Delirium, Frailty, and Mortality: Interactions in a Prospective Study of Hospitalized Older People

Electroencephalography as a tool for assessing delirium in hospitalized patients: A single-center tertiary hospital experience

Background

Delirium is a prevalent yet underdiagnosed disorder characterized by acute cognitive impairment. Various screening tools are available, including the Confusion Assessment Method (CAM) and 4 A's test (4AT). However, the results of these assessments may vary among raters. Therefore, we investigated the objective use of electroencephalography (EEG) in delirium and its clinical associations and predictive value.

Method

This cross-sectional observational study was conducted at Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan, Malaysia, from April 2021 to April 2023. This study included patients aged ≥18 years with a preliminary diagnosis of delirium. Demographic and clinical data were collected along with EEG recordings evaluated by certified neurologists to classify abnormalities and compare the associated factors between patients with delirium with or without EEG abnormalities.

Results

One hundred and twenty patients were recruited, with 80.0% displaying EEG abnormalities, mostly generalized slowing (moderate to severe) and primarily generalized slowing (mild to severe), and were characterized by theta activity. Age was significantly associated with EEG abnormalities, with patients aged 75 and older demonstrating the highest incidence (88.2%). The CAM scores were strongly correlated with EEG abnormalities (r = 0.639, P < 0.001) and was a predictor of EEG abnormalities (P < 0.012), indicating that EEG can complement clinical assessments for delirium. The Richmond Agitation and Sedation Scale (RASS) scores (r = -0.452, P < 0.001) and Barthel index (BI) (r = -0.582, P < 0.001) were negatively correlated with EEG abnormalities. Additionally, a longer hospitalization duration was associated with EEG abnormalities (r = 0.250, P = 0.006) and emerged as a predictor of such changes (P = 0.030).

Conclusion

EEG abnormalities are prevalent in patients with delirium, particularly in elderly patients. CAM scores and the duration of hospitalization are valuable predictors of EEG abnormalities. EEG can be an objective tool for enhancing delirium diagnosis and prognosis, thereby facilitating timely interventions.

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.

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.

Gender-specific linkages: frailty, polypharmacy, anti-cholinergic burden, and 5-year mortality risk-a real-world analysis

Background

With higher age, frailty escalates the risk of falls, unexpected physical dysfunction, hospitalization, and mortality. Polypharmacy in the older population is a major challenge that not only increases medical costs, but also may worsen the risk of hospitalization and death. More importantly, the properties of anti-cholinergic drugs contribute various negative effects. This study aimed to investigate the sex difference in the association of polypharmacy, anticholinergic burden, and frailty with mortality.

Methods

Participants older than 65 years who attended the geriatric outpatient clinic of the study center between January 2015 and July 2020 were invited to participate in this retrospective study. Comprehensive geriatric assessment data were collected and the phenotype of frailty was determined by Fried's criteria. Cox regression and the Kaplan-Meier curve were used to identify risk factors of 5-year survival along with intergroup differences in the risks.

Results

Of the 2,077 participants, 47.5% were female. The prevalence of frailty and the rate of polypharmacy were 44.7% and 60.6%, respectively. Higher age, male sex, low body mass index, low Mini-Mental State Examination scores, low activities of daily living, frailty status, polypharmacy, and a high Charlson Comorbidity Index score, and greater anticholinergic burden were significant risk factors that were associated with the 5-year all-cause mortality. Male patients with frailty exhibited the highest risks of mortality compared with male patients without frailty and female patients with or without frailty. Polypharmacy was significantly associated with a higher 5-year mortality rate in the frail male group compared with the non-frail male. In frail female group, individuals with a higher anticholinergic burden (as indicated by the Anticholinergic Cognitive Burden Scale) from drug usage exhibited an elevated 5-year mortality rate.

Conclusions

Polypharmacy and greater anticholinergic burden, synergistically interacted with frailty and intensified the 5-year mortality risk in a gender-specific manner. To mitigate mortality risks, clinicians should prudently identify polypharmacy and anticholinergic burden in the older population.

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background

We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.

Objective(s), study design, settings and participants

Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.

Results

A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.

Limitations

Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.

Conclusions

We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.

Future work

Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.

Study registrations

This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.

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.

Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts

Background

Guidelines recommend routine frailty screening for all hospitalised older adults to inform care decisions, based mainly on studies in elective or speciality-specific settings. However, most hospital bed days are accounted for by acute non-elective admissions, in which the prevalence and prognostic value of frailty might differ, and uptake of screening is limited. We therefore did a systematic review and meta-analysis of frailty prevalence and outcomes in unplanned hospital admissions.

Methods

We searched MEDLINE, EMBASE and CINAHL up to 31/01/2023 and included observational studies using validated frailty measures in adult hospital-wide or general medicine admissions. Summary data on the prevalence of frailty and associated outcomes, measurement tools, study setting (hospital-wide vs general medicine), and design (prospective vs retrospective) were extracted and risk of bias assessed (modified Joanna Briggs Institute checklists). Unadjusted relative risks (RR; moderate/severe frailty vs no/mild) for mortality (within one year), length of stay (LOS), discharge destination and readmission were calculated and pooled, where appropriate, using random-effects models. PROSPERO CRD42021235663.

Findings

Among 45 cohorts (median/SD age = 80/5 years; n = 39,041,266 admissions, n = 22 measurement tools) moderate/severe frailty ranged from 14.3% to 79.6% overall (and in the 26 cohorts with low-moderate risk of bias) with considerable heterogeneity between studies (p_het < 0.001) preventing pooling of results but with rates <25% in only 3 cohorts. Moderate/severe vs no/mild frailty was associated with increased mortality (n = 19 cohorts; RR range = 1.08-3.70), more consistently among cohorts using clinically administered tools (n = 11; RR range = 1.63-3.70; p_het = 0.08; pooled RR = 2.53, 95% CI = 2.15-2.97) vs cohorts using (retrospective) administrative coding data (n = 8; RR range = 1.08-3.02; p_het < 0.001). Clinically administered tools also predicted increasing mortality across the full range of frailty severity in each of the six cohorts that allowed ordinal analysis (all p < 0.05). Moderate/severe vs no/mild frailty was also associated with a LOS >8 days (RR range = 2.14-3.04; n = 6) and discharge to a location other than home (RR range = 1.97-2.82; n = 4) but was inconsistently related to 30-day readmission (RR range = 0.83-1.94; n = 12). Associations remained clinically significant after adjustment for age, sex and comorbidity where reported.

Interpretation

Frailty is common in older patients with acute, non-elective hospital admission and remains predictive of mortality, LOS and discharge home with more severe frailty associated with greater risk, justifying more widespread implementation of screening using clinically administered tools.

Funding

None.

Improving outcomes for older people with emergency care needs

This article describes work on emergency care for older people. It summarises patient experience in emergency care settings, the evidence base relating to improvement of outcomes and emerging interventions and describes tools that can support teams as they work on service improvement. Finally, it calls for the measurement of outcomes that matter to older people, as a mechanism to drive more person-centred approaches to emergency care.

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.

The Association between Electroencephalography with Auditory Steady-State Response and Postoperative Delirium

Delirium is a disorder of consciousness and a risk factor for cognitive dysfunction and poor prognosis. We hypothesized that preoperative gamma activities would be linked to postoperative delirium. We enrolled 71 subjects for elective surgery and recorded auditory steady-state response (ASSR) by electroencephalography (EEG) before the surgery and examined postoperative delirium with DSM-5. The EEG data were analyzed for baseline power, and ASSR evoked power (EP) and phase-locking factor (PLF) within the gamma range. Postoperative delirium was found in 18 patients (delirium group) but not in 53 patients (non-delirium group). There were no significant differences in the 40-Hz EP or PLF between the two groups. The baseline gamma activity negatively correlated with the 40-Hz PLF in the non-delirium group (ρ = −0.444, p < 0.01). The correlation between baseline gamma activity and 40-Hz EP was not significant in either the delirium or non-delirium group. In all patients, both preoperative PLF and EP had no significant correlations with the Delirium Rating Scale Revised-98 and the Memorial Delirium Assessment Measure at the post-operation, respectively. The disruption of the neurophysiological relationship between baseline gamma activity before sound stimuli and the PLF of the 40-Hz ASSR may be one of the potential neurophysiological indicators associated with postoperative delirium.

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.

Investigating areas for improvement in the transition from hospital-to-home for frail older adults: A mixed methods study

Background

The planning and execution of discharge plans to successfully transition frail older adults from hospital-to-home can be a complicated endeavour.

Objective

To identify areas for improvement in the transitional process of frail older adults who were discharged from hospital based, geriatric units to their homes in the community.

Method

A prospective multi-phased mixed methods design was used, and cross-case thematic analysis of Phase 2 data were triangulated with Phase 1 findings.

Results

Thematic analysis findings indicated several related areas of importance within the transitional process: 1) Coordination of discharge; 2) Transition-to-home planning; 3) Home and community care; 4) Following of recommendations; and, 5) Medical follow-up.

Conclusions

Strengthening communication between stakeholders, as well as the implementation of harmonized policies and guidelines are needed to facilitate more consistent care delivery and provide patients and families with information on what to expect during the transitional process.

Association of delirium screening on hospitalized adults and postacute care utilization: A retrospective cohort study

BACKGROUND

Patients with delirium have increased hospital length of stay (LOS), morbidity and mortality. Impact of delirium on postacute care (PAC) utilization is not fully characterized. Impact of screening for delirium on general medicine patients is unknown. The objective of this study was to assess impact of screening for delirium on inpatient PAC utilization.

METHODS

This was a single center, retrospective cohort study at an academic tertiary care center in Charleston, SC. Patients were selected from adults hospitalized from home and discharged alive between June 2014 and June 2018. The brief confusion assessment method (bCAM) screening was conducted and documented by nursing on admission and every shift thereafter. Outcome measure was the proportion of patients discharged to facility.

RESULTS

Of 93,388 non-ICU adult admission between June 2014 and June 2018, 4.4% of those not screened for delirium were discharged to facility versus 15.0% in those screened and 41.4% in those screening positive. Multivariable regression analysis showed that patients screened for delirium were 2.3 times more likely to discharge to facility (95% CI (2.145, 2.429)) while those with a positive bCAM were 3.3 times more likely than those with a negative bCAM to discharge to facility (95% CI (2.949, 3.712)).

CONCLUSIONS

After adjusting for demographics, medication orders and comorbidities there was an association between screening for delirium, positive delirium screen and discharge to facility. An appreciation of where and why patients are discharged is imperative to optimize both patient care and cost utilization.

Frailty and delirium in hospitalized older adults: A systematic review with meta-analysis

OBJECTIVE

to estimate the prevalence and synthesize diverse evidence about the relationship between frailty and delirium in hospitalized older adults.

METHOD

a systematic review with meta-analysis in which observational studies conducted with older adults about frailty, delirium and hospitalization, were selected without time of language restrictions. The search was conducted in the MEDLINE, EMBASE, CINAHL, Scopus, Web of Science and CENTRAL databases during August 2021. The precepts set forth by the Joanna Briggs Institute (JBI) - Evidence Synthesis Groups were followed. The meta-analysis model estimated the relative risk corresponding to the prevalence of frailty and delirium. The inverse variance method for proportions was used to estimate the prevalence values and relative risks for binary outcomes.

RESULTS

initially, 1,244 articles were identified, of which 26 were included in the meta-analysis (n=13,502 participants), with 34% prevalence of frailty (95% CI:0.26-0.42; I 2=99%; t 2=0.7618, p=0) and 21% for delirium (95% CI:0.17-0,25; I 2=95%; t 2=0.3454, p<0.01). The risk for hospitalized older adults to develop delirium was 66% (RR: 1.66; 95% CI:1.23-2.22; I2=92%; t2=0.4154; p<0.01).

CONCLUSION

34% prevalence of frailty and 21% of delirium in hospitalized older adults, with frailty being an independent risk factor for developing delirium, with an increased chance of 66% when compared to non-frail individuals.

Incidence and interaction factors of delirium as an independent risk of mortality in elderly patients in the intensive units: a retrospective analysis from MIMIC-IV database

BACKGROUND

As delirium is a common problem in critcal elderly patients, the aim of the study was to investigate the interaction factors of delirium as an independent risk of mortality in elderly patients in the intensive care unit (ICU).

PATIENTS AND METHODS

Elderly patients (age ≥ 65) were selected from Medical Information Mart for Intensive Care (MIMIC)-IV database. Demographics data were collected on the 1st day of admission to ICU. The main outcome is in-hospital mortality. Propensity score matching analysis (PSMA) was used to remove the influence of comfounding factors between survival and nonsurvival groups. Chi-square test and logistic regression analysis was used to identify the association between delirium and in-hospital death. Stratified analysis and interaction analysis was used to evaluate the interaction factors of delirium as a risk of in-hospital mortality.

RESULTS

22,361 patients were selected, and in which 2809 patients died. 5453 patients had delirium (about 24.4%). There is a significant difference in delirium between the survival and nonsurvival groups before and after PSMA (p = 0.000 and p = 0.030). Logistic regression showed delirium, sequential organ failure assessment (SOFA), and hemoglobin were all significantly related to in-hospital death (p = 0.000). SOFA score and hemoglobin concentration were proved to be remarkable interaction factors of delirium (p = 0.000, and p = 0.041). Significant correlation between delirium and hospital mortality was inhibited when SOFA was more than 12 or hemoglobin was higher than 15 g/dL. In-hospital mortality (49.1% vs. 10.5%, p = 0.000) and shock incidence (87.9% vs. 15.8%, p = 0.000) of the patients with SOFA ≥ 12 was much higher than that of the patients with SOFA ≤ 11.

CONCLUSION

SOFA and hemoglobin are interaction factors of delirium as an independent risk of in-hospital mortality in elderly patients in the intensive care unit.

The effect of baseline cognition and delirium on long-term cognitive impairment and mortality: a prospective population-based study

Background

There is an unmet public health need to understand better the relationship between baseline cognitive function, the occurrence and severity of delirium, and subsequent cognitive decline. Our aim was to quantify the relationship between baseline cognition and delirium and follow-up cognitive impairment.

Methods

We did a prospective longitudinal study in a stable representative community sample of adults aged 70 years or older who were registered with a Camden-based general practitioner in the London Borough of Camden (London, UK). Participants were recruited by invitation letters from general practice lists or by direct recruitment of patients from memory clinics or patients recently discharged from secondary care. We quantified baseline cognitive function with the modified Telephone Interview for Cognitive Status. In patients who were admitted to hospital, we undertook daily assessments of delirium using the Memorial Delirium Assessment Scale (MDAS). We estimated the association of pre-admission baseline cognitive function with delirium prevalence, severity, and duration. We assessed subsequent cognitive function 2 years after baseline recruitment using the Telephone Interview for Cognitive Status. Regression models were adjusted by age, sex, education, illness severity, and frailty.

Findings

We recruited 1510 participants (median age 77 [IQR 73-82], 57% women) between March, 2017, and October, 2018. 209 participants were admitted to hospital across 371 episodes (1999 person-days of assessment). Better baseline cognition was associated with a lower risk of delirium (odds ratio 0·63, 95% CI 0·45 to 0·89) and with less severe delirium (-1·6 MDAS point, 95% CI -2·6 to -0·7). Individuals with high baseline cognition (baseline Z score +2·0 SD) had demonstrable decline even without delirium (follow-up Z score +1·2 SD). However, those with a high delirium burden had an even larger absolute decline of 2·2 SD in Z score (follow-up Z score -0·2). Once individuals had more than 2 days of moderate delirium, the rates of death over 2 years were similar regardless of baseline cognition; a better baseline cognition no longer conferred any mortality benefit.

Interpretation

A higher baseline cognitive function is associated with a good prognosis with regard to likelihood and severity of delirium. However, those with a high baseline cognition and with delirium had the highest degree of cognitive decline, a change similar to the decline observed in individuals with a high amyloid burden in other cohorts. Older people with a healthy baseline cognitive function who develop delirium stand to lose the most after delirium. This group could benefit from targeted cognitive rehabilitation interventions after delirium.

Survival of Frail Elderly with Delirium

This study aims to determine when frailty increases the risks of delirium mortality. Hospital patients falling into the elderly frail or pre-frail category were recruited, some without delirium, some with delirium at admission, and some who developed delirium during admission. We screened for frailty, cognitive status, and co-morbidities whenever possible and extracted drug information and mortality data from electronic health records. Kaplan–Meier estimates of survival probability functions were computed at four times, comparing delirium versus non delirium patients. Differences in survival were assessed by a log-rank test. Independent Cox’s regression was carried out to identify significant hazard risks (HR) at 1 month, 6 months, 1 year, and 2 years. Delirium predicted mortality (log-rank test, p < 0.0001) at all four censoring points. Variables with significant HRs were frailty indicators, comorbidities, polypharmacy, and the use of specific drugs. For the delirium cohort, variables with the most significant 2-year hazard risks (HR(95%CI)) were: male gender (0.43 20 (0.26,0.69)), weight loss (0.45 (0.26,0.74)), sit and stand up test (0.67 (0.49,0.92)), readmission within 30 days of discharge (0.50 (0.30,0.80)), cerebrovascular disease (0.45 (0.27,0.76)), head trauma (0.54 22 (0.29,0.98)), number of prescribed drugs (1.10 (1.03,1.18)), and the use of diuretics (0.57 (0.34,0.96)). These results suggest that polypharmacy and the use of diuretics increase mortality in frail elderly patients with delirium.

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.

Hospitalizations of older people in an emergency department related to potential medication-induced hyperactive delirium: a cross-sectional study

Background Although delirium is one of the most common adverse drug reactions observed in hospitalized older people, it remains underdiagnosed. Aim To estimate the prevalence of hospitalization of older people with potential medication-induced hyperactive delirium in the emergency department (ED); to identify the risk factors and the medicines frequently associated with the occurrence of the syndrome. Method A cross-sectional, retrospective study was performed with older people (age ≥ 60) admitted in 2018 to a Brazilian ED. The hospitalizations with suspected hyperactive delirium were screened with the aid of trigger-tools: International Code of Diseases-10th Revision, intra-hospital prescriptions of antipsychotics, and trigger-words related to the syndrome. A chart-review and medication review were developed to establish the causality assessment between adverse event and medicine. Logistic regression was used to determine risk factors for occurrence. Results Among the hospitalizations included, 67.5% (193/286) were screened by at least one trigger-tool. Of these, potential medication-induced hyperactive delirium was observed in 26.0% (50/193). The prevalence estimated in the ward was 17.5% (50/286). Opioids (31.9%), benzodiazepines (18.8%) and corticosteroids (10.6%) were the commonest medicines associated with delirium. Long-lived patients (p = 0.005), potentially inappropriate medicines (PIMs) (p = 0.025), and high weighted deliriogenic load (p = 0.014) were associated with potential medication-induced hyperactive delirium. Conclusion Approximately one in six hospitalizations of older people in the ED showed potential medication-induced hyperactive delirium. Data suggest PIMs and high weighted deliriogenic load, rather than polypharmacy or anticholinergic burden, are considered the most important characteristics of pharmacotherapy associated with avoidable hyperactive delirium among long-lived patients.

Comparison of verbal and computerised months backwards tests in a hospitalized older population

BACKGROUND

Delirium is extremely prevalent, yet underdiagnosed, in older patients and is associated with prolonged length of hospital stay and higher mortality rates. Impaired attention is the cardinal deficit in delirium and is a required feature in diagnostic criteria. The verbal months backwards test (MBT) is the most sensitive bedside test of attention, however, hospital staff occasionally have difficulty with its administration and interpretation. We hypothesise that the MBT on an electronic tablet may be easier and more consistent to use for both experienced and unexperienced medical professionals and, if the diagnostic efficacy was similar, aid delirium diagnosis.

AIM

We aim to investigate the correlation of the verbal MBT with a computerised MBT application.

METHODS

Participants recruited (age > 65, n = 75) were allocated to different cohorts (Dementia and Delirium (DMDL), Dementia (DM), Delirium (DL), No Neurocognitive Disorder (NNCD)) and were administered both the verbal and electronic versions.

RESULTS

Correlation between measurements were: overall Spearman's rho = 0.772 (p < 0.0001); DMDL rho = 0.666 (p < 0.0001); DL rho = 0.778 (p = 0.039); DM rho = 0.378 (p = 0.203); NNCD rho = 0.143 (p = 0.559).

DISCUSSION

Overall, and for the delirious subset, statistically significant agreement was present. Poor inter-test correlation existed in the groups without delirium (DM, NNCD).

CONCLUSIONS

The MBTc correlates well with the MBTv in patients who are clinically suspected to have delirium but has poor correlation in patients without delirium. Visuospatial cognition and psychomotor deficits in a dementia cohort and mechanical factors (such as tremor, poor fingernail hygiene and visual impairment) in a group with no neurocognitive disorder may limit the utility of the MBTc in a hospitalised older population.

Delirium in the elderly admitted to an emergency hospital service

ABSTRACT Objective: To check for the presence of delirium in the elderly entering the emergency room (ER) of the University Hospital of Santa Maria (HUSM) and their relationship with sociodemographic variables, reason and time of hospitalization, comorbidities, and death. Methods: A quantitative, cross-sectional exploratory study, which analyzed data from the sociodemographic profile, Confusion Assessment Method, Charlson Comorbidities Index, and follow-up of the outcomes “in-hospital death” and “length of hospitalization.” The period analyzed in the study was between July and December 2019. Results: Of the 732 participants, 394 (53.90%) were men, with an average age of 72 years. The study identified Delirium in 99 (13.52%) participants, and death, in 120 (16.39%). There was an association of this disorder with age, comorbidities, length of hospitalization, death, and some reasons for hospitalization, such as diseases of the circulatory, respiratory and genitourinary systems. Conclusion: The results warn of the high incidence of delirium in emergency units and their relationship with a worse prognosis.

Fragilidad y delirium en adultos mayores hospitalizados: revisión sistemática con metanálisis

Resumen Objetivo: estimar la prevalencia y sintetizar evidencias sobre la relación entre fragilidad y delirium en adultos mayores hospitalizados. Método: revisión sistemática con metanálisis en el que se seleccionaron estudios observacionales realizados con adultos mayores sobre fragilidad, delirium y hospitalización, sin recorte temporal ni de idioma. La búsqueda se realizó en las bases de datos MEDLINE, EMBASE, CINAHL, Scopus, Web of Science y CENTRAL en agosto de 2021. Se siguieron los preceptos del Instituto Joanna Briggs (Joanna Briggs Institute, JBI) - Evidence Synthesis Groups. El modelo de metanálisis estimó el riesgo relativo de la prevalencia de fragilidad y delirium. Se utilizó el método de la varianza inversa para proporciones para estimar la prevalencia y el riesgo relativo de los desenlaces binarios. Resultados: inicialmente se identificaron 1.244 artículos, se incluyen en el metanálisis 26 (n=13.502 participantes), la prevalencia de fragilidad fue del 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) y de delirium del 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). El riesgo de que el adulto mayor frágil hospitalizado desarrolle delirium fue del 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusión: los adultos mayores hospitalizados tienen una prevalencia de fragilidad del 34% y de delirium del 21%, la fragilidad es un factor de riesgo independiente para el desarrollo de delirium, cuando se compara a los frágiles con los no frágiles, la probabilidad de delirium de los primeros es de un 66% más.

Fragilidade e delirium em idosos hospitalizados: revisão sistemática com metanálise

Resumo Objetivo: estimar a prevalência e sintetizar evidências sobre a relação entre fragilidade e delirium em idosos hospitalizados. Método: revisão sistemática com metanálise na qual foram selecionados estudos observacionais realizados com idosos sobre fragilidade, delirium e hospitalização, sem recortes temporais e de idioma. A busca foi realizada nas bases de dados MEDLINE, EMBASE, CINAHL, Scopus, Web of Science e CENTRAL durante o mês de agosto de 2021. Foram seguidos os preceitos estabelecidos pelo Joanna Briggs Institute (JBI) - Grupos de Síntese de Evidências.. O modelo de metanálise estimou risco relativo da prevalência de fragilidade e delirium. Utilizou-se método da variância inversa para proporções para estimar as prevalências e risco relativo para desfechos binários. Resultados: identificaram-se, inicialmente, 1.244 artigos, 26 incluídos na metanálise (n=13.502 participantes), sendo a prevalência de fragilidade 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) e delirium 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). O risco do idoso frágil hospitalizado desenvolver delirium foi de 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusão: prevalência de 34% de fragilidade e 21% de delirium em idosos hospitalizados, sendo a fragilidade um fator de risco independente para desenvolvimento de delirium, com um aumento de chance de 66% comparado aos não frágeis.

Characterizing the long-term cognitive impairment following delirium episodes: A call to action

The possible link between delirium and a long-term cognitive impairment is significant for patients, carers, and clinicians. To make progress, we need urgently novel advances in understanding the neural substrates underlying this cognitive impairment and any accompanying behavioral symptoms.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I² = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I² = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I² = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I²=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I²=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I² = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

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.

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.

Incidence of delirium following hospitalization of elderly people with fractures: risk factors and mortality

OBJECTIVE

To identify the incidence, risk factors for delirium, and its association with death in the elderly hospitalized with fractures.

METHOD

Prospective cohort, with a one-year follow-up of elderly people with clinical or radiological diagnosis of fracture, from an emergency and trauma hospital in the state of Goiás. The outcome delirium was defined by the medical description in the medical record. The predictor variables were demographic, health conditions, and hospitalization complications. A hierarchical multiple analysis was performed using robust Poisson regression, with Relative Risk as a measure of effect.

RESULTS

A total of 376 elderly patients were included. The incidence of delirium was 12.8% (n = 48). Risk factors were male gender, age ≥80 years, dementia, heart disease, osteoporosis, chronic obstructive pulmonary disease, high-energy traumas, pneumonia, urinary tract infection, and surgery. The risk of death in the sample was 1.97 times higher (HR: 1.97 95% CI 1.19-3.25) in elderly people with delirium.

CONCLUSION

Delirium had an intermediate incidence (12.8%); the risk of death in this group was about 2 times higher in one year after hospital admission. Demographic factors, past history of diseases, surgery, and complications have increased the risk and require monitoring during hospitalization of elderly people with fractures.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

The effect of foot reflexology massage on delirium and sleep quality following cardiac surgery: A randomized clinical trial

BACKGROUND

Delirium is the most common neurologic disorder after cardiac surgery and affects both short and long-term outcomes. This study was conducted to evaluate the effect of foot reflexology massage on the incidence of delirium and sleep quality in patients undergoing cardiac surgery.

METHODS

In this randomized clinical trial, 60 patients who were candidates for CABG surgery were randomly assigned into two equal groups (n = 30); intervention and control groups. In the intervention group, foot reflexology massage was done on each foot for 15 min, for two consecutive days. Delirium observation screening scale, the Richard Campbell sleep questionnaire (RSCQ), and pain intensity using VAS were compared.

RESULTS

in the second postoperative day, delirium was observed in 8 (26.7 %) and 7 (23.3 %) of patients in the intervention and control groups, respectively (p > 0.05). The measured odds ratio for the effect of massage on delirium is 0.83 (95 %CI 0.71-2.69, p = 0.76). The difference in RSCQ scores was not significant between groups of intervention and control (68.32 ± 10.41 VS. 62.80 ± 11.86, P = 0.06). The pain intensity was lower in the intervention group (P < 0.001).

CONCLUSION

Foot reflexology was not effective in reducing delirium and improving the sleep quality, but the pain intensity was decreased. It seems that the precise pathology and predicting model of delirium should be identified, and appropriate interventions should be planned accordingly.

Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study

BACKGROUND

Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population.

OBJECTIVES

Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients.

METHODS

We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality.

RESULTS

The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship.

CONCLUSIONS

ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.

A CRHR1 antagonist prevents synaptic loss and memory deficits in a trauma-induced delirium-like syndrome

Older patients with severe physical trauma are at high risk of developing neuropsychiatric syndromes with global impairment of cognition, attention, and consciousness. We employed a thoracic trauma (TxT) mouse model and thoroughly analyzed age-dependent spatial and temporal posttraumatic alterations in the central nervous system. Up to 5 days after trauma, we observed a transient 50% decrease in the number of excitatory synapses specifically in hippocampal pyramidal neurons accompanied by alterations in attention and motor activity and disruption of contextual memory consolidation. In parallel, hippocampal corticotropin-releasing hormone (CRH) expression was highly upregulated, and brain-derived neurotrophic factor (BDNF) levels were significantly reduced. In vitro experiments revealed that CRH application induced neuronal autophagy with rapid lysosomal degradation of BDNF via the NF-κB pathway. The subsequent synaptic loss was rescued by BDNF as well as by specific NF-κB and CRH receptor 1 (CRHR1) antagonists. In vivo, the chronic application of a CRHR1 antagonist after TxT resulted in reversal of the observed histological, molecular, and behavioral alterations. The data suggest that neuropsychiatric syndromes (i.e., delirium) after peripheral trauma might be at least in part due to the activation of the hippocampal CRH/NF-κB/BDNF pathway, which results in a dramatic loss of synaptic contacts. The successful rescue by stress hormone receptor antagonists should encourage clinical trials focusing on trauma-induced delirium and/or other posttraumatic syndromes.

Does the Clinical Frailty Scale at Triage Predict Outcomes From Emergency Care for Older People?

STUDY OBJECTIVE

We determine whether the Clinical Frailty Scale applied at emergency department (ED) triage is associated with important service- and patient-related outcomes.

METHODS

We undertook a single-center, retrospective cohort study examining hospital-related outcomes and their associations with frailty scores assessed at ED triage. Participants were aged 65 years or older, registered on their first ED presentation during the study period at a single, centralized ED in the United Kingdom. Baseline data included age, sex, Clinical Frailty Scale score, National Early Warning Score-2 and the Charlson Comorbidity Index score; outcomes included length of stay, readmissions (any future admissions), and mortality (inhospital or out of hospital) up to 2 years after ED presentation. Survival analysis methods (standard and competing risks) were applied to assess associations between ED triage frailty scores and outcomes. Unadjusted incidence curves and adjusted hazard ratios are presented.

RESULTS

A total of 52,562 individuals representing 138,328 ED attendances were included; participants' mean age was 78.0 years, and 55% were women. Initial admission rates generally increased with frailty. Mean length of stay after 30- or 180-day follow-up was relatively low; all Clinical Frailty Scale categories included patients who experienced zero days' length of stay (ie, ambulatory care) and patients with relatively high numbers of inhospital days. Overall, 46% of study participants were readmitted by the 2-year follow-up. Readmissions increased with Clinical Frailty Scale score up until a score of 6 and then attenuated. Mortality rates increased with increasing frailty; the adjusted hazard ratio was 3.6 for Clinical Frailty Scale score 7 to 8 compared with score 1 to 3.

CONCLUSION

Frailty assessed at ED triage (with the Clinical Frailty Scale) is associated with adverse outcomes in older people. Its use in ED triage might aid immediate clinical decisionmaking and service configuration.

Delirium is an important predictor of mortality in elderly patients with ST-elevation myocardial infarction: insight from National Inpatient Sample database

OBJECTIVE

Delirium is a frequently encountered clinical condition in hospitalized patients and is known to be associated with poor outcomes. This study aims to assess the impacts of delirium in elderly patients undergoing percutaneous coronary intervention (PCI) following ST-elevation myocardial infarction (STEMI).

METHODS

We queried the National Inpatient Samples from 2010 to 2014 to identify all patients aged 65 and older, and admitted with a primary diagnosis of STEMI undergoing PCI by using the International Classification of Diseases-Ninth Edition-Clinical Modification diagnosis codes. The patients with delirium from this cohort were further evaluated. Multivariate regression model with SPSS Statistics 25.0 (IBM Corp., Armonk, New York, USA) was used to study the association between delirium and clinical outcomes including in-hospital mortality and length of stay (LOS).

RESULTS

Out of weighted 42 980 patients aged ≥65 years with STEMI and PCI, delirium was present in 774 patients, accounting for 1.8% of this cohort. These patients were found to be older and had more underlying co-morbidities, compared to those without delirium [Median Charlson score 2 (1; 3) vs. 0 (0; 2); P < 0.001]. In-hospital mortality in STEMI patients with delirium was significantly higher than those without delirium [42.7% vs. 7.6%; unadjusted odds ratio (OR) 9.07; 95% confidence interval (CI) 6.55-12.57; P < 0.001; adjusted OR 1.86; 95% CI 1.13-3.04; P = 0.014].

CONCLUSION

Older age and comorbidities are known predisposing factors for delirium, which is in turn associated with higher in-hospital mortality and increased LOS in elderly patients with STEMI who undergo PCI. This study underscores the role of delirium and implicates the importance of further studies in recognition and targeted care of delirium.

Death in delirious palliative-care patients occurs irrespective of age: A prospective, observational cohort study of 229 delirious palliative-care patients

Objectives

Patients with terminal illness are at high risk of developing delirium, in particular, those with multiple predisposing and precipitating risk factors. Delirium in palliative care is largely under-researched, and few studies have systematically assessed key aspects of delirium in elderly, palliative-care patients.

Methods

In this prospective, observational cohort study at a tertiary care center, 229 delirious palliative-care patients stratified by age: <65 (N = 105) and ≥65 years (N = 124), were analyzed with logistic regression models to identify associations with respect to predisposing and precipitating factors.

Results

In 88% of the patients, the underlying diagnosis was cancer. Mortality rate and median time to death did not differ significantly between the two age groups. No inter-group differences were detected with respect to gender, care requirements, length of hospital stay, or medical costs. In patients ≥65 years, exclusively predisposing factors were relevant for delirium, including hearing impairment [odds ratio (OR) 3.64; confidence interval (CI) 1.90–6.99; P < 0.001], hypertension (OR 3.57; CI 1.84–6.92; P < 0.001), and chronic kidney disease (OR 4.84; CI 1.19–19.72; P = 0.028). In contrast, in patients <65 years, only precipitating factors were relevant for delirium, including cerebral edema (OR 0.02; CI 0.01–0.43; P = 0.012).

Significance of results

The results of this study demonstrate that death in delirious palliative-care patients occurs irrespective of age. The multifactorial nature and adverse outcomes of delirium across all age in these patients require clinical recognition. Potentially reversible factors should be detected early to prevent or mitigate delirium and its poor survival outcomes.

A call to action for delirium research: Meta-analysis and regression of delirium associated mortality

Background

Delirium is an extremely common hospital complication. No study to date has assessed whether a priori defined covariates; type of hospital setting and year of study publication, influence the relationship between delirium and mortality. This is also the first study to examine the longitudinal trend of delirium-associated mortality over recent decades, to analyse the trajectory of our efforts in combating this disease.

Methods

MEDLINE, EMBASE and PsycINFO, were searched from January 1981 to May 2018 for English-language primary articles. Rigorous title and abstract screen and full-text screen were conducted independently by two reviewers. This paper adhered to MOOSE guidelines. Data was extracted independently by one reviewer using standardised data-collection sheets, with a separate reviewer verifying for accuracy. The quality of included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Unadjusted effect sizes and event counts were analysed with a random effects model in primary meta-analysis and meta-regression, whereas a mixed effect model was used in secondary sub-group analysis. Mortality data at longest follow-up and cumulative mortality (hospital mortality combined with mortality at longest follow-up) data were analysed.

Results

As part of a larger project, 446 of 6790 articles were retrieved, including 71 studies that measured mortality. Our results demonstrate that elderly inpatients with delirium had significantly greater odds of mortality (OR 3.18 [95%CI: 2.73, 3.70]) compared to non-delirious controls. Patients with delirium in the ICU had the highest odds for mortality (OR: 7.09 [95%CI: 3.60, 14.0]); double the risk compared to the average. Curiously, despite advancements in delirium research, delirium associated in-hospital odds of mortality has not changed in 30 years.

Conclusion

This is the largest meta-analysis to confirm the association between delirium and mortality, in older (age ≥ 65) hospital inpatients.

The current meta-analysis highlights the significant odds of mortality after an episode of delirium, and these odds are much higher for ICU patients. However, in contrast to other medical conditions that have seen a decrease in associated mortality over the past few decades, delirium associated mortality remains unchanged. These findings underscore the urgent need for better delirium treatments.

PROSPERO Registration Number: CRD42018098627, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=98627

Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.

The relationship among frailty, delirium and attentional tests to detect delirium: a cohort study

BACKGROUND

Few studies explored if frailty predisposes to delirium in hospitalized older patients. The aims of this study were to evaluate if frailty: 1) is independently associated with delirium, and 2) affects the patient's performance in three tests of attention used to detect delirium.

METHODS

Data are from a prospective cohort study of patients admitted to an Acute Geriatric Unit (AGU). Frailty was operationalized using the health deficit accumulation model (38-item Frailty Index). Delirium was screened using the 4AT, and the diagnosis confirmed with the DSM-5th criteria. During the first 7 days from the hospital admission, patients also underwent a double-blind assessment of attention using three ad hoc tests (i.e., Months of the year backwards, MOTYB; Days of the week backwards, DOWB; and Count backwards from 20 to 1, CB).

RESULTS

Eighty-nine patients were included (mean age 83.1 years, standard deviation 6.0). Forty-two (47.19%) patients were frail, and 37 (41.7%) had delirium. The likelihood of delirium was significantly higher in frail compared to the non-frail patients; it was also inversely associated with the three attention tests. Using the MOTYB test, the ability to discriminate delirium was similar in patients with (Area Under the Receiving Operator Characteristic [AUROC] 0.88, 95% Confidence Interval [CI] 0.82-0.92) and without frailty (AUROC 0.93, 95%CI 0.90-0.95) whilst was markedly different between the same groups using either DOWB and CB.

CONCLUSIONS

Frailty is associated with delirium in hospitalized older patients and can influence the patient's performances at attentional tests that are commonly used to screen delirium.

Predisposing and precipitating risk factors for delirium in palliative care patients

Objective

Delirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.

Method

In this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.

Results

The prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).

Significance of results

Our study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.

Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients

INTRODUCTION

Predisposing and precipitating factors for delirium are well known; however, their interaction and impact on delirium in neurological patients remains largely unknown. Therefore, those factors were evaluated in hospitalized patients with neurological disorders.

METHODS

In this prospective cohort study, 1487 neurological patients were included, 356 patients with delirium and 1131 without delirium. Relevant neurological- and medical-related clusters were assessed with multiple regression analyses, prediction models, and cluster analysis evaluating their association with delirium.

RESULTS

The 1-year incidence of delirium in this cohort was 23.9%. Delirium developed in 31% of patients with stroke, in 39.5% with epilepsy, and in 58.4% with ICH. The most relevant predisposing factors were substance-use disorders (OR 4.24, 2.28-7.78, p < 0.001), advanced age (OR 3.44, CI 2.40-4.92, p < 0.001), and neurodegenerative disorders (OR 2.58, CI 1.47-4.54, p = 0.001). The most relevant precipitating factors were meningitis (OR 21.52, CI 1.22-379.83, p = 0.036), acute renal failure (OR 10.01, CI 1.13-88.73, p = 0.039), and intracranial hemorrhage (OR 3.62, CI 2.08-6.30, p < 0.001). Delirious patients were hospitalized 6 days longer, had higher in-hospital mortality, and were discharged more often to nursing homes and rehabilitation. Best predictor for delirium was the coexistence of advanced age with epilepsy (58.3%, p < 0.001), while patients aged < 65 years without epilepsy and stroke rarely developed delirium (5.1%, p < 0.001).

CONCLUSIONS

Delirium is common in elder neurological patients and associated with worse outcome. Primary cerebral conditions most frequently precipitate delirium in neurology. Neurologists are advised to monitor symptoms of delirium in the presence of risk factors to enable both timely diagnostic work-up and management of delirium.

Impact of a Premorbid Psychiatric Disorder on the Incidence of Delirium during ICU Stay, Morbidity, and Long-Term Mortality

Introduction

Delirium during ICU stay is a widespread problem with complex aetiology. A premorbid psychiatric disorder has been associated with an increased incidence of delirium in the general hospital population, but data on the impact of ICU delirium and consequences for morbidity and long-term mortality remain scarce.

Methods

In this single-centre retrospective analysis, 472 patients with an ICU stay >48 hours were included during a 2-year period. Postresuscitation and neurosurgical patients were not included. The primary aim of the study was to establish the incidence and duration of delirium during ICU stay in patients with (PS group) and without (NPS group) a premorbid psychiatric disorder. Data were analysed with applicable nonparametric tests. In a secondary analysis, patients were compared according to the presence or absence of delirium. Finally, a binary logistic regression model was constructed to correct for potential confounders.

Results

Of all patients, 19.7% were included in the PS group. Baseline characteristics with respect to severity of illness and type of admission did not differ between groups, but PS patients were significantly younger and more often female in comparison with NPS patients. The overall incidence of delirium during ICU was 57% and did not significantly differ between groups (65% in PS group vs. 56% in the NPS group, p=0.13). In a univariate analysis, the presence of a psychiatric history was also associated with prolonged mechanical ventilation, length of stay ICU, and hospital stay, but not with long-term all-cause mortality. The presence of delirium at any time during ICU admission was significantly associated with prolonged mechanical ventilation and prolonged ICU and hospital stay, but not with mortality. In a Kaplan–Meier analysis, 5-year all-cause mortality was clearly separated between groups, but the difference remained statistically insignificant (X²=3.01, p=0.08). In a binary logistic regression model, age, male sex, APACHE III score, and premorbid psychiatric disorder (OR 1.8, CI 1.1–3.0; p=0.023) were all independently associated with the presence of delirium.

Conclusions

In ICU patients with a length of stay >48 hours and a premorbid psychiatric disorder, the incidence of delirium was not significantly higher in comparison with patients without a premorbid psychiatric disorder.

Outcomes of hospital admissions among frail older people: a 2-year cohort study

Background

‘Frailty crises’ are a common cause of hospital admission among older people and there is significant focus on admission avoidance. However, identifying frailty before a crisis occurs is challenging, making it difficult to effectively target community services. Better longer-term outcome data are needed if services are to reflect the needs of the growing population of older people with frailty.

Aim

To determine long-term outcomes of older people discharged from hospital following short (<72 hours) and longer hospital admissions compared by frailty status.

Design and setting

Two populations aged ≥70 years discharged from hospital units: those following short ‘ambulatory’ admissions (<72 hours) and those following longer inpatient stays.

Method

Data for 2-year mortality and hospital use were compared using frailty measures derived from clinical and hospital data.

Results

Mortality after 2 years was increased for frail compared with non-frail individuals in both cohorts. Patients in the ambulatory cohort classified as frail had increased mortality (Rockwood hazard ratio 2.3 [95% confidence interval {CI} = 1.5 to 3.4]) and hospital use (Rockwood rate ratio 2.1 [95% CI = 1.7 to 2.6]) compared with those patients classified as non-frail.

Conclusion

Individuals with frailty who are discharged from hospital experience increased mortality and resource use, even after short ‘ambulatory’ admissions. This is an easily identifiable group that is at increased risk of poor outcomes. Health and social care systems might wish to examine their current care response for frail older people discharged from hospital. There may be value in a ‘secondary prevention’ approach to frailty crises targeting individuals who are discharged from hospital.

How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults? A cohort study

OBJECTIVES

To test whether the use of potentially inappropriate central nervous system acting medications, proton pump inhibitors (PPIs) or polypharmacy are associated with mortality in cognitively impaired older adults and whether frailer people are at greater risk of harm.

SETTING

A cohort study nested within the Cognitive Function and Ageing Study II, a population representative cohort study of the older population in Cambridgeshire, Nottingham and Newcastle, UK.

PARTICIPANTS

A total of 1154 cognitively impaired participants, aged 65 years or older.

EXPOSURES

Any use of antipsychotics, antidepressants, other anticholinergic medication, benzodiazepines or PPIs, polypharmacy (5-9) and hyperpolypharmacy (≥10 reported medications) were ascertained at baseline. Frailty was assessed using the Fried criteria.

PRIMARY OUTCOME

Mortality up to 8 years follow-up. HRs associated with potentially inappropriate medication (PIM), frailty and their interaction were estimated adjusting for covariates.

RESULTS

Within the sample, 44% were taking one or more PIM. Apart from antipsychotics (adjusted HR=3.24, 95% CI 1.83 to 5.73), use of specific PIM was not associated with greater subsequent mortality. Polypharmacy (HR=1.17, 95% CI 0.95 to 1.45) and hyperpolypharmacy were associated with mortality (HR=1.60, 95% CI 1.16 to 2.22). Being frail (HR=1.90, 95% CI 1.32 to 2.72) or prefrail (HR=1.56, 95% CI 1.10 to 2.20) was associated with increased mortality. There was some evidence that the HR for polypharmacy on mortality was lower among frailer individuals, but the overall polypharmacy by frailty interaction was not statistically significant (p=0.102).

CONCLUSIONS

For those with cognitive impairment, greater concern should be afforded to the number of medications than the prescription of specific classes. Frailer individuals may have a lower relative risk of mortality associated with polypharmacy than less frail individuals.

Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department

BACKGROUND

Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium.

AIM

To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland.

METHOD

A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver.

RESULTS

The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference.

CONCLUSION

Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.

Impairments in balance and mobility identify delirium in patients with comorbid dementia

ABSTRACTDiagnosing delirium superimposed on dementia (DSD) remains challenging because of a lack of specific tools, though motor dysfunction in delirium has been relatively under-explored. This study aimed to use dysfunction in balance and mobility (with the Hierarchical Assessment of Balance And Mobility: HABAM) to identify DSD. This is a cross-sectional multicenter study, recruiting consecutive patients ≥70 years admitted to five acute or rehabilitation hospitals in Ireland, Italy, Portugal, and Switzerland. Delirium was diagnosed using DSM-5 criteria; dementia was determined by the Mini-Mental State Examination and the Questionnaire of Cognitive Decline in the Elderly. HABAM score was recorded at admission. Out of 114 patients (mean age ± SD = 82 ± 7; 54% female), dementia alone was present in 24.6% (n = 28), delirium alone in 18.4% (n = 21) and DSD in 27.2% (n = 31). Patients with DSD had a mean HABAM score 7 points greater than those with dementia alone (19.8 ± 8.7 vs 12.5 ± 9.5; p &lt; 0.001); 70% of participants with DSD were correctly identified using the HABAM at a cut off of 22 (sensitivity 61%, specificity 79%, AUC = 0.76). Individuals with delirium have worse motor function than those without delirium, even in the context of comorbid dementia. Measuring motor function using the HABAM in older people at admission may help to diagnose DSD.