Delirium motor subtypes and prognosis in hospitalized geriatric patients - A prospective observational study

Detection of delirium in older patients-A point prevalence study in surgical and non-surgical hospital wards

AIMS AND OBJECTIVES

To (i) determine the prevalence of delirium and identify delirium subtypes in surgical and non-surgical patients aged ≥65 years, (ii) determine whether certain precipitating factors affect the prevalence of delirium and (iii) review patients' medical records for description of delirium symptoms and the presence of International Classification of Diseases (ICD-10) coding for delirium in discharge summaries.

METHODOLOGICAL DESIGN AND JUSTIFICATIONS

Despite being a robust predictor of morbidity and mortality in older adults, delirium might be inadequately recognised and under-reported in patients' medical records and discharge summaries. A point prevalence study (24-h) of patients ≥65 years from surgical and non-surgical wards was therefore conducted in a tertiary university hospital.

ETHICAL ISSUES AND APPROVAL

The study was approved by the Data Protection Officer at the university hospital (2018/3454).

RESEARCH METHODS, INSTRUMENTS AND/OR INTERVENTIONS

Patients were assessed for delirium with 4AT and delirium subtypes with the Delirium Motor Subtype Scale. Information about room transfers, need and use of sensory aids and medical equipment was collected onsite. Patients' medical records were reviewed for description of delirium symptoms and of ICD-10 codes.

RESULTS

Overall, 123 patients were screened (52% female). Delirium was identified in 27% of them. Prevalence was associated with advanced age (≥85 years). The uncharacterised delirium subtype was most common (36%), followed by hypoactive (30%), hyperactive (24%) and mixed (9%). There were significant associations between positive screening tests and the need and use of sensory aids. Delirium symptoms were described in 58% of the patients who tested positive for delirium and the ICD-10 code for delirium was registered in 12% of these patients' discharge summaries.

CONCLUSIONS

The high prevalence of delirium and limited use of discharge codes highlight the need to improve the identification of delirium in hospital settings and at discharge. Increased awareness and detection of delirium in hospital settings are vital to improve patient care.

Circadian disturbances, anxiety and motor disturbances differentiate delirium superimposed on dementia from dementia-only

Background

To ensure adequate treatment, individuals with delirium superimposed on dementia (DSD) need to be differentiated reliably from those with dementia only (DO). Therefore, we aimed to examine the clinical indicators of DSD by assessing motor subtypes, cognitive performance and neuropsychiatric symptoms in DSD and DO patients.

Methods

Cross-sectional design with the Delirium-Motor-Subtyping Scale (DMSS), Mini-Mental-State-Examination (MMSE), Clock-Drawing-Test (CDT), DemTect, and Neuropsychiatric Inventory assessed after admission to an acute hospital.

Results

94 patients were included, 43 with DSD (78 ± 7 years, MMSE = 11 ± 9) and 51 with DO (79 ± 7 years, MMSE = 9 ± 8). DMSS "no subtype" was more common in the DO group (26% vs. 10%, p = .04). The DSD group showed lower CDT scores (DSD: M = 4 ± 3 vs. DO: M = 6 ± 1; p < .001) and higher anxiety (DSD: MED = 3 ± 8 vs. DO: MED = 3 ± 4; p = .01) and sleep/night-time behavior disturbances (DSD: MED = 0 ± 6 vs. DO: MED = 0 ± 0; p = .02).

Conclusions

Sleep/night-time behavior disturbances appear to be a clinical indicator of DSD. Motor subtypes can identify cases at increased risk of developing delirium or unrecognized delirium.

Clinical trial registration

https://drks.de/search/de/trial/DRKS00025439, identifier DRKS00025439.

Delirium is associated with low levels of upright activity in geriatric inpatients-results from a prospective observational study

BACKGROUND

Delirium is common in geriatric inpatients and associated with poor outcomes. Hospitalization is associated with low levels of physical activity. Motor symptoms are common in delirium, but how delirium affects physical activity remains unknown.

AIMS

To investigate differences in physical activity between geriatric inpatients with and without delirium.

METHODS

We included acutely admitted patients ≥ 75 years in a prospective observational study at a medical geriatric ward at a Norwegian University Hospital. Delirium was diagnosed according to the DSM-5 criteria. Physical activity was measured by an accelerometer-based device worn on the right thigh. The main outcome was time in upright position (upright time) per 24 h (00.00 to 23.59) on the first day of hospitalization with verified delirium status. Group differences were analysed using t test.

