The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis

Modified frailty index effectively predicts adverse outcomes in sepsis patients in the intensive care unit

BACKGROUND

Frailty and sepsis have a significant impact on patient prognosis. However, research into the relationship between frailty and sepsis in the general adult population remains inadequate. This paper aims to investigate the association between frailty and adverse outcomes in this population.

METHOD

This retrospective analysis investigated sepsis patients who were initially admitted to the intensive care unit (ICU). The Modified Frailty Index (MFI) was derived by tracking patients' International Classification of Diseases (ICD) codes during their hospitalization. Patients were classified into two groups based on their MFI scores: a frail group (MFI ≥ 3) and a non-frail group (MFI = 0-2). The key outcomes were mortality rates at 90 and 180 days, with secondary outcomes including the incidence of delirium and pressure injury.

RESULT

Of the 21,338 patients who were recruited for this study (median age about 68 years, 41.8 % female), 5,507 were classified as frail and 15,831 were classified as non-frail. Frail patients were significantly more likely to have delirium (48.9 % vs. 36.1 %, p < 0.001) and pressure injury (60.5 % vs. 51.4 %, p < 0.001). After controlling for confounding variables, the multifactorial Cox proportional hazard regression analyses revealed a significantly elevated mortality rate at 90 days (adjusted HR: 1.58, 95 % CI: 1.24-2.02, p < 0.001) and 180 days (adjusted HR: 1.47, 95 % CI: 1.18, 1.83, p < 0.001) in the frail group compared to their non-frail counterparts.

CONCLUSIONS

Frailty independently predisposes adult sepsis patients in the ICU to adverse outcomes. Future investigations should concentrate on evaluating frailty and developing targeted interventions to improve patient prognosis.

IMPLICATION FOR CLINICAL PRACTICE

The MFI provides a simple clinical assessment tool that can be integrated into electronic medical records for immediate calculation. This simplifies the assessment process and plays a key role in predicting patient outcomes.

Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity

BACKGROUND

Recent studies have reported an association between presurgical frailty and postoperative delirium. However, it remains unclear whether the frailty-delirium relationship differs by measurement tool (e.g., frailty index vs. frailty phenotype) and whether frailty is associated with delirium, independent of preoperative cognition.

METHODS

We used the successful aging after elective surgery (SAGES) study, a prospective cohort of older adults age ≥70 undergoing major non-cardiac surgery (N = 505). Preoperative measurement of the modified mini-mental (3MS) test, frailty index and frailty phenotype were obtained. The confusion assessment method (CAM), supplemented by chart review, identified postoperative delirium. Delirium feature severity was measured by the sum of CAM-severity (CAM-S) scores. Generalized linear models were used to determine the relative risk of each frailty measure with delirium incidence and severity. Subsequent models adjusted for age, sex, surgery type, Charlson comorbidity index, and 3MS.

RESULTS

On average, patients were 76.7 years old (standard deviation 5.22), 58.8% of women. For the frailty index, the incidence of delirium was 14% in robust, 17% in prefrail, and 31% in frail patients (p < 0.001). For the frailty phenotype, delirium incidence was 13% in robust, 21% in prefrail, and 27% in frail patients (p = 0.016). Frailty index, but not phenotype, was independently associated with delirium after adjustment for comorbidities (relative risk [RR] 2.13, 95% confidence interval [CI] 1.23-3.70; RR 1.61, 95% CI 0.77-3.37, respectively). Both frailty measures were associated with delirium feature severity. After adjustment for preoperative cognition, only the frailty index was associated with delirium incidence; neither index nor phenotype was associated with delirium feature severity.

CONCLUSION

Both the frailty index and phenotype were associated with the development of postoperative delirium. The index showed stronger associations that remained significant after adjusting for baseline comorbidities and preoperative cognition. Measuring frailty prior to surgery can assist in identifying patients at risk for postoperative delirium.

Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults

AIM

To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients.

METHODS

A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non-frail (MFI = 0-2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated.

RESULTS

Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non-frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23-2.10, p < 0.001, E-value: 1.85).

CONCLUSIONS

Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes.

ICU admission Braden score independently predicts delirium in critically ill patients with ischemic stroke

BACKGROUND

Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management.

OBJECTIVE

To examine the association between the Braden score and delirium.

METHODS

A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated.

RESULTS

The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001).

CONCLUSIONS

The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke.

