Prevalence and incidence of delirium in long-term care

The effect of the COVID-19 pandemic on delirium incidence in Ontario long-term care homes: A retrospective cohort study

OBJECTIVES

To describe delirium incidence before and during the COVID-19 pandemic and examine factors associated with delirium incidence in the long-term care setting.

METHODS

We conducted a retrospective cohort study of Ontario long-term care residents without severe cognitive impairment or baseline delirium with an assessment between February 1, 2019, and March 31, 2021. Data were collected from the interRAI Minimum Data Set (MDS) 2.0. The outcome of interest was delirium development. Selected independent variables were entered into univariate longitudinal generalized estimating equations, followed by multivariate analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

RESULTS

A total of 63,913 residents were included within the comparison sample from February 2019 to February 2020. The pandemic sample consisted of 54,867 residents from March 2020 to March 2021. Incidence of delirium in the comparison sample was 3.4% (2158 residents) compared to 3.2% (1746 residents) in the pandemic sample (P = 0.06). Residents who were older, cognitively impaired, and increasingly frail had greater odds of developing delirium. Increased odds were associated with a diagnosis of bipolar disorder (OR 1.27, 95% CI 1.07-1.51) and anxiolytic use (OR 1.12, 95% CI 1.01-1.25). Residents who were newly admitted (OR 0.65, 95% CI 0.60-0.71) and those dependent for activities of daily living (OR 0.46, 95% CI 0.33-0.64) had lower odds of delirium development.

CONCLUSIONS AND IMPLICATIONS

The incidence of delirium did not differ between the year prior to and the first year of the COVID-19 pandemic, indicating that preventative interventions employed by long-term care homes may have been effective. Long-term care residents who are older, frail, cognitively impaired, or had unstable health would benefit from targeted interventions to prevent delirium. Newly admitted residents or those dependent in activities of daily living had lower odds of developing delirium, which could indicate under detection in these groups.

Delirium Incidence and Predictors in SARS-CoV-2 Vaccinated Residents in Long-Term Care Facilities (LTCF): Insights from the GeroCovid Vax Study

OBJECTIVE

SARS-CoV-2 vaccination can bring an important benefit for older people in terms of reduction of mortality and hospitalization; however, reports of rare adverse effects like altered consciousness and delirium among this demographic have raised concerns. This study aimed to assess delirium incidence post-SARS-CoV-2 vaccination and its predictors in older residents across 60 Italian long-term care facilities (LTCFs).

DESIGN

This is a prospective cohort study considering data from GeroCovid Vax, a multicenter cohort study jointly performed by the Italian Society of Gerontology and Geriatrics (SIGG) (Florence, Italy) and the Italian National Institute of Health (Istituto Superiore di Sanità-ISS, Rome, Italy), and sponsored by the Italian Medicines Agency (Agenzia Italiana del Farmaco-AIFA).

SETTING AND PARTICIPANTS

GeroCovid Vax enrolled LTCFs residents aged ≥60 who received at least 1 anti-SARS-CoV-2 vaccine dose.

METHODS

Baseline data covered sociodemographic details, chronic diseases, medications, nutritional status, cognitive and functional assessments, mobility, and frailty. Delirium was assessed post-first, second, and booster vaccine doses using DSM-5 criteria. Data analysis involved descriptive statistics, multivariate logistic regression, and network analysis.

RESULTS

A total of 2521 participants (mean age 83.10 ± 9.21 years, 70.7% female) were analyzed. Delirium incidence post-first, second, and booster doses was 3.5%, 1.6%, and 1.5%, respectively. Age, preexisting cognitive disorders, and frailty were significant predictors of delirium, with odds ratios (ORs) of 1.70 (95% CI, 1.08-2.77), 2.05 (95% CI, 1.40-2.97), and 1.77 (95% CI, 1.25-2.52), respectively. Prior use of antipsychotics (OR, 1.75; 95% CI, 1.22-2.51) and antidepressants (OR, 1.77; 95% CI, 1.25-2.52) correlated significantly with delirium. Network analysis indicated a strong association between anorexia and delirium.

