LOS. Mental and behavioral manifestations also predicted greater LOS. On average, mental manifestations appeared first and were followed by behavioral manifestations, and the appearance of both types of manifestations occurred before the mean LOS. The results suggest that elderly patients with dementia and/or delirium who become symptomatic after admission to a general hospital first show mental signs and symptoms, then show behavioral disturbances, which appear to be the proximate causes of greater LOS.

Effect of postoperative delirium on outcome after hip fracture

Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year.

Meperidine analgesia and delirium in aged hip fracture patients

Delirium is quite frequent in elderly patients who sustain hip fractures. The use of Meperidine by physicians, unaware of the possible emergence of delirium in elderly patients, is very popular. We have retrospectively examined the incidence of delirium in 181 consecutive patients admitted to the orthogeriatric ward with hip fractures. We used the confusion assessment method to establish the presence of delirium in all patients. A database search was conducted to identify which patients were treated by Meperidine, or Morphine, prior to delirium onset. We identified 92 cases, 44 of whom were treated by Meperidine alone, and the other 48 treated by Morphine alone. Delirium was diagnosed in 13 (27.1%) Morphine treated patients as compared with 19 (43.2%) treated by Meperidine (P<0.001). Age, cognitive status and opiate use were associated with perioperative delirium. A subset regression analysis showed that exposure to Meperidine was significantly associated with delirium (odds ratio 2.5, P<0.01), in contrast with Morphine. Our results confirm the association between exposure to Meperidine and delirium, suggesting that this drug should be withdrawn in elderly hip fractured patients undergoing surgery, and substituted by low dose Morphine analgesia. Reducing the incidence of delirium, by adopting such an approach, may result in a significant potential of savings in direct costs, related to treatment of delirium in this population.

Cognitive impairment in the intensive care unit

Delirium is a frequent complication in older patients in the ICU and often persists beyond their ICU stay. Delirium in older persons in the ICU is a dynamic and complex process. There is a high prevalence of pre-existing cognitive impairment in patients who are admitted to the medical ICU. This pre-existing cognitive impairment is an important predisposing risk factor for the development of delirium during and after the ICU stay. Given the high rates of delirium in the ICU that range from 50% to 80% (see references [27, 28, 34]), future studies are urgently needed to examine risk factors for delirium in the ICU setting, such as examining the impact of psychoactive medication use on delirium rates and persistence in the ICU setting. Moreover, studies that examine the impact of delirium prevention in the ICU on rates of delirium, duration and persistence of delirium, and long-term cognitive and functional outcomes post-ICU stay are greatly needed.

Impaired cognitive function and mental performance in mild dehydration

Dehydration is a reliable predictor of impaired cognitive status. Objective data, using tests of cortical function, support the deterioration of mental performance in mildly dehydrated younger adults. Dehydration frequently results in delirium as a manifestation of cognitive dysfunction. Although, the occurrence of delirium suggests transient acute global cerebral dysfunction, cognitive impairment may not be completely reversible. Animal studies have identified neuronal mitochondrial damage and glutamate hypertransmission in dehydrated rats. Additional studies have identified an increase in cerebral nicotinamide adenine dinucleotide phosphate-diaphorase activity (nitric oxide synthase, NOS) with dehydration. Available evidence also implicates NOS as a neurotransmitter in long-term potentiation, rendering this a critical enzyme in facilitating learning and memory. With ageing, a reduction of NOS activity has been identified in the cortex and striatum of rats. The reduction of NOs synthase activity that occurs with ageing may blunt the rise that occurs with dehydration, and possibly interfere with memory processing and cognitive function. Dehydration has been shown to be a reliable predictor of increasing frailty, deteriorating mental performance and poor quality of life. Intervention models directed toward improving outcomes in dehydration must incorporate strategies to enhance prompt recognition of cognitive dysfunction.

Delirium, depression, and anxiety

Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.

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

OBJECTIVES

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

DESIGN

Longitudinal cohort study.

SETTING

Eight hospitals in Baltimore, Maryland.

PARTICIPANTS

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

MEASUREMENT

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

RESULTS

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

CONCLUSION

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

Use of the cognitive test for delirium in patients with traumatic brain injury

The sensitivity and specificity of the Cognitive Test for Delirium, which was originally developed for use in intensive care units, were tested in a group of patients with traumatic brain injury who were admitted to a neurorehabilitation center. Sixty-five consecutive patients were evaluated weekly by using the DSM-IV criteria for delirium and the Cognitive Test for Delirium. Complete ratings were available for 249 of 304 weekly observations. Analysis of the receiver operating characteristic curve suggested an optimum cutoff score of less than 22 for identification of delirium by using the Cognitive Test for Delirium, with a sensitivity of 72% and a specificity of 71% compared with the DSM-IV diagnosis. The results suggest that the Cognitive Test for Delirium provides an acceptable level of differentiation between delirious and nondelirious patients with traumatic brain injury.

