The Effect of an Impaired Arousal on Short- and Long-Term Mortality of Elderly Patients Admitted to an Acute Geriatric Unit

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

VE-CAM-S: Visual EEG-Based Grading of Delirium Severity and Associations With Clinical Outcomes

Supplemental Digital Content is available in the text.

To develop a physiologic grading system for the severity of acute encephalopathy manifesting as delirium or coma, based on EEG, and to investigate its association with clinical outcomes.

Delirium symptoms duration and mortality in SARS-COV2 elderly: results of a multicenter retrospective cohort study

Background

Since the occurrence of the SARS-COV2 pandemic, there has been an increasing interest in investigating the epidemiology of delirium. Delirium is frequent in SARS-COV2 patients and it is associated with increased mortality; however, no information is available on the association between delirium duration in SARS-COV2 patients and related outcomes.

Aims

The aim of this study is to investigate the association between the duration of delirium symptoms and in-hospital mortality in older patients with SARS-COV2 infection.

Methods

Retrospective cohort study of patients 65 years of age and older with SARS-CoV 2 infection admitted to two acute geriatric wards and one rehabilitation ward. Delirium symptoms duration was assessed retrospectively with a chart-based validated method. In-hospital mortality was ascertained via medical records.

Results

A total of 241 patients were included. The prevalence of delirium on admission was 16%. The median number of days with delirium symptoms was 4 (IQR 2–6.5) vs. 0 (IQR 0–2) in patients with and without delirium on admission. In the multivariable Cox regression model, each day with a delirium symptom in a patient with the same length of stay was associated with a 10% increase in in-hospital mortality (Hazard ratio 1.1, 95% Confidence interval 1.01–1.2; p = 0.03). Other variables associated with increased risk of in-hospital death were age, comorbidity, CPAP, CRP levels and total number of drugs on admission.

Conclusions

The study supports the necessity to establish protocols for the monitoring and management of delirium during emergency conditions to allow an appropriate care for older patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01899-8.

Delirium in older adults

This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.

Arousal changes and delirium in acute medically-ill male older patients with and without dementia: a prospective study during hospitalization

Objectives: Previous research has characterized the prevalence, natural course and outcomes of delirium superimposed in dementia but much less is known about the relation between preexisting dementia and the emergence of altered arousal (such as drowsiness, obtundation, stupor or agitation) during acute medical illness. This study aimed to determine the natural course of delirium and abnormal arousal states in acute medically-ill older patients with and without prior dementia during hospital stay.Methods: Observational prospective study in an acute male geriatric ward. Patients aged ≥ 65 years old were assessed by a psychiatrist within the first 72h of admission and in every other day until discharge to determine the level of arousal and the presence of delirium. Prior cognitive impairment, sociodemographic data, chronic comorbidities, psychotropic prescription and functional status were assessed at baseline.Results: 43.5% of participants in the final sample (n= 269) had dementia. Prior dementia was associated with higher rates of moderate/severe hypoarousal (29.9% vs. 4.6%; p<0.001) and delirium (20.5% vs. 7.2%; p<0.001) at admission. RASS ≤ -3 at admission predicted a 4-fold increased intra-hospital mortality risk and RASS ≠ 0 had a sensitivity of 82.8% and a specificity of85.9% for delirium.Conclusions: Moderate/severe hypoarousal is associated with adverse outcomes and should be assessed as part of delirium spectrum, particularly in subjects with prior dementia.

Association Between Level of Arousal and 30-Day Survival in Acutely Ill Older Adults

OBJECTIVE

To investigate the association between impaired arousal on admission and 30-day mortality in acutely ill older adults.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients age +65 years admitted to the geriatric ward of a tertiary university hospital from 2010 to 2018 in Sao Paulo, Brazil.

METHODS

Participants were evaluated on admission according to a standardized comprehensive geriatric assessment model. Delirium was detected using the short version of the Confusion Assessment Method (Short-CAM). We used 2 alternative criteria to define impaired arousal: lethargy, stupor, or coma according to the Short-CAM; and a Glasgow Coma Scale (GCS) score of ≤13. Our primary outcome was time-to-death in 30 days, and we used Cox proportional hazards models to explore the association between impaired arousal and decreased survival.

RESULTS

We included 1554 admissions with a mean age of 81 years and of whom 61% were women. Overall, prevalent delirium was observed in 28% of the cases. We found that in 33% of admissions, patients were lethargic, stuporous, or comatose, and that in 23%, they had GCS scores of ≤13. General 30-day mortality was 19% but reached 32% in patients with GCS scores of ≤13. Impaired arousal was independently associated with lower survival in 30 days, both when defined using Short-CAM criteria [lethargy + stupor + coma: hazard ratio (HR) 2.33, 95% confidence interval (CI) 1.66‒3.27] and GCS scores (GCS 12‒13: HR 1.62, 95% CI 1.13‒2.33; GCS ≤ 11: HR 2.53, 95% CI 1.68‒3.80). In interaction analyses, we confirmed our results in patients who had impaired arousal but were neither delirious (lethargy + stupor + coma: HR 2.16, 95% CI 1.44‒3.24; GCS ≤ 11: HR 3.07; 95% CI 1.50‒6.29) nor demented (lethargy + stupor + coma: HR 1.95, 95% CI 1.15‒3.28).

CONCLUSIONS AND IMPLICATIONS

Level of arousal on admission was an independent predictor of 30-day survival in acutely ill older adults, regardless of delirium or baseline dementia. Clinicians should be aware that even if unsure of whether a patient has delirium, arousal assessment can provide crucial clinical and prognostic insight.

Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia

The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.

Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method

BACKGROUND

Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM).

METHODS

This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment.

RESULTS

Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%).

CONCLUSIONS

The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care.

TRIAL REGISTRATION

International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.

Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis

Background

Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality.

Methods

We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model.

Results

From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias).

Conclusions

Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0661-7) contains supplementary material, which is available to authorized users.

Association Between Preoperative Malnutrition and Postoperative Delirium After Hip Fracture Surgery in Older Adults

OBJECTIVES

To determine whether poor nutritional status can predict postoperative delirium in elderly adults undergoing hip fracture surgery.

DESIGN

Prospective observational cohort study.

SETTING

Italian orthogeriatric unit.

PARTICIPANTS

Individuals aged 70 and older (mean age 84.0 ± 6.6, 74.5% female) consecutively admitted for surgical repair of a proximal femur fracture between September 2012 and April 2016 (N = 415).

MEASUREMENTS

Participants underwent a comprehensive geriatric assessment including nutritional status, which was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). The MNA-SF-based three-class stratification was tested using multivariable logistic regression to assess its role in predicting postoperative delirium (outcome).

RESULTS

Seventy-eight malnourished individuals (MNA-SF score 0-7), 185 at risk of malnutrition (MNA-SF score 8-11), and 152 who were well nourished (MNA-SF score 12-14) were compared. On average, individuals with poor nutritional status were more disabled and more cognitively impaired than those who were well nourished and those at risk of malnutrition. Moreover, those who were malnourished were more likely to have postoperative delirium. Multivariate regression analysis adjusted for age, sex, comorbidity, functional impairment, preoperative cognitive status, and American Society of Anesthesiologists score showed that those who were at risk of malnutrition (odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.29-4.53) and those who were overtly malnourished (OR = 2.98, 95% CI = 1.43-6.19) were more likely to develop postoperative delirium.

CONCLUSION

This is the first study in a Western population showing that risk of malnutrition and overt malnutrition, as assessed using the MNA-SF, are independent predictors of postoperative delirium. Accordingly, nutritional status should be assessed in individuals with hip fracture before surgery to determine risk of developing delirium.

Detecting Delirium Superimposed on Dementia: Evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale

OBJECTIVES

Delirium disproportionately affects patients with dementia and is associated with adverse outcomes. The diagnosis of delirium superimposed on dementia (DSD), however, can be challenging due to several factors, including the absence of caregivers or the severity of preexisting cognitive impairment. Altered level of consciousness has been advocated as a possible useful indicator of delirium in this population. Here we evaluated the performance of the Richmond Agitation and Sedation Scale (RASS) and the modified-RASS (m-RASS), an ultra-brief measure of the level of consciousness, in the diagnosis of DSD.

DESIGN

Multicenter prospective observational study. RASS and m-RASS results were analyzed together, labeled RASS/m-RASS.

SETTING

Acute geriatric wards, in-hospital rehabilitation, emergency department.

PARTICIPANTS

Patients 65 years and older with dementia.

MEASUREMENTS

Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or with the Delirium Rating Scale-Revised (DRS-R-98), or with the 4 A's Test (4AT). Dementia was detected with the Clinical Dementia Rating (CDR) Scale, the Short Form-Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or via the clinical records.

RESULTS

Of the 645 patients included, 376 (58%) had delirium. According to the instrument used to evaluate delirium, the prevalence was 66% with the 4AT, 23% with the DSM, and 100% with the DRS-R-98. Overall a RASS/m-RASS score other than 0 was 70.5% sensitive (95% confidence interval [CI] 65.9%-75.1%) and 84.8% (CI 80.5%-89.1%) specific for DSD. Using a RASS/m-RASS value greater than +1 or less than -1 as a cutoff, the sensitivity was 30.6% (CI 25.9%-35.2%) and the specificity was 95.5% (CI 93.1%-98.0%). The sensitivity and the specificity did not greatly vary according to the method of delirium diagnosis and the dementia ascertainment, although the specificity was slightly higher when the DSM and the IQCODE were used.

CONCLUSION

In older patients admitted to different clinical settings, the RASS and m-RASS analyzed as a single group had moderate sensitivity and very high specificity for the detection of DSD. Level of consciousness is therefore a valuable clinical indicator that should form part of delirium screening strategies, although for higher sensitivity other methods of assessment should be used.