CONCLUSION AND IMPLICATIONS

Post-vaccination delirium is infrequent and decreases with subsequent doses. Timely assessments for frailty and cognitive impairment could aid in stratifying delirium risk among LTCF residents, facilitating enhanced prevention measures and close monitoring for delirium indicators.

Delirium in nursing home residents: is there a role of antidepressants? A cross sectional study

BACKGROUND

Delirium is strongly associated with poor health outcomes, yet it is frequently underdiagnosed. Limited research on delirium has been conducted in Nursing Homes (NHs). Our aim is to assess delirium prevalence and its associated factors, in particular pharmacological prescription, in this care setting.

METHODS

Data from the Italian "Delirium Day" 2016 Edition, a national multicenter point-prevalence study on patients aged 65 and older were analyzed to examine the associations between the prevalence of delirium and its subtypes with demographics and information about medical history and pharmacological treatment. Delirium was assessed using the Assessment test for delirium and cognitive impairment (4AT). Motor subtype was evaluated using the Delirium Motor Subtype Scale (DMSS).

RESULTS

955 residents, from 32 Italian NHs with a mean age of 84.72 ± 7.78 years were included. According to the 4AT, delirium was present in 260 (27.2%) NHs residents, mainly hyperactive (35.4%) or mixed subtypes (20.7%). Antidepressant treatment with selective serotonin reuptake inhibitors (SSRIs) was associated with lower delirium prevalence in univariate and multivariate analyses.

CONCLUSIONS

The high prevalence of delirium in NHs highlights the need to systematically assess its occurrence in this care settings. The inverse association between SSRIs and delirium might imply a possible preventive role of this class of therapeutic agents against delirium in NHs, yet further studies are warranted to ascertain any causal relationship between SSRIs intake and reduced delirium incidence.

Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients

Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

IMPORTANCE

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

OBJECTIVE

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

EVIDENCE REVIEW

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

FINDINGS

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

CONCLUSIONS AND RELEVANCE

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Delirium in Nursing Home Residents: A Narrative Review

Delirium is an important component of the geriatric syndromes and has been recognized to negatively influence the prognosis of older people in hospital and in a post-acute setting. About 2–5% of older people world-wide live in nursing homes and are characterized by functional impairment, cognitive decline, dementia, comorbidities, and polypharmacotherapy, all factors which influence the development of delirium. However, in this setting, delirium remains often understudied. Therefore, in this narrative review, we aimed to describe the latest evidence regarding delirium screening tools, epidemiology characteristics, outcomes, risk factors, and preventions strategies in nursing homes.

The PREvention Program for Alzheimer's RElated Delirium (PREPARED) cluster randomized trial: a study protocol

BACKGROUND

Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30-73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs.

METHODS

The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45-50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400-600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation.

DISCUSSION

This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale.

TRIAL REGISTRATION

NCT03718156 , ClinicalTrials.gov .

Nurses' experiences of delirium and how to identify delirium-A qualitative study

AIM

Delirium is a serious, acute medical condition which places a heavy burden on the patient, his or her family and healthcare professionals. There have been only a limited number of studies to explore nurses' experiences of delirium and how delirium is identified in community care. The research questions of the study are as follows: "How do community care nurses' experience delirium?" and "How is delirium identified?".

DESIGN

This study has been designed as an explorative and descriptive study.

METHODS

A topic-based interview guide was developed containing questions associated with the Registered Nurses' experiences of their meetings with people with delirium and their identification of delirium.

RESULTS

Nurses working in the community care need to know more about delirium as they play a key role in treatment. Our results also show that the participants have difficulty in establishing whether a patient is suffering from acute confusion/delirium, depression or dementia.

A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial

Introduction

Although various preventive strategies have been advocated, delirium is common in critically ill patients and is associated with increased morbidity, mortality, and long-term adverse effects. The efficacy of a novel delirium prevention bundle in mechanically ventilated critically ill patients was investigated in this study.

Methods

In this randomized controlled trial, 50 mechanically ventilated adult patients in a tertiary care medical-surgical intensive care unit (ICU) were randomized to receive either delirium prevention bundle protocol or standard of care protocol. Delirium was assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU) score by an independent investigator up to 28 days or death or discharge. The primary outcome was the incidence of new-onset delirium. Secondary outcomes were duration of mechanical ventilation, ICU length of stay (ICU-LOS), hospital LOS, and other adverse events.

Results

There was a 20% reduction in the incidence of delirium in the intervention group (36 vs 56%; p = 0.156). The 28-day mortality (28 vs 24%; p = 0.747), duration of mechanical ventilation (9 vs 12 days; p = 0.281), ICU-LOS (11 vs 12 days; p = 0.221), and hospital LOS (16 vs 20 days; p = 0.062) were similar between the groups.

Conclusion

Implementation of delirium prevention bundle does not reduce the incidence of delirium compared to standard of care protocol in mechanically ventilated critically ill patients.

How to cite this article

Malik AK, Baidya DK, Anand RK, Subramaniam R. A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial. Indian J Crit Care Med 2021;25(7):754–760.

Economic impact of delirium in Australia: a cost of illness study

OBJECTIVES

To estimate the economic impact of delirium in the Australian population in 2016-2017, including financial costs, and its burden on health.

DESIGN, SETTING AND PARTICIPANTS

A cost of illness study was conducted for the Australian population in the 2016-2017 financial year. The prevalence of delirium in 2016-2017 was calculated to inform cost estimations. The costs estimated in this study also include dementia attributable to delirium.

MAIN OUTCOME MEASURES

The total and per capita costs were analysed for three categories: health systems costs, other financial costs including productivity losses and informal care and cost associated with loss of well-being (burden of disease). Costs were expressed in 2016-2017 pound sterling (£) and Australian dollars ($A).

RESULTS

There were an estimated 132 595 occurrences of delirium in 2016-2017, and more than 900 deaths were attributed to delirium in 2016-2017. Delirium causes an estimated 10.6% of dementia in Australia. The total costs of delirium in Australia were estimated to be £4.3 billion ($A8.8 billion) in 2016-2017, ranging between £2.6 billion ($A5.3 billion) and £5.9 billion ($A12.1 billion). The total estimated costs comprised financial costs of £1.7 billion and the value of healthy life lost of £2.5 billion. Dementia attributable to delirium accounted for £2.2 billion of the total cost of delirium.

CONCLUSIONS

These findings highlight the substantial burden that delirium imposes on Australian society-both in terms of financial costs associated with health system expenditure and the increased need for residential aged care due to the functional and cognitive decline associated with delirium and dementia. To reduce the substantial well-being costs of delirium, further research should seek to better understand the potential pathways from an episode of delirium to subsequent mortality and reduced cognitive functioning outcomes.

Interventions for preventing delirium in older people in institutional long-term care

BACKGROUND

Delirium is a common and distressing mental disorder. It is often caused by a combination of stressor events in susceptible people, particularly older people living with frailty and dementia. Adults living in institutional long-term care (LTC) are at particularly high risk of delirium. An episode of delirium increases risks of admission to hospital, development or worsening of dementia and death. Multicomponent interventions can reduce the incidence of delirium by a third in the hospital setting. However, it is currently unclear whether interventions to prevent delirium in LTC are effective. This is an update of a Cochrane Review first published in 2014.

OBJECTIVES

To assess the effectiveness of interventions for preventing delirium in older people in institutional long-term care settings.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group (CDCIG) 's Specialised Register of dementia trials (dementia.cochrane.org/our-trials-register), to 27 February 2019. The search was sufficiently sensitive to identify all studies relating to delirium. We ran additional separate searches in the Cochrane Central Register of Controlled Trials (CENTRAL), major healthcare databases, trial registers and grey literature sources to ensure that the search was comprehensive.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single and multicomponent, non-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were prevalence, incidence and severity of delirium; and mortality. Secondary outcomes included falls, hospital admissions and other adverse events; cognitive function; new diagnoses of dementia; activities of daily living; quality of life; and cost-related outcomes. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes, hazard ratios (HR) for time-to-event outcomes and mean difference (MD) for continuous outcomes. For each outcome, we assessed the overall certainty of the evidence using GRADE methods.

MAIN RESULTS

We included three trials with 3851 participants. All three were cluster-RCTs. Two of the trials were of complex, single-component, non-pharmacological interventions and one trial was a feasibility trial of a complex, multicomponent, non-pharmacological intervention. Risk of bias ratings were mixed across the three trials. Due to the heterogeneous nature of the interventions, we did not combine the results statistically, but produced a narrative summary.It was not possible to determine the effect of a hydration-based intervention on delirium incidence (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00; 1 study, 98 participants; very low-certainty evidence downgraded for risk of bias and very serious imprecision). This study did not assess delirium prevalence, severity or mortality.The introduction of a computerised system to identify medications that may contribute to delirium risk and trigger a medication review was probably associated with a reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51; 1 study, 7311 participant-months; moderate-certainty evidence downgraded for risk of bias) but probably had little or no effect on mortality (HR 0.88, CI 0.66 to 1.17; 1 study, 9412 participant-months; moderate-certainty evidence downgraded for imprecision), hospital admissions (HR 0.89, CI 0.72 to 1.10; 1 study, 7599 participant-months; moderate-certainty evidence downgraded for imprecision) or falls (HR 1.03, CI 0.92 to 1.15; 1 study, 2275 participant-months; low-certainty evidence downgraded for imprecision and risk of bias). Delirium prevalence and severity were not assessed.In the enhanced educational intervention study, aimed at changing practice to address key delirium risk factors, it was not possible to determine the effect of the intervention on delirium incidence (RR 0.62, 95% CI 0.16 to 2.39; 1 study, 137 resident months; very low-certainty evidence downgraded for risk of bias and serious imprecision) or delirium prevalence (RR 0.57, 95% CI 0.15 to 2.19; 1 study, 160 participants; very low-certainty evidence downgraded for risk of bias and serious imprecision). There was probably little or no effect on mortality (RR 0.82, CI 0.50 to 1.34; 1 study, 215 participants; moderate-certainty evidence downgraded for imprecision). The intervention was probably associated with a reduction in hospital admissions (RR 0.67, CI 0.57 to 0.79; 1 study, 494 participants; moderate-certainty evidence downgraded due to indirectness).

AUTHORS' CONCLUSIONS

Our review identified limited evidence on interventions for preventing delirium in older people in LTC. A software-based intervention to identify medications that could contribute to delirium risk and trigger a pharmacist-led medication review, probably reduces incidence of delirium in older people in institutional LTC. This is based on one large RCT in the US and may not be practical in other countries or settings which do not have comparable information technology services available in care homes. In the educational intervention aimed at identifying risk factors for delirium and developing bespoke solutions within care homes, it was not possible to determine the effect of the intervention on delirium incidence, prevalence or mortality. This evidence is based on a small feasibility trial. Our review identified three ongoing trials of multicomponent delirium prevention interventions. We identified no trials of pharmacological agents. Future trials of multicomponent non-pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence-based care for this vulnerable group.

Use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults: a nested case-control study

OBJECTIVE

The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults.

METHODS

A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium.

RESULTS

Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant.

CONCLUSION

The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.

Subsyndromal delirium compared with delirium, dementia, and subjects without delirium or dementia in elderly general hospital admissions and nursing home residents

Introduction

Subsyndromal delirium (SSD) complicates diagnosis of delirium and dementia, although there is little research comparing their symptom profiles.

Methods

Cross-sectional study of 400 elderly patients' admission to a general hospital or nursing home diagnosed with delirium, SSD, dementia, or no-delirium/no-dementia (NDND). Symptom profiles were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98).

Results

Twenty percent patients had delirium, 19.3% had SSD, 29.8% had dementia-only, and 31% had NDND. Eighty-one percent of subsyndromal and 76% of delirium groups had comorbid dementia. DRS-R98 scores showed ascending severity from NDND < dementia-only < SSD < delirium. DRS-R98 scores for items evaluating the three core symptom domains (cognitive, higher-order thinking, and circadian) distinguished SSD from delirium and both from nondelirium groups. DRS-R98 profiles were essentially the same in delirium and SSD subgroups with or without dementia, although total scale scores were generally higher when in comorbid subgroups.

Discussion

SSD shared characteristic core domain symptoms with delirium, which distinguished each from nondelirium groups, although severity was intermediate in the subsyndromal group. Delirium core symptoms overshadowed the dementia phenotype when comorbid. Milder disturbances of delirium core domain symptoms are highly suggestive of SSD.

The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people

BACKGROUND AND OBJECTIVES

delirium is a distressing but potentially preventable condition common in older people in long-term care. It is associated with increased morbidity, mortality, functional decline, hospitalization and significant healthcare costs. Multicomponent interventions, addressing delirium risk factors, have been shown to reduce delirium by one-third in hospitals. It is not known whether this approach is also effective in long-term care. In previous work, we designed a bespoke delirium prevention intervention, called 'Stop Delirium!' In preparation for a definitive trial of Stop Delirium, we sought to address key aspects of trial design for the particular circumstances of care homes.

DESIGN

a cluster randomized feasibility study with an embedded process evaluation.

SETTING AND PARTICIPANTS

residents of 14 care homes for older people in one metropolitan district in the UK.

INTERVENTION

Stop Delirium!: a 16-month-enhanced educational package to support care home staff to address key delirium risk factors. Control homes received usual care.

MEASUREMENTS

we collected data to determine the following: recruitment and attrition; delirium rates and variability between homes; feasibility of measuring delirium, resource use, quality of life, hospital admissions and falls; and intervention implementation and adherence.

RESULTS

two-thirds (215) of eligible care home residents were recruited. One-month delirium prevalence was 4.0% in intervention and 7.1% in control homes. Proposed outcome measurements were feasible, although our approach appeared to underestimate delirium. Health economic evaluation was feasible using routinely collected data.

CONCLUSION

a definitive trial of delirium prevention in long-term care is needed but will require some further design modifications and pilot work.

Frequency of full, partial and no recovery from subsyndromal deliriumin older hospital inpatients

OBJECTIVES

To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium.

METHODS

SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium.

RESULTS

Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium.

CONCLUSION

Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients.

Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents

OBJECTIVE

This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States.

METHOD

Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity.

CONCLUSION

This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.

The Language of Delirium: Keywords for Identifying Delirium from Medical Records

Electronic medical records (EMRs) offer the opportunity to streamline the search for patients with possible delirium. The purpose of the current study was to identify words and phrases commonly noted in charts of patients with delirium. The current study included 67 patients (nested within a cohort study of 300 patients) ages 70 and older undergoing major elective surgery with evidence of confusion in their medical charts. Eight keywords or phrases had positive predictive values of 60% to 100% for delirium. Keywords were charted more often in nursing notes than physician notes. A brief list of keywords may serve as a building block for a methodology to screen for possible delirium from charts, with particular attention to nursing notes, for research and real-time clinical decision making.

[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.

Nursing Documentation in Long-Term Care Settings

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review

OBJECTIVE

The aim of this study is to provide an overview of prevalence, symptoms, risk factors and prognosis of delirium in primary care and institutionalized long-term care.

DESIGN

The method used in this study is a systematic PubMed search and literature review.

RESULTS

The prevalence of delirium in the population among the elderly aged 65+ years is 1-2%. Prevalence rises with age: 10% among a "general" population aged 85+ years. Prevalence rises up to 22% in populations with higher percentages of demented elder. In long-term care, prevalence ranges between 1.4% and 70%, depending on diagnostic criteria and on the prevalence of dementia. There is a significant increase of the risk of delirium with age and cognitive decline in all groups. Concerning prognosis, most studies agree that older people who previously experienced delirium have a higher risk of dementia and a higher mortality rate. Population and long-term care studies show the same tendency.

CONCLUSIONS

Delirium in a non-selected population aged 65+ years is uncommon. However, prevalence rises very quickly in selected older groups. Primary care doctors should be aware of a relatively high risk of delirium among the elderly in long-term care, those older than 85 years and those with dementia.

Development of a delirium risk screening tool for long-term care facilities

OBJECTIVE

The aim of this study is to develop a delirium risk screening tool for use in long-term care (LTC) facilities.

METHODS

The sample comprised residents aged 65 years and over of seven LTC facilities in Montreal and Quebec City, Canada, admitted for LTC. Primary analyses were conducted among residents without delirium at baseline. Incident delirium was diagnosed using multiple data sources during the 6-month follow-up. Risk factors, all measured at or prior to baseline, included the following six groups: sociodemographic, medical, cognitive status, physical function, agitated behavior, and symptoms of depression. Variables were analyzed individually and by group using Cox regression models. Clinical judgment was used to select the most feasible among similarly performing factors.

RESULTS

The cohort comprised 206 residents without delirium at baseline; 69 cases of incident delirium were observed (rate 7.6 per 100 person weeks). The best-performing screening tool comprised five items, with an overall area under the curve of 0.82 (95% CI 0.76, 0.88). These items included brief measures of cognitive status, physical function, behavioral, and emotional problems. Using cut-points of 2 (or 3) over 5, the scale has a sensitivity of 90% (63%), specificity of 59% (85%), and positive predictive value of 52% (66%).

CONCLUSIONS

This brief screening tool allows nurses to identify LTC residents at increased risk for delirium. These residents can be targeted for closer monitoring and preventive interventions.

The prevalence, incidence and risk factors for delirium in Dutch nursing homes and residential care homes

OBJECTIVE

To estimate and compare the prevalence and incidence of delirium and its risk factors in residents of Dutch nursing homes and residential care homes.

METHODS

Data were extracted from the Long-Term Care Facility (inter RAI-LTCF) version of the Resident Assessment Instrument, which was filled in a routine care cohort for a total of 3627 residents. 828 residents of six nursing homes and 1365 residents of 23 residential homes were included in the analyses. Delirium was defined as a positive score on the adjusted Nursing Home-CAM.

RESULTS

The prevalence of delirium was 8.9% in the nursing homes and 8.2% in the residential homes. The incidence was highest in the nursing homes with 20.7 versus 14.6 per 100 person-years. Multivariate tests of risk factors for developing delirium included chair restraints (OR 2.3; 95% CI 1.27-4.28), dementia (odds ratio (OR) 3.3; 95% confidence interval (CI) 2.03-5.24) and Parkinson's disease (OR 2.3; 95% CI 0.96-5.63) for residents in nursing homes, and dementia (OR 1.8; 95% CI 1.31-2.55) and fall incidents (OR 1.7; 95% CI 1.20-2.48) for residents in residential care homes.

CONCLUSION

The prevalence and incidence of delirium was high in both nursing homes and residential care homes. More focus on modifiable risk factors such as the use of restraints in nursing homes and fall incidents in residential care homes may help to prevent delirium.

Delirium in elderly people: a review

The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.

Delirium in older adults

Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis, and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and nonpharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and nonpharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research.