IMPLICATION FOR CLINICAL PRACTICE

The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs.

Can admission Braden skin score predict delirium in older adults in the intensive care unit? Results from a multicenter study

AIMS AND OBJECTIVES

To investigate whether a low Braden Skin Score (BSS), reflecting an increased risk of pressure injury, could predict the risk of delirium in older patients in the intensive care unit (ICU).

BACKGROUND

Delirium, a common acute encephalopathy syndrome in older ICU patients, is associated with prolonged hospital stay, long-term cognitive impairment and increased mortality. However, few studies have explored the relationship between BSS and delirium.

DESIGN

Multicenter cohort study.

METHODS

The study included 24,123 older adults from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and 1090 older adults from the eICU Collaborative Research Database (eICU-CRD), all of whom had a record of BSS on admission to the ICU. We used structured query language to extract relevant data from the electronic health records. Delirium, the primary outcome, was primarily diagnosed by the Confusion Assessment Method for the ICU or the Intensive Care Delirium Screening Checklist. Logistic regression models were used to validate the association between BSS and outcome. A STROBE checklist was the reporting guide for this study.

RESULTS

The median age within the MIMIC-IV and eICU-CRD databases was approximately 77 and 75 years, respectively, with 11,195 (46.4%) and 524 (48.1%) being female. The median BSS at enrollment in both databases was 15 (interquartile range: 13, 17). Multivariate logistic regression showed a negative association between BSS on ICU admission and the prevalence of delirium. Similar patterns were found in the eICU-CRD database.

CONCLUSIONS

This study found a significant negative relationship between ICU admission BSS and the prevalence of delirium in older patients.

RELEVANCE TO CLINICAL PRACTICE

The BSS, which is simple and accessible, may reflect the health and frailty of older patients. It is recommended that BSS assessment be included as an essential component of delirium management strategies for older patients in the ICU.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a retrospective cohort study, and no patients or the public were involved in the design and conduct of the study.

Frailty index and risk of delirium in hospitalized patients: a two-sample Mendelian randomization study

Objective

Observational studies suggest that the frailty index (FI) is closely related to delirium, but the relationship between them is still uncertain due to the influence of various confounding factors. Therefore, two-sample Mendelian randomization (MR) was used to explore the causal relationship between the FI and delirium risk.

Methods

This study obtained pooled statistics for the FI and delirium from two of the most extensive genome-wide association studies. To make the results more robust and reliable, supplementary analyses were performed using several robust analytical methods (inverse-variance weighting, MR-Egger regression, and weighted median). In addition, this study used the MR-Egger intercept test, Cochran's Q test, funnel plots and the leave-one-out method to evaluate the pleiotropy and heterogeneity among the abovementioned genetic variation instrumental variables.

Results

Frailty might increase the relative risk of delirium, as shown by IVW (OR = 1.849, 95% CI 0.027∼2.067, P = 0.044), weighted median (OR = 1.726, 95% CI -0.178∼2.664, P = 0.083), MR-Egger regression (OR = 1.768, 95% CI -3.08∼6.171, P = 0.525) and leave-one-out sensitivity analysis (P = 0.058). Although the WME method and MR-Egger regression analysis showed no statistically significant causal relationship between the FI and the risk of delirium, the direction of the causal effect was consistent with the IVW method.

Conclusion

There is a notable correlation between a higher FI and an elevated risk of delirium. This indicates that healthcare providers should take proactive measures to prevent delirium in hospitalized patients with a higher FI.

The intersection of frailty and metabolism

On average, aging is associated with unfavorable changes in cellular metabolism, which are the processes involved in the storage and expenditure of energy. However, metabolic dysregulation may not occur to the same extent in all older individuals as people age at different rates. Those who are aging rapidly are at increased risk of adverse health outcomes and are said to be "frail." Here, we explore the links between frailty and metabolism, including metabolic contributors and consequences of frailty. We examine how metabolic diseases may modify the degree of frailty in old age and suggest that frailty may predispose toward metabolic disease. Metabolic interventions that can mitigate the degree of frailty in people are reviewed. New treatment strategies developed in animal models that are poised for translation to humans are also considered. We suggest that maintaining a youthful metabolism into older age may be protective against frailty.

Factors associated with delirium in a real-world acute-care setting: analysis considering the interdependence of clinical variables with the frailty syndrome

PURPOSE

Delirium risk assessment in the acute-care setting generally does not account for frailty. The objective of this retrospective study was to identify factors associated with delirium, considering the interdependency of clinical variables with frailty syndrome in complex older patients.

METHODS

The clinical records of 587 participants (248 M, median age 84) were reviewed, collecting clinical, anamnestic and pharmacological data. Frailty syndrome was assessed with the Clinical Frailty Scale (CFS). Delirium was the main study endpoint. The correlations of the considered anamnestic and clinical variables with delirium and its subtypes were investigated selecting only those variables not showing a high overlap with frailty. Correlations associated with a 25% excess of frequency of delirium in comparison with the average of the population were considered as statistically significant.

RESULTS

Delirium was detected in 117 (20%) participants. The presence of one among age > 85 years old, CFS > 4 and invasive devices explained 95% of delirium cases. The main factors maximizing delirium incidence at the individual level were dementia, other psychiatric illness, chronic antipsychotic treatment, and invasive devices. The coexistence of three of these parameters was associated with a peak frequency of delirium, ranging from 57 to 61%, mostly hypoactive forms.

CONCLUSIONS

In acute-care wards, frailty exhibited a strong association with delirium during hospitalization, while at the individual level, dementia and the use of antipsychotics remained important risk factors. Modern clinical prediction tools for delirium should account for frailty syndrome.

Geriatric nutritional risk index independently predicts delirium in older patients in intensive care units: A multicenter cohort study

BACKGROUND

Malnutrition is associated with clinical outcomes in several diseases. However, the role of malnutrition in the risk of delirium in elderly patients in intensive care units (ICU) remains unclear. This study aimed to elucidate the association between the Geriatric Nutritional Risk Index (GNRI) and the risk of delirium in elderly patients in the ICU.

METHODS

Elderly patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD) were included in this study, totaling 11,310 and 5,627, respectively. All subjects were stratified according to their GNRI score: those with no nutritional risk (GNRI > 98), mild nutritional risk (92 ≤ GNRI ≤ 98), moderate nutritional risk (82 ≤ GNRI ≤ 92), and severe nutritional risk (GNRI < 82). The primary outcome was delirium.

RESULTS

The GNRI in MIMIC-IV and eICU-CRD were 93.82 (84.88, 101.26) and 83.39 (75.95, 89.35), respectively. Compared to the cohort without nutritional risk, there was an increased risk of delirium in patients with mild nutritional risk (OR: 1.39, 95 % CI: 1.23-1.58), moderate nutritional risk (OR: 1.72, 95 % CI: 1.52-1.95), and severe nutritional risk (OR: 2.07, 95 % CI: 1.79-2.39). Inclusion of the GNRI score in the multivariate models improved the prediction of delirium. Similar results were found in the eICU-CRD database.

CONCLUSIONS

Nutritional assessment using the GNRI may be an independent predictor of the development of delirium in elderly patients in the ICU. The addition of the GNRI score to the delirium prediction model improves its predictive accuracy.

Delirium is more common and associated with worse outcomes in Parkinson's disease compared to older adult controls: results of two prospective longitudinal cohort studies

BACKGROUND

Inpatient prevalence of Parkinson's disease (PD) delirium varies widely across the literature. Delirium in general older populations is associated with adverse outcomes, such as increased mortality, dementia, and institutionalisation. However, to date there are no comprehensive prospective studies in PD delirium. This study aimed to determine delirium prevalence in hospitalised PD participants and the association with adverse outcomes, compared to a control group of older adults without PD.

METHODS

Participants were hospitalised inpatients from the 'Defining Delirium and its Impact in Parkinson's Disease' and the 'Delirium and Cognitive Impact in Dementia' studies comprising 121 PD participants and 199 older adult controls. Delirium was diagnosed prospectively using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Outcomes were determined by medical note reviews and/or home visits 12 months post hospital discharge.

RESULTS

Delirium was identified in 66.9% of PD participants compared to 38.7% of controls (p < 0.001). In PD participants only, delirium was associated with a significantly higher risk of mortality (HR = 3.3 (95% confidence interval [CI] = 1.3-8.6), p = 0.014) and institutionalisation (OR = 10.7 (95% CI = 2.1-54.6), p = 0.004) 12 months post-discharge, compared to older adult controls. However, delirium was associated with an increased risk of developing dementia 12 months post-discharge in both PD participants (OR = 6.1 (95% CI = 1.3-29.5), p = 0.024) and in controls (OR = 13.4 (95% CI = 2.5-72.6), p = 0.003).

CONCLUSION

Delirium is common in hospitalised PD patients, affecting two thirds of patients, and is associated with increased mortality, institutionalisation, and dementia. Further research is essential to understand how to accurately identify, prevent and manage delirium in people with PD who are in hospital.

Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review

INTRODUCTION

Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms.

CASE PRESENTATION

We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery.

CONCLUSION

RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Update on Perioperative Delirium

A strong association between frailty and in-hospital delirium in nonsurgical patients has been shown. Physical and cognitive frailties have been associated with decline and dysfunction in the frontal cognitive domains. Risk factors for frailty are similar to risk factors for postoperative delirium (POD). Frailty can be screened and diagnosed by various tools and instruments. Different anesthetic techniques have been studied to decrease the incidence of POD. However, no anesthetic technique has been conclusively proven to decrease the risk of POD. Patients with dementia develop delirium more often, and delirium is associated with accelerated cognitive decline.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Symptom Management in the Older Adult: 2023 Update

In the older adult with a serious illness, the goal of palliative medicine and symptom management is to optimize quality of life. Frailty has become an overarching finding in many older adults with serious illness. Symptom management options need to be considered in the lens of increasing frailty along an illness trajectory. Here, the authors emphasize literature updates and best practices for the most common symptoms experienced by the older adult with a serious illness.

Medium and long-term prognosis in hospitalised older adults with multimorbidity. A prospective cohort study

BACKGROUND

Data about long-term prognosis after hospitalisation of elderly multimorbid patients remains scarce.

OBJECTIVES

Evaluate medium and long-term prognosis in hospitalised patients older than 75 years of age with multimorbidity. Explore the impact of gender, age, frailty, physical dependence, and chronic diseases on mortality over a seven-year period.

METHODS

We included prospectively all patients hospitalised for medical reasons over 75 years of age with two or more chronic illnesses in a specialised ward. Data on chronic diseases were collected using the Charlson comorbidity index and a questionnaire for disorders not included in this index. Demographic characteristics, Clinical Frailty Scale, Barthel index, and complications during hospitalisation were collected.

RESULTS

514 patients (46% males) with a mean age of 85 (± 5) years were included. The median follow-up was 755 days (interquartile range 25-75%: 76-1,342). Mortality ranged from 44% to 68%, 82% and 91% at one, three, five, and seven years. At inclusion, men were slightly younger and with lower levels of physical impairment. Nevertheless, in the multivariate analysis, men had higher mortality (p<0.001; H.R.:1.43; 95% C.I.95%:1.16-1.75). Age, Clinical Frailty Scale, Barthel, and Charlson indexes were significant predictors in the univariate and multivariate analysis (all p<0.001). Dementia and neoplastic diseases were statistically significant in the unadjusted but not the adjusted model. In a cluster analysis, three patterns of patients were identified, with increasing significant mortality differences between them (p<0.001; H.R.:1.67; 95% CI: 1.49-1.88).

CONCLUSIONS

In our cohort, individual diseases had a limited predictive prognostic capacity, while the combination of chronic illness, frailty, and physical dependence were independent predictors of survival.

The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons

Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.

Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study

INTRODUCTION

Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI).

METHODS

We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI.

RESULTS

The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92).

CONCLUSIONS

The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.

Delirium is significantly associated with hospital frailty risk score derived from administrative data

OBJECTIVES

Delirium is highly prevalent in hospitalised older adults, under-diagnosed and associated with poor outcomes. We aim to determine (i) association of frailty measured using Hospital Frailty Risk Score (HFRS) with delirium, (ii) impact of delirium on mortality, 30-days readmission, extended length of stay (eLOS) and cost (eCOST).

METHODS

Retrospective cohort study was conducted on 902 older adults ≥75 years discharged from an academic tertiary hospital between March and September 2021. Data was obtained from hospital administrative database.

RESULTS

Delirium was prevalent in 39.1%, 58.1% were female with mean age 85.3 ± 6.2 years. Patients with delirium were significantly older, had higher HFRS, pneumonia, urinary tract infection (UTI), E.coli and Klebsiella infection, constipation, dehydration, stroke and intracranial bleed, with comorbidities including dementia, diabetes, hypertension, hyperlipidaemia and chronic kidney disease. In-hospital mortality, 30-days mortality, 30-days readmission, median LOS and cost was significantly higher. Delirium was significantly associated with at least intermediate frailty (OR = 3.52; CI = 2.48-4.98), dementia (OR = 2.39; CI = 1.61-3.54), UTI (OR = 1.95; CI = 1.29-2.95), constipation (OR = 2.49; CI = 1.43-4.33), Klebsiella infection (OR = 3.06; CI = 1.28-7.30), dehydration (OR = 2.01; CI = 1.40 - 2.88), 30-day mortality (OR = 2.52; CI = 1.42-4.47), 30-day readmission (OR = 2.18; CI = 1.36-3.48), eLOS (OR = 1.80; CI = 1.30-2.49) and eCOST (OR = 1.67; CI = 1.20-2.35).

CONCLUSIONS

Delirium was highly prevalent in older inpatients, and associated with dementia, frailty, increased cost, LOS, 30-day readmissions and mortality. Hospital Frailty Risk Score had robust association with delirium and can be auto-populated from electronic medical records. Prospective studies are needed on multicomponent delirium preventive measures in high-risk groups identified by HFRS in acute care settings.

Mediating effects of cognitive reserve on the relationship between frailty and cognition in older people without dementia

PURPOSE

This study aimed to explore the potential mediating effects of cognitive reserve on the association between frailty and cognition in the older people without dementia.

METHODS

We performed a cross-sectional analysis of data from 3122 community-dwelling older adults (≥ 65-years-old) without dementia of the Cognitive Function and Ageing Study in Wales. A 31-item frailty index was used to assess frailty. A cognitive lifestyle score was constructed to evaluate cognitive reserve, which includes participants' educational level, occupational attainment, and engagement in social and cognitive activities in later life. Linear regression and mediation modeling were used to investigate the relationship between frailty and cognition and the mediating effects of cognitive reserve as well as social and cognitive activities, an alterable component of cognitive reserve for older adults.

RESULTS

Frailty was negatively associated with cognition. Cognitive reserve was a mediator of the association between frailty and global cognition (- 1.92; 95% CI: - 2.50, - 1.35), as well as individual cognitive domains, with indirect effects contributing to 13-59% of the total effects. Social and cognitive activities have smaller but similar mediating effects on these associations.

CONCLUSIONS

Negative effect of frailty on cognition was partially mediated by a reduction in cognitive reserve. Our results support the possibility that enhancing cognitive reserve, especially engagement in social and cognitive activities may protect cognitive health against frailty.

Association between frailty, delirium, and mortality in older critically ill patients: a binational registry study

Background

Frailty and delirium are prevalent among older adults admitted to the intensive care unit (ICU) and associated with adverse outcomes; however, their relationships have not been extensively explored. This study examined the association between frailty and mortality and length of hospital stay (LOS) in ICU patients, and whether the associations are mediated or modified by an episode of delirium.

Methods

Retrospective analysis of data from the Australian New Zealand Intensive Care Society Adult Patient Database. A total of 149,320 patients aged 65 years or older admitted to 203 participating ICUs between 1 January 2017 and 31 December 2020 who had data for frailty and delirium were included in the analysis.

Results

A total of 41,719 (27.9%) older ICU patients were frail on admission, and 9,179 patients (6.1%) developed delirium during ICU admission. Frail patients had significantly higher odds of in-hospital mortality (OR: 2.15, 95% CI 2.05–2.25), episodes of delirium (OR: 1.86, 95% CI 1.77–1.95), and longer LOS (log-transformed mean difference (MD): 0.24, 95% CI 0.23–0.25). Acute delirium was associated with 32% increased odds of in-hospital mortality (OR: 1.32, 95% CI 1.23–1.43) and longer LOS (MD: 0.54, 95% CI 0.50–0.54). The odds ratios (95% CI) for in-hospital mortality were 1.37 (1.23–1.52), 2.14 (2.04–2.24) and 2.77 (2.51–3.05) for non-frail who developed delirium, frail without delirium, and frail and developed delirium during ICU admission, respectively. There was very small but statistically significant effect of frailty on in-hospital mortality (b for indirect effect: 0.00037, P < 0.001) and LOS (b for indirect effect: 0.019, P < 0.001) mediated through delirium.

