Risk Factors and Outcomes of Delirium in Older Patients Admitted to Postacute Care with and without Dementia

Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review

OBJECTIVES

To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD).

DESIGN

Systematic review of published literature without date restrictions through April 2023.

SETTING AND PARTICIPANTS

PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization.

METHODS

A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences."

RESULTS

Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD.

CONCLUSIONS AND IMPLICATIONS

Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.

Gabapentinoids-Related Delirium Adverse Events: A Real-World Study from 2004 to 2022 Based on FAERS

Purpose

This study comprehensively describes and evaluates the correlation between gabapentinoids and all types of delirium.

Methods

We used AERSMine to select all adverse reaction data from 2004 Q1 to the 2022 Q4 in the FDA Adverse Event Reporting System (FAERS) database, and delirium events reported by gabapentinoids drugs were included in this study. Collected and analyzed the clinical details of these reports. We have developed four models. Among the four models, reporting odds ratio (ROR) and proportional reporting ratio (PRR) were used to evaluate the potential association between and delirium. We undertook a subgroup analysis for the age and sex cohorts.

Results

A total of 2950 reports of gabapentinoids-related delirium was collected. Excluding cases with a history of delirium (Model 2), opioid drugs (Model 3), and other adverse events related to gabapentinoids drugs (Model 4), pain cases with gabapentin drugs as the main suspected drug were selected. In model 1, the reporting rates of delirium at the delirium and delirium tremens levels were higher in the gabapentinoids group than in the non-gabapentinoids group (ROR 1.09(1.05,1.13); ROR 1.54(1.16,2.04)). In model 2.3 the delira and the delirium level were higher in the gabapentinoids group (ROR 1.42(1.29,1.56), ROR 1.44(1.31,1.59); ROR 1.43(1.30,1.58), ROR 1.46(1.33,1.61)). There is no difference in delirium levels in Model 4. Delirium levels were higher in the gabapentinoids group than in the non-gabapentinoids group in ≥65 years old. The delirium and deliria levels were higher in the male group than in the female group.

Conclusion

The delirium adverse reactions of the gabapentinoids group were significantly higher than those of non-gabapentinoids group in the first three models. However, with the removal of confounding factors, there was no significant difference in this type of adverse reaction in Model 4. In elderly and male patients, the incidence of delirium with gabapentinoids was significantly increased.

Mediating role of care partner burden among dementia care partners during post-hospital transition

OBJECTIVES

This study examined the mediating role of care partner burden on the relationship between patient clinical factors (i.e. cognition, physical function, and behavioral and psychological symptoms of dementia [BPSD]) and care partner mental health (i.e. anxiety and depression) among dementia care partners at hospital discharge.

METHOD

The sample consisted of 431 patient and care partner dyads enrolled in the Family centered Function-focused Care (Fam-FFC) study; ClinicalTrials.gov identifier NCT03046121. Mediation analyses were conducted to test the role of care partner burden on the associations between patient clinical factors, and care partner anxiety and depression.

RESULTS

Mediation models demonstrated that care partner burden partially mediated the relationship between patient physical function and care partner anxiety and depression, as well as patient BPSD and care partner anxiety and depression.

CONCLUSION

Findings highlight the need for clinicians and service providers to implement comprehensive strategies that address both patient clinical factors (i.e. physical function and BPSD) and care partner burden, to optimize care partner mental health outcomes during post-hospital transition.

Mortality Among the Dementia Population in Not-For-Profit Hospitals with Better Nursing Resources

The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.

Hospital admission and the occurrence of delirium in older adults with physical frailty: cross-sectional study

OBJECTIVE

To analyze the relationship between hospitalization and the occurrence of delirium in older adults with physical frailty.

METHOD

Cross-sectional study carried out in a public hospital in southern Brazil. Hospitalized older adults aged ≥ 60 years participated. Sociodemographic and clinical data were collected, physical frailty phenotype tests were performed and the Confusion Assessment Method was used. Descriptive analyzes were carried out and odds ratio values were estimated for the frailty and delirium variables.

RESULTS

Of the 320 older adults evaluated, 21.14% presented delirium, 49% were identified as pre-frail and 36.2% as frail. Of those affected by delirium, 71.6% were classified as frail and 28.3% as pre-frail (p < 0.001). An association was observed between the occurrence of delirium and frailty (OR 1.22; 95% CI 1.07 to 1.38), age ≥ 80 years (OR 1.14; 95% CI 1.01 to 1.32), epilepsy (OR 1.38; 95% CI 1.09 to 1.76), dementia (OR 1.58; 95% CI 1.37 to 1.82), and history of stroke (OR 1.14; 95% CI 1.03 to 1.26).

CONCLUSION

There was a high frequency of pre-frail and frail older adults, and the occurrence of delirium in frail was significantly higher. Special attention should be paid to frail older adults to prevent the occurrence of delirium during hospitalization.

Assessing the Risk of Developing Delirium on Admission to Inpatient Rehabilitation: A Clinical Prediction Model

OBJECTIVES

To develop a clinical model to predict the risk of an individual patient developing delirium during inpatient rehabilitation, based on patient characteristics and clinical data available on admission.

DESIGN

Retrospective observational study based on electronic health record data.

SETTING AND PARTICIPANTS

We studied a previously validated data set of inpatients including incident delirium episodes during rehabilitation. These patients were admitted to ZURZACH Care, Rehaklinik Bad Zurzach, a Swiss inpatient rehabilitation clinic, between January 1, 2015, and December 31, 2018.

METHODS

We performed logistic regression analysis using backward and forward selection with alpha = 0.01 to remove any noninformative potential predictor. We subsequentially used the Akaike information criterion (AIC) to select the final model among the resulting "intermediate" models. Discrimination of the final prediction model was evaluated using the C-statistic.

RESULTS

Of the 20 candidate predictor variables, 6 were included in the final prediction model: a linear spline of age with 1 knot at 60 years and a linear spline of the functional independence measure (FIM), a measure of the functional degree of patients independency, with 1 knot at 64 points, diagnosis of disorders of fluid, electrolyte, and acid-base balance (E87), use of other analgesic and antipyretics (N02B), use of anti-parkinson drugs (N04B), and an anticholinergic burden score (ACB) of ≥3 points.

CONCLUSIONS AND IMPLICATIONS

Our clinical prediction model could, upon validation, identify patients at risk of incident delirium at admission to inpatient rehabilitation, and thus enable targeted prevention strategies.

Delirium in older patients with COVID-19: Prevalence, risk factors and clinical outcomes across the first three waves of the pandemic

OBJECTIVES

Delirium is a serious condition, which poses treatment challenges during hospitalisation for COVID-19. Improvements in testing, vaccination and treatment might have changed patient characteristics and outcomes through the pandemic. We evaluated whether the prevalence and risk factors for delirium, and the association of delirium with in-hospital mortality changed through the pandemic.

METHODS

This study was part of the COVID-OLD study in 19 Dutch hospitals including patients ≥70 years in the first (spring 2020), second (autumn 2020) and third wave (autumn 2021). Multivariable logistic regression models were used to study risk factors for delirium, and in-hospital mortality. Differences in effect sizes between waves were studied by including interaction terms between wave and risk factor in logistic regression models.

RESULTS

1540, 884 and 370 patients were included in the first, second and third wave, respectively. Prevalence of delirium in the third wave (12.7%) was significantly lower compared to the first (22.5%) and second wave (23.5%). In multivariable-adjusted analyses, pre-existing memory problems was a consistent risk factor for delirium across waves. Previous delirium was a risk factor for delirium in the first wave (OR 4.02), but not in the second (OR 1.61) and third wave (OR 2.59, p-value interaction-term 0.028). In multivariable-adjusted analyses, delirium was not associated with in-hospital mortality in all waves.

CONCLUSION

Delirium prevalence declined in the third wave, which might be the result of vaccination and improved treatment strategies. Risk factors for delirium remained consistent across waves, although some attenuation was seen in the second wave.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Electronic Health Record Usability and Postsurgical Outcomes Among Older Adults With Dementia

INTRODUCTION

Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS).

METHODS

A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models.

RESULTS

The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS.

DISCUSSION

Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.

Potential Risk Factors for, and Clinical Implications of, Delirium during Inpatient Rehabilitation: A Matched Case-Control Study

OBJECTIVES

To investigate the association between a wide set of baseline characteristics (age, sex, rehabilitation discipline), functional scores [Functional Independence Measure (FIM), cumulative Illness Rating Scale (CIRS)], diseases, and administered drugs and incident delirium in rehabilitation inpatients and, furthermore, to assess clinical implications of developing delirium during rehabilitation.

DESIGN

Matched case-control study based on electronic health record data.

SETTING AND PARTICIPANTS

We studied rehabilitation stays of inpatients admitted between January 1, 2015, and December 31, 2018, to ZURZACH Care, Rehaklinik Bad Zurzach, an inpatient rehabilitation clinic in Switzerland.

METHODS

We conducted unconditional logistic regression analyses to estimate adjusted odds ratios (AORs) with 95% CIs of exposures that were recorded in ≥5 cases and controls.

RESULTS

Among a total of 10,503 rehabilitation stays, we identified 125 validated cases. Older age, undergoing neurologic rehabilitation, a low FIM, and a high CIRS were associated with an increased risk of incident delirium. Being diagnosed with a bacterial infection (AOR 2.62, 95% CI 1.06-6.49), a disorder of fluid, electrolyte, or acid-base balance (AOR 2.76, 95% CI 1.19-6.38), Parkinson's disease (AOR 5.68, 95% CI 2.54-12.68), and administration of antipsychotic drugs (AOR 8.06, 95% CI 4.26-15.22), antiparkinson drugs (AOR 2.86, 95% CI 1.42-5.77), drugs for constipation (AOR 2.11, 95% CI 1.25-3.58), heparins (AOR 2.04, 95% CI 1.29-3.24), or antidepressant drugs (AOR 1.88, 95% CI 1.14-3.10) during rehabilitation, or an increased anticholinergic burden (ACB ≥ 3) (AOR 2.59, 95% CI 1.41-4.73) were also associated with an increased risk of incident delirium.

CONCLUSIONS AND IMPLICATIONS

We identified a set of factors associated with an increased risk of incident delirium during inpatient rehabilitation. Our findings contribute to detect patients at risk of delirium during inpatient rehabilitation.

The Association between Primary Care Practices' Structural Capabilities and Hospitalizations among Persons Living with Dementia

Background: Persons living with dementia (PLWD) are more likely to be hospitalized than individuals without dementia. Little is known about key features (i.e., structural capabilities) in primary care practices where PLWD receive care. This study assessed the relationship between structural capabilities (i.e., care coordination, community integration, and reminder systems) and hospitalizations among PLWD. Methods: We conducted a secondary analysis of cross-sectional data from 5001 PLWD in 192 practices and used three datasets: nurse practitioner surveys, Medicare claims, and Minimum Data Set. Using generalized estimating equations, we evaluated the association between structural capabilities and hospitalizations. Results: PLWD who received care from practices with care coordination were less likely to have hospitalizations (OR = 0.62, p < .05). No statistically significant associations were observed between community integration and reminder systems and hospitalizations. Conclusion: Primary care practices need to tailor structural capabilities to address the needs of PLWD to reduce hospitalizations.

Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization

Importance

There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults.

Objective

To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults.

Design, Setting, and Participants

This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022.

Exposures

New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc).

Main Outcomes and Measures

The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used.

Results

Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs.

Conclusions and Relevance

The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

IMPORTANCE

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

OBJECTIVE

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

EVIDENCE REVIEW

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

FINDINGS

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

CONCLUSIONS AND RELEVANCE

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Regional cerebral hypometabolism on 18F-FDG PET/CT scan in delirium is independent of acute illness and dementia

INTRODUCTION

Delirium is associated with new onset dementia and accelerated cognitive decline; however, its pathophysiology remains unknown. Cerebral glucose metabolism previously seen in delirium may have been attributable to acute illness and/or dementia. We aimed to statistically map cerebral glucose metabolism attributable to delirium.

METHODS

We assessed cerebral glucose metabolism using ¹⁸ F-fluorodeoxyglucose positron emission tomography (FDG-PET) in sick, older patients with and without delirium, all without clinical dementia (N = 20). Strict exclusion criteria were adopted to minimize the effect of established confounders on FDG-PET.

RESULTS

Patients with delirium demonstrated hypometabolism in the bilateral thalami and right superior frontal, right posterior cingulate, right infero-lateral anterior temporal, and left superior parietal cortices. Regional hypometabolism correlated with delirium severity and performance on neuropsychological testing.

DISCUSSION

In patients with acute illness but without clinical dementia, delirium is accompanied by regional cerebral hypometabolism. While some hypometabolic regions may represent preclinical Alzheimer's disease (AD), thalamic hypometabolism is atypical of AD and consistent with the clinical features that are unique to delirium.

Fatores de risco associados ao delirium em idosos hospitalizados para tratamento clínico

Objetivo: identificar fatores de risco associados ao desenvolvimento de delirium em pessoas idosas hospitalizadas para tratamento clínico. Método: revisão integrativa da literatura. Busca realizada em fevereiro de 2022 através da aplicação de estratégia de busca em portais e bases de dados eletrônicas, como a Biblioteca Virtual em Saúde, o PubMed/MEDLINE e o Web of Science. Resultados: a busca resultou em 965 artigos. Após retirada de duplicatas, 583 tiveram títulos e resumos lidos. Respeitados critérios de elegibilidade, chegou-se a 127 estudos para leitura completa, dos quais 110 foram excluídos e 17 analisados, totalizando amostra de 6.170 pacientes. Foram incluídos estudos com pacientes ≥ 60 anos de idade, tratamento clínico, avaliação de fatores de risco para delirium; e excluídos estudos que utilizaram instrumentos não validados, relatos de casos, teses, monografias, artigos de revisão ou que não responderam à questão de pesquisa. Os fatores de risco mais encontrados foram a presença de déficit cognitivo e demência. Outros fatores também encontrados foram: idade avançada, presença de febre/infecção, desidratação, déficit funcional, uso de psicotrópicos antes do internamento, severidade das doenças de base, polifarmácia, déficit visual, dor ao repouso, presença de diabetes mellitus, fragilidade e tempo de internamento na emergência. Conclusões: os estudos apontam diversos fatores de risco associados ao delirium e destacam a relevância do reconhecimento do delirium pela equipe assistencial. Ação rápida e eficaz na prevenção do delirium em idosos depende da sua identificação. A equipe de saúde deve estar atenta durante o cuidado de populações vulneráveis para que o rastreio de sinais, muitas vezes flutuantes, seja facilitado.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Applicability of the interventions recommended for patients at risk or with delirium in medical and post-acute settings: a systematic review and a Nominal Group Technique study

BACKGROUND

Delirium is a common condition during hospitalisation that should be prevented and treated. Several recommendations have been established to date, whereas few studies have investigated their applicability in daily practice for medical and post-acute settings.

AIM

The aim of this research exercise was to emerge the applicability of the interventions recommended by studies in the daily care of patients at risk or with delirium cared in medical and post-acute settings.

METHODS

The study was organised in three phases. A systematic literature review according to Centre for Reviews and Dissemination was conducted (January-February 2021). Cochrane Library, Pubmed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Psychological Information Database, and the Joanna Briggs Institute databases were searched. Primary and secondary studies were evaluated in their methodological quality with the Standard Quality Assessment Criteria, the Critical Appraisal Skills Programme, and the Appraisal of Guidelines for Research & Evaluation. Then, the interventions identified were assessed in their applicability using the Nominal Group Technique who ranked their judgement on a four-point Likert scale from 1 (totally inapplicable) to 4 (totally applicable). Qualitative feedbacks were also considered, and a validation of the final list was performed by the Nominal Group.

RESULTS

A total of 12 studies were included producing a list of 96 interventions categorised into four macro-areas (prevention, non-pharmacological, communication and pharmacological management). The Nominal Group identified 51 interventions (average score > 3.5) as applicable in medical and post-acute settings. Then, through a process of re-reading, and revising according to the comments provided by the Nominal Group, a list of 35 interventions out of the initial 96 were judged as applicable.

CONCLUSION

Applicability should be assessed with experts in the field to understand the involved factors. One-third of interventions have been judged as applicable in the Italian context; the nurses' expertise, the work environment features, and the time required for each intervention in a high workload setting may prevent the full applicability of the interventions recommended by the literature.

The Impact of Ambulatory Dementia Care Models on Hospitalization of Persons Living With Dementia: A Systematic Review

This systