Delirium in Postacute and Long-term Care

Postoperative Delirium in Patients After Brain Tumor Surgery

BACKGROUND

Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium.

METHODS

Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05.

RESULTS

Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536).

CONCLUSIONS

Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.

Emergency physician recognition of delirium

OBJECTIVE

To compare the recognition of delirium by emergency physicians based on observations made during routine clinical care with concurrent ratings made by a trained researcher after formal cognitive assessment and to examine each of the four individual features of delirium separately to determine the variation in identification across features.

METHODS

In a prospective study, a convenience sample of 259 patients, aged ≥65 years, who presented to two urban, teaching hospital emergency departments (EDs) in Western Pennsylvania between 21 June and 29 August 2011, underwent paired delirium ratings by an emergency physician and a trained researcher. Emergency physicians were asked to use their clinical judgment to decide whether the patient had any of the following delirium features: (1) acute change in mental status, (2) inattention, (3) disorganised thinking and (4) altered level of consciousness. Questions were prompted with examples of delirium features from the Confusion Assessment Method. Concurrently, a trained researcher interviewed surrogates to determine feature 1, conducted a cognitive test for delirium (Confusion Assessment Method for the intensive care unit) to determine delirium features 2 and 3 and used the Richmond Agitation and Sedation Scale to determine feature 4.

RESULTS

In the 2-month study period, trained researchers identified delirium in 24/259 (9%; 95% CI 0.06 to 0.13) older patients admitted to the ED. However, attending emergency physicians recognised delirium in only 8 of the 24 and misidentified delirium in a further seven patients. Emergency physicians were particularly poor at recognising altered level of consciousness but were better at recognising acute change in mental status and inattention.

CONCLUSIONS

When emergency physicians use routine clinical observations, they may miss diagnosing up to two-thirds of patients with delirium. Recognition of delirium can be enhanced with standardised cognitive testing.

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.

Stop Delirium! A complex intervention to prevent delirium in care homes: a mixed-methods feasibility study

BACKGROUND

delirium is likely to be particularly common in care homes, given the clustering of known risk factors in these settings. Preventing delirium should result in significant benefits, including better quality of care and improved outcomes for residents.

OBJECTIVE

to test the feasibility of 'Stop Delirium!', an intervention to prevent delirium in care homes for older people, and to optimise parameters to inform the design of a future trial evaluation.

METHOD

we delivered Stop Delirium! to six care homes over 10 months, in a mixed methods before and after study.

RESULTS

Stop Delirium! was successfully implemented in the study homes. We found evidence supporting positive changes in staff attitudes and practice after the intervention. Although qualitative data suggested it was too early to expect changes in resident outcomes, we also found preliminary evidence suggesting potential improvements in a range of outcomes, including a reduction in the number of falls and prescribed medications.

CONCLUSION

a complex intervention for delirium prevention in care homes is feasible and has the potential to improve staff practice and outcomes for residents. This work provides the basis for the next phase of the evaluation to establish its effectiveness and cost-effectiveness.

Insomnia among hospitalized older persons

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit

OBJECTIVES

This study investigates the cognitive, functional, and clinical variables associated with the risk of institutionalization, rehospitalization, and death at 12 months among a population of elderly discharged from a Rehabilitation and Aged Care Unit (RACU) within a 1-year period (May 1, 2004 to April 30, 2005). The RACU is a relatively new setting of care providing intensive rehabilitation and clinical support to elderly with highly heterogeneous reasons for admission.

METHODS

There were 1303 patients (> or =65 years old) contacted 12 months after discharge from the RACU. We obtained information about institutionalization, rehospitalization, and death. Predictors were all the demographic and clinical variables potentially related to these outcomes. The relationship among predictors and outcomes was tested with multiple stepwise logistic regression models.

RESULTS

Among the 1072 patients alive at the 12-month follow-up, 90 (8.4%) were institutionalized (3.4% early at discharge and 4.9% within the next period). The logistic regression analysis showed that 2 ranges of age (78 to 83 years and 84 years or more), living alone, occurrence of delirium, cognitive impairment (Mini Mental State Examination lower or equal to 20/30), and poor functional status at discharge (Barthel Index scores ranging from 69 to 85 and Barthel Index scores lower than 68/100) were independently and significantly associated with the risk of institutionalization during the 12 months following discharge from the RACU. Three hundred and twenty-three (30.1%) patients had been rehospitalized once and 86 (8.0%) patients twice at the 12-month follow-up. In the multivariate analysis, comorbidity (Charlson Index scores ranging from 2 to 3 and Charlson Index scores higher than 4) and delirium were significantly and independently associated with this outcome. One hundred and thirty-six (11.3%) patients had died by the 12-month follow-up. The stepwise logistic regression analysis showed that age greater than 83 years, poor functional status (Barthel Index lower than 60/100 at discharge), high comorbidity (Charlson Index scores ranging from 3 to 4 and Charlson Index scores higher than 4, respectively), and albumin serum levels ranging from 3.2 to 2.9 mg/dL and lower than 2.9 mg/dL independently and significantly predicted the 12-month risk of death. Absence of depressive symptoms (Geriatric Depression Scale <2/15) had instead a protective effect.

CONCLUSION

Variables related to the sociodemographic, cognitive, functional, and health status predicted, with different degree of association, the 12-month risk of institutionalization, rehospitalization, and death among a population of elderly patients discharged from a RACU. Accordingly, various clinical and organizational approaches may be planned for prevention.