RESULTS

We included 237 patients, mean age 86.1 years (Standard Deviation (SD) 5.1), and 73 patients (30.8%) had delirium. Mean upright time day 1 for the entire group was 92.2 min (SD 84.3), with 50.9 min (SD 50.7) in the delirium group and 110.6 min (SD 89.7) in the no-delirium group, mean difference 59.7 minutes, 95% Confidence Interval 41.6 to 77.8, p value < 0.001.

DISCUSSION

Low levels of physical activity in patients with delirium raise the question if immobilization may contribute to poor outcomes in delirium. Future studies should investigate if mobilization interventions could improve outcomes of delirium.

CONCLUSIONS

In this sample of geriatric inpatients, the group with delirium had lower levels of physical activity than the group without delirium.

Incidence of confusional syndrome (delirium) in a Latin American university hospital

BACKGROUND

Little is known about the incidence of delirium and its subtypes in patients admitted to different departments of university hospitals in Latin America.

OBJECTIVE

To determine the incidence of delirium and the frequency of its subtypes, as well as its associated factors, in patients admitted to different departments of a university hospital in Bogotá, Colombia.

METHODS

A cohort of patients over 18 years of age admitted to the internal medicine (IM), geriatrics (GU), general surgery (GSU), orthopaedics (OU) and intensive care unit (ICU) services of a university hospital was followed up between January and June 2018. To detect the presence of delirium, we used the CAM (Confusion Assessment Method) and the CAM-ICU if the patient had decreased communication skills. The delirium subtype was characterised using the RASS (Richmond Agitation and Sedation Scale). Patients were assessed on their admission date and then every two days until discharged from the hospital. Those in whom delirium was identified were referred for specialised intra-institutional interdisciplinary management.

RESULTS

A total of 531 patients admitted during the period were assessed. The overall incidence of delirium was 12% (95% CI, 0.3-14.8). They represented 31.8% of patients in the GU, 15.6% in the ICU, 8.7% in IM, 5.1% in the OU, and 3.9% in the GSU. The most frequent clinical display was the mixed subtype, at 60.9%, followed by the normoactive subtype (34.4%) and the hypoactive subtype (4.7%). The factors most associated with delirium were age (adjusted RR = 1.07; 95% CI, 1.05-1.09), the presence of four or more comorbidities (adjusted RR = 2.04; 95% CI, 1.31-3.20), and being a patient in the ICU (adjusted RR = 2.02; 95% CI, 1.22-3.35).

CONCLUSIONS

The incidence of delirium is heterogeneous in the different departments of the university hospital. The highest incidence occurred in patients that were admitted to the GU. The mixed subtype was the most frequent one, and the main associated factors were age, the presence of four or more comorbidities, and being an ICU patient.

Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study

PURPOSE

Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention.

MATERIALS AND METHODS

Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted.

RESULTS

The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification.

CONCLUSION

Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.

The Association between Delirium and In-Hospital Falls: A Cross-Sectional Analysis of a Delirium Screening Program

Methods

A cross-sectional study using delirium screening and falls reports was used to measure the association between delirium and falls. All inpatient data from August, 2018, to January, 2020, at a large academic medical center were analyzed. A multivariable logistic regression of 29,655 hospital admissions was used to understand the association between in-hospital delirium and falls.

Results

Analysis revealed a delirium rate of 12.5% (n = 3,707) of all admissions and 286 (0.9%) admissions with falls; of the falls studied, 37.6% of these patients screened positive for delirium during their admission. Relative to those who screened negative for delirium, admissions that screened positive for delirium had a 2.81 increased odds of falling.

Conclusions

Delirium and falls are related. This strong association should motivate health systems to look closely at both problems. Falls and delirium can both have immense impacts on the patient and the health system. The powerful association between them provides a window to reduce these additional patient harms. More specifically, a modern delirium screening tool should be used as part of routine risk assessment focused on reducing in-hospital falls.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

In-Hospital Delirium as a Prognostic Factor for New Cognitive Disorder in a 1-Year Post-Hip Fracture Follow-Up

BACKGROUND

Older hip fracture patients are at high risk of delirium during acute hospital care. Pre-fracture dementia is known to increase the risk of in-hospital delirium. Data on the development of new cognitive disorders in patients with delirium are scarce.

OBJECTIVE

The objective of this study is to evaluate the prognostic significance of in-hospital delirium on the development of new cognitive disorders in a 1-year follow-up in older hip fracture patients.

MATERIAL AND METHODS

Data consisted of 476 hip fracture patients aged 65 years or more with no known cognitive disorder on admission. Delirium was assessed using the Confusion Assessment Method (CAM). Cognitive disorders were diagnosed following the national guidelines. Information on the new diagnoses of cognitive disorders (NDCD) at 1-year follow-up was elicited in a telephone interview and confirmed from the electronic patient files. Logistic regression analyses were conducted to examine the association of delirium with NDCDs.

RESULTS

Of the 476 patients, 87 (18%) had delirium during hospital stay. Patients with delirium were older, they had poorer nutritional status, lower mobility level, and more supported living arrangements than did patients without delirium. At the 1-year time point, 205 (43%) had NDCDs or were strongly suspected of this. CAM result was statistically significantly associated with development of NDCD in multivariable-adjusted analysis (odds ratio [OR] 2.29; 95% confidence interval [CI]: 1.39-3.79). Also, poor nutritional status continued to be associated with NDCDs (multivariable-adjusted OR 1.58; 95% CI: 1.03-2.43).

CONCLUSION

Delirium during hospitalization and poor nutritional status on admission are independent prognostic factors for development of subsequent cognitive disorders in older hip fracture patients.

Subtypes of delirium after ischaemic stroke-predisposing factors and outcomes: a prospective observational study (PROPOLIS)

BACKGROUND AND PURPOSE

Delirium is a serious complication after stroke. It remains unclear whether different motor subtypes of delirium are associated with diverse risk factors and outcomes. The aim was to investigate if delirium subtypes differ in predisposing factors, clinical characteristics and outcomes.

METHODS

In all, 698 patients with ischaemic stroke or transient ischaemic attack (median age 73 years; 53.7% female) were prospectively included. Core features of delirium during the first 7 days after admission were examined. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for delirium were used. Pre-stroke characteristics were compared between different delirium subtypes and logistic regression and Cox proportional hazard models were used to explore the association between delirium, functional outcome and death.

RESULTS

Hyperactive, hypoactive and mixed delirium were diagnosed in 28, 75 and 66 patients, respectively. Patients with hyperactive delirium had less severe neurological deficit on admission and more often had transient ischaemic attack compared with patients with hypoactive and mixed delirium. Compared with patients with hypoactive delirium, those with hyperactive delirium more often suffered from irritability/lability prior to stroke. Hyperactive and hypoactive delirium did not differ in age, sex, comorbidities, pre-stroke dependency, cognitive decline and severity of delirium. Hyperactive, hypoactive and mixed delirium were associated with an increased risk of poor 3- and 12-month functional outcome compared with patients without delirium. Moreover, patients with hypoactive and mixed delirium had an elevated risk of death.

CONCLUSIONS

Hyperactive delirium is associated with less severe stroke and higher scores of pre-existing irritability/lability. All three motor subtypes of delirium are associated with poor outcome, although hyperactive delirium seems to have a less unfavourable prognosis.

Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study

OBJECTIVES

To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium.

DESIGN

Population-based cross-sectional study using routinely collected administrative health data.

SETTING AND PARTICIPANTS

All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217).

METHODS

Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported.

RESULTS

Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability).

CONCLUSIONS AND IMPLICATIONS

There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.

The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity

Aim

Investigate if 4AT score predicts 1 year mortality and explore the sensitivity and specificity of the 4AT when applied as part of a clinical routine.

Findings

4AT score is one of several clinical characteristics predicting 1 year mortality. The 4AT has reasonable sensitivity and specificity to detect delirium in a clinical routine setting.

Message

The 4AT seems to be a useful tool for delirium screening and may predict mortality.

Purpose

Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A’s test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine.

Methods

Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1–3, 4–7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC).

Results

Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28–6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70–4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively.

Conclusions

4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.

Distribution of agitation and related symptoms among hospitalized patients using a scalable natural language processing method

BACKGROUND

Agitation is a common feature of many neuropsychiatric disorders.

OBJECTIVE

Understanding the prevalence, implications, and characteristics of agitation among hospitalized populations can facilitate more precise recognition of disability arising from neuropsychiatric diseases.

METHODS

We developed two agitation phenotypes using an expansion of expert curated term lists. These phenotypes were used to characterize five years of psychiatric admissions. The relationship of agitation symptoms and length of stay was examined.

RESULTS

Among 4548 psychiatric admissions, 1134 (24.9%) included documentation of agitation based on the primary agitation phenotype. These symptoms were greater among individuals with public insurance, and those with mania and psychosis compared to major depressive disorder. Greater symptoms were associated with longer hospital stay, with ~0.9 day increase in stay for every 10% increase in agitation phenotype.

CONCLUSION

Agitation was common at hospital admission and associated with diagnosis and longer length of stay. Characterizing agitation-related symptoms through natural language processing may provide new tools for understanding agitated behaviors and their relationship to delirium.

Delirium prevalence in a Colombian hospital, association with geriatric syndromes and complications during hospitalization

BACKGROUND

The aim of this paper is to describe the prevalence of Delirium and the factors associated with its presentation and complications identified in a geriatric unit in Colombia.

MATERIAL AND METHODS

This is a retrospective observational study that included all patients admitted consecutively for two years in a geriatric unit of a hospital in Bogotá, Colombia. We assessed delirium prevalence with the Confusion Assessment Method (CAM). The independent variables were age, sex, functional impairment (Barthel<90), malnutrition (MNA<12), pressure ulcers at admission, state of the social support network, number of comorbidities, polypharmacy (5 or more drugs), complications such as ICU requirement, hospital stay, in-hospital functional impairment and mortality were also evaluated. As an exclusion criterion: not having CAM registered in the medical record, all the patients had this information.

RESULTS

We studied 1599 subjects with a mean age of 86 years (IQR 9). Delirium prevalence was 51.03%. Delirium was associated with a higher rate of: pressure ulcers on admission [OR 3.76 (CI 2.60-5.43 p<0.001)], functional impairment [OR 2.38 (CI 1.79-3.16 p<0.001)], malnutrition [OR 2.06 (CI 1.56-2.73 p<0.001)], and infection [OR 1.46 (CI 1.17-1.82 p<0.001)]. Moreover delirium has a higher association with mortality [OR 2.80 (1.03-7.54 p=0.042)], in-hospital functional decline [OR 1.82 (1.41-2.36 p<0.001)], and longer hospital stay [OR 1.04 (1.04-1.09 p=0.006)]; independently of age, sex, pressure ulcers on admission, functional impairment, malnutrition, dementia, infection and limited social network.

CONCLUSION

Our study suggests that infectious diseases and geriatric syndromes such as, functional dependence, pressure ulcers, malnutrition or major cognitive impairment are independently associated with the presence of delirium on admission. Additionally, the presence of delirium is independently associated during hospitalization with complications, longer hospital stay, functional impairment and mortality.

Cross-Cultural Adaptation and Validation of the Italian Version of the Observational Scale of Level of Arousal

OBJECTIVES

Along with deficit of attention, level of arousal is a primary criterion for the diagnosis of delirium. The Observational Scale of Level of Arousal (OSLA) is a quick, simple, and observational instrument used to evaluate the variation of arousal for rapid screening of delirium in clinical practice. The current study aims to perform a cross-cultural adaption of and to validate the Italian version of the OSLA scale to detect delirium in older aged, hospitalized patients.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

In hospital and transitional care setting. Old age patients.

METHODS

A cross-cultural adaptation of the OSLA from English into Italian was conducted, including back-translation. The validation of the OSLA was assessed in 116 older patients (age >65 years) admitted to geriatric, internal medicine, and transitional care wards. The 4 "A"s Test serves as the gold standard for the measurement of delirium.

RESULTS

Incident delirium was assessed longitudinally at different time points during hospitalization. The Italian version of OSLA demonstrated adequate internal consistency, specificity, sensitivity, agreement, test-retest reliability, and sensitivity to change, indicating adequate its clinometric properties in the detection of delirium in a real world hospitalized cohort of older adults.

CONCLUSIONS AND IMPLICATIONS

The current study is among the few studies to assess arousal as a core feature of delirium by virtue of a longitudinal assessment of delirium, moving a step forward in the implementation of a brief and easy to use delirium-screening tool for the measurement of important clinical outcomes in a frail, old aged hospitalized population.