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses ("organic psychoses"); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses.

The unfavorable nature of preoperative delirium in elderly hip fractured patients

The onset of delirium is frequent in elderly patients who sustain hip fractures. The purpose of this study was to characterize different patterns of preoperative and postoperative delirium, to study factors associated with preoperative delirium and to evaluate the possible different outcome of these patients. This retrospective study comprised 281 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini mental state examination (MMSE), assessment of possible delirium by the confusion assessment method (CAM) and functional outcome assessed by functional independence measure (FIM). A database search was conducted to identify whether delirium onset occurred prior to or following surgery. About 31% of the total sample developed delirium. Delirious patients tended to be more disabled (P = 0.03) and cognitively impaired (P = 0.018), compared with non-delirious patients. Most delirious cases (53%) had their onset in the preoperative period. Patients with preoperative delirium were older (P = 0.03), had a lower prefracture mobility (P < 0.01), impaired cognition (P = 0.04) and showed an adverse functional outcome in terms of FIM score. Regression analysis showed that prefracture dementia, prefracture mobility and low MMSE scores were strongly associated with higher probability of having preoperative delirium, with no additional effect of other variables. It is concluded that preoperative delirium should be viewed as a separate entity with unfavorable nature and adverse outcome. Careful preventive measures and better treating strategies should be employed to avoid this clinical condition.

The economic impact of medical complications in geriatric patients with hip fracture

The records of 510 elderly patients with hip fractures admitted to our institution between January 1995 and December 2000 were retrospectively reviewed to determine the incidence and type of developed medical complications and their economic implications. Of those 510 patients, 217 (43%) developed at least 1 medical complication, most frequently electrolyte imbalance (11%), urinary tract infection (10%), respiratory failure (10%), and delirium (9%). Patients who developed medical complications had significantly longer mean hospital stays (10 days) and higher mean hospital costs ($16,203) than patients without such complications (5 days and $10,284, respectively) (P<.001).

Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery

OBJECTIVES

To determine the prevalence of delirium symptoms at the time of admission to post-acute facilities, the persistence of delirium symptoms in this setting, and the association of delirium symptoms with functional recovery.

DESIGN

Prospective cohort study.

SETTING

Eighty-five post-acute care facilities: 55 rehabilitation hospitals and 30 skilled nursing facilities in 29 states.

PARTICIPANTS

Five hundred fifty-one consenting patients aged 65 and older newly admitted to participating facilities from acute care hospitals.

MEASUREMENTS

Data were collected as part of a field study effort related to the Minimum Data Set (MDS). Basic demographic data, medical comorbidity, delirium symptoms, and functional status--activities of daily living (ADLs) and instrumental activities of daily living (IADLs)--were obtained from MDS assessments performed within 4 days of admission and again 1 week later by the patient's primary nurse. Six delirium symptoms (easily distracted, periods of altered perception, disorganized speech, periods of restlessness, periods of lethargy, and mental function varies over the course of a day) were assessed after appropriate training.

RESULTS

Of the 551 patients (mean age +/- standard deviation 78 +/- 7, 64% women), 126 had delirium symptoms on post-acute admission, for an overall prevalence of 23%. In patients with delirium symptoms on the admission assessment, 1 week later, 14% had completely resolved, 22% had fewer delirium symptoms, 52% had the same number of symptoms, and 12% had more symptoms. Of those with no delirium symptoms on admission, 4% had new symptoms 1 week later. Patients who had the same number of or more delirium symptoms at the second assessment had significantly worse ADL and IADL recovery than those with fewer or resolved delirium symptoms or those with no delirium symptoms at either assessment. Persistent delirium symptoms remained significantly associated with worse ADL and IADL recovery after adjusting for age, comorbidity, dementia, and baseline functional status.

CONCLUSIONS

The data from this study provide strong preliminary evidence that, in patients newly admitted to post-acute care facilities from acute care hospitals, delirium symptoms are prevalent, persistent, and associated with poor functional recovery. Educational efforts are warranted to help post-acute facility staff recognize and manage this common and morbid condition.