Conclusion

Both frailty and delirium independently increase the risk of in-hospital mortality and LOS. Acute delirium is more common in frail patients; however, it does not mediate or modify a clinically meaningful amount of the association between frailty and in-hospital mortality and LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01080-y.

Decision making in frail patients at risk of postoperative delirium: A case study and literature review

Preoperative frailty is strongly associated with risks of postoperative delirium. However, gaps exist in targeted recommendations for clinical decision making related to surgical interventions in frail older patients. A case study is presented involving a frail 74-year-old referred to the palliative care team for assistance with clinical decision making and in weighing risks and benefits of a surgical intervention. A literature review on the quantification of postoperative delirium risk and how this information might inform medical decision making in frail surgical patients did not identify clear clinical guidelines. In the absence of practice guidelines, the Patient Priorities Care model is proposed as a framework to help providers working with patients and caregivers facing complex medical decisions to better align interventions with patient values.

Delirium in older COVID-19 patients: Evaluating risk factors and outcomes

OBJECTIVES

A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID-19). We aimed to identify determinants of delirium, including the Clinical Frailty Scale, in hospitalized older patients with COVID-19. Furthermore, we aimed to study the association of delirium independent of frailty with in-hospital outcomes in older COVID-19 patients.

METHODS

This study was performed within the framework of the multi-center COVID-OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID-19 in the Netherlands between February and May 2020. Data were collected on demographics, co-morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In-hospital outcomes included length of stay, discharge destination, and mortality.

RESULTS

A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio [OR] 8.9 [95% CI 2.3-33.6] p = 0.001), and pre-existent memory problems (OR 7.6 [95% CI 3.1-22.5] p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 [95%CI 1.40-1.90] p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C-reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 [95% CI1.71-4.72] p < 0.001), but not in multivariable analyses.

CONCLUSIONS

A previous delirium and pre-existent memory problems were associated with delirium risk in COVID-19. Delirium was not an independent predictor of mortality after adjustment for frailty.

Serum C-reactive protein adds predictive information for post-stroke delirium: The PROPOLIS study

OBJECTIVE

Delirium is common and serious complication after stroke. Accurate prediction of delirium is important for prevention and monitoring of high-risk patients. Our study aimed to determine if addition of C-reactive protein (CRP) to a model based on easy-to-access clinical predictors improves accuracy of delirium prediction in acute stroke patients.

METHODS

We analyzed data of patients participating in the Prospective Observational Polish Study on post-stroke delirium. We included patients admitted within 24 h after stroke or transient ischemic attack (TIA) in whom serum CRP was measured on admission. We examined core features of delirium during first 7 days of hospitalization. We assessed if addition of CRP to two clinical models improved metrics of discrimination and reclassification. Model A included age and stroke severity and Model B included stroke severity, atrial fibrillation, diabetes mellitus, pre-stroke dependency, and hemorrhagic stroke.

RESULTS

We included 459 patients. We diagnosed delirium in 29.2% of them. Patients who developed delirium had higher CRP level than those without delirium (median: 13.2 vs. 4.4 mg/L, p < 0.001). CRP >7.09 mg/L was associated with an increased risk of delirium (adjusted OR: 2.98, 95%CI: 1.71-5.19, p < 0.001). After adding CRP to clinical models, an area under receiver operator curve increased from 0.77 to 0.80 (p = 0.038) for Model A and from 0.81 to 0.84 (p = 0.016) for Model B. There was also improvement in reclassification.

CONCLUSIONS

Addition of CRP to clinical predictors moderately improved prediction of post-stroke delirium. CRP could be considered as a potential biomarker to stratify risk of delirium after stroke.

The development of a web-based app employing machine learning for delirium prevention in long-term care facilities in South Korea

Background

Long-term care facilities (LCFs) in South Korea have limited knowledge of and capability to care for patients with delirium. They also often lack an electronic medical record system. These barriers hinder systematic approaches to delirium monitoring and intervention. Therefore, this study aims to develop a web-based app for delirium prevention in LCFs and analyse its feasibility and usability.

Methods

The app was developed based on the validity of the AI prediction model algorithm. A total of 173 participants were selected from LCFs to participate in a study to determine the predictive risk factors for delerium.

The app was developed in five phases: (1) the identification of risk factors and preventive intervention strategies from a review of evidence-based literature, (2) the iterative design of the app and components of delirium prevention, (3) the development of a delirium prediction algorithm and cloud platform, (4) a pilot test and validation conducted with 33 patients living in a LCF, and (5) an evaluation of the usability and feasibility of the app, completed by nurses (Main users).

Results

A web-based app was developed to predict high risk of delirium and apply preventive interventions accordingly. Moreover, its validity, usability, and feasibility were confirmed after app development. By employing machine learning, the app can predict the degree of delirium risk and issue a warning alarm. Therefore, it can be used to support clinical decision-making, help initiate the assessment of delirium, and assist in applying preventive interventions.

Conclusions

This web-based app is evidence-based and can be easily mobilised to support care for patients with delirium in LCFs. This app can improve the recognition of delirium and predict the degree of delirium risk, thereby helping develop initiatives for delirium prevention and providing interventions. Moreover, this app can be extended to predict various risk factors of LCF and apply preventive interventions. Its use can ultimately improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01966-8.

Delirium in hospitalized patients with COVID-19 pneumonia: a prospective, cross-sectional, cohort study

Delirium is an acute confusional state characterized by altered level of consciousness and attention. Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), can manifest itself with this neuropsychiatric disorder. The endpoints of our study were: the frequency of delirium in subjects with COVID-19 pneumonia; the risk factors that predispose to this condition; and the impact of delirium on mortality. Subjects were consecutively enrolled in a Geriatric Unit from January 5th to March 5th, 2021. Inclusion criteria were: diagnosis of SARS-CoV-2 infection, a radiologically documented pneumonia, and the ability of providing informed consent. Exclusion criteria were: absence of radiological evidence of pneumonia, sepsis, and the need of intensive care unit treatment. All subjects were evaluated by means of Richmond Agitation Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) at least twice per day. In the study cohort (n = 71), twenty patients (28.2%) had delirium. Delirium was present on admission in 11.3%, and occurred during hospitalization in 19.0%. Compared to patients without delirium, patients who developed this neuropsychiatric disorder had a higher mortality rate (35% vs 5.9%) and an increased average hospital length of stay (21 days vs 17 days). In the multivariate analysis delirium was associated with frailty (OR = 2.81; CI = 1.4-5.8) and helmet ventilation (OR = 141.05; CI = 4.3-4663.9). Delirium was an independent predictor of mortality. Nearly a third of subjects (28.2%) had delirium during hospitalization for COVID-19. This finding supports the notion that delirium is a common complication of SARS-CoV2 infection. Since delirium is associated with longer hospital stay, and it is an independent marker of increased mortality, clinicians should assess and prevent it.

A comparison of clinical characteristics between old and oldest-old patients hospitalised for SARS-COV2

OBJECTIVES

Oldest-old patients may have an unusual SARS-COV2 presentation that can jeopardise diagnosis and management. The aim of this study was to compare the clinical characteristics and outcomes of oldest-old (≥85 years) and old patients (75-85 years) admitted with COVID-19 to Belgian hospitals during the first wave of the pandemic.

METHODS

We conducted a multicentre, retrospective, observational study in ten Belgian hospitals. We reviewed the electronic clinical records of patients ≥75 years hospitalised with COVID-19 from March to June 2020.

RESULTS

A total of 986 patients were placed on the register (old group: n = 507; oldest-old group: n = 479). Before hospitalisation, the oldest-old (OO) group presented with more geriatric syndromes including comorbidities, frailty, falls, cognitive impairment, and incontinence. At admission, the OO group presented with less cough, less headache, and less fever but significantly more delirium than old (O) group. Members of the OO group were admitted less frequently to intensive care units (ICUs). A geriatrician was consulted to help in the decision-making process more often for the OO group. The global mortality of the cohort was 47%, with no difference between the two groups. Patients in the OO group were more often institutionalised after hospitalisation and less often referred for rehabilitation.

CONCLUSIONS

The OO patients presented with more geriatric syndromes that make them vulnerable to dependence and institutionalisation after a hospital stay, without having a higher mortality rate than O patients. Geriatrician expertise is necessary in the management of frail older patients.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

Discharge Destinations of Delirious Patients: Findings from a Prospective Cohort Study of 27,026 Patients From a Large Health Care System

OBJECTIVES

Delirium is known to contribute to increased rates of institutionalization and mortality. The full extent of adverse outcomes, however, remains understudied. We aimed to systematically assess the discharge destinations and mortality risk in delirious patients in a large sample across all hospital services.

DESIGN

Pragmatic prospective cohort study of consecutive admissions to a large health care system.

SETTING AND PARTICIPANTS

A total of 27,026 consecutive adults (>18 years old) with length of stay of at least 24 hours in a tertiary care center from January 1 to December 31, 2014.

METHODS

Presence of delirium determined by routine delirium screening. Clinical characteristics, discharge destination, and mortality were collected. Calculation of odds ratios (ORs) with logistic regression with adjustment for age, sex, and Charlson comorbidity index (CCI).

RESULTS

Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious patients was 56 years (25-75 interquartile range = 37-70). The electronic health record (DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses made by consultation-liaison psychiatrists. Across services, the odds of delirious patients returning home was significantly reduced [OR 0.12; confidence interval (CI) 0.10-0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15; CI 3.78-4.55; P < .001) or nursing homes (OR 4.12; CI 3.45-4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk (OR 30.0; CI 23.2-39.4; P < .001).

CONCLUSIONS AND IMPLICATIONS

This study advances our understanding of the discharge destination across all services in adults admitted to a large hospital system. Delirium was associated with reduced odds of returning home, increased odds of discharge to a setting of higher dependency, and excess mortality independent of comorbidity, age, and sex. These findings emphasize the potentially devastating outcomes associated with delirium and highlight the need for timely diagnosis and hospital-wide management.

"Emergency Room Evaluation and Recommendations" (ER2) Tool for the Screening of Older Emergency Department Visitors With Major Neurocognitive Disorders: Results From the ER2 Database

Purpose: The Emergency Room Evaluation and Recommendation (ER²) is an application in the electronic medical file of patients visiting the Emergency Department (ED) of the Jewish General Hospital (JGH; Montreal, Quebec, Canada). It screens for older ED visitors at high risk of undesirable events. The aim of this study is to examine the performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive likelihood ratio [LR+], negative likelihood ratio [LR-] and area under the receiver operating characteristic curve [AUROC]) of the ER² high-risk level and its "temporal disorientation" item alone to screen for major neurocognitive disorders in older ED visitors at the JGH. Methods: Based on a cross-sectional design, 999 older adults (age 84.9 ± 5.6, 65.1% female) visiting the ED of the JGH were selected from the ER² database. ER² was completed upon the patients' arrival at the ED. The outcomes were ER²'s high-risk level, the answer to ER²'s temporal disorientation item (present vs. absent), and the diagnosis of major neurocognitive disorders (yes vs. no) which was confirmed when it was present in a letter or other files signed by a physician. Results: The sensitivities of both ER²'s high-risk level and temporal disorientation item were high (≥0.91). Specificity, the PPV, LR+, and AROC were higher for the temporal disorientation item compared to ER²'s high-risk level, whereas a highest sensitivity, LR-, and NPV were obtained with the ER² high-risk level. Both area under the receiver operating characteristic curves were high (0.71 for ER²'s high-risk level and 0.82 for ER² temporal disorientation item). The odds ratios (OR) of ER²'s high-risk level and of temporal disorientation item for the diagnosis of major neurocognitive disorders were positive and significant with all OR above 18, the highest OR being reported for the temporal disorientation item in the unadjusted model [OR = 26.4 with 95% confidence interval (CI) = 17.7-39.3]. Conclusion: Our results suggest that ER² and especially its temporal disorientation item may be used to screen for major neurocognitive disorders in older ED users.

Delirium in Frail Older Adults

Delirium and frailty are prevalent geriatric syndromes and important public health issues among older adults. The prevalence of delirium among hospitalized older adults ranges from 15% to 75%, while that of frailty ranges from 12% to 24%. The exact pathophysiology of these two conditions has not been clearly identified, although several hypotheses have been proposed. However, these conditions are considered to be multifactorial in etiology and are associated with inflammation related to aging, alterations in vascular systems, genetics, and nutritional deficiency. Furthermore, clinically, they are significantly associated with frailty, which increases the risk of delirium by almost two- to three-fold among hospitalized older adults. With their multifactorial etiology and unknown pathophysiology, current evidence supports more practical multicomponent patient-centered approaches to prevent and manage delirium with frailty among hospitalized older adults. These comprehensive and organized bundled approaches can identify high-risk patients with frailty and more effectively manage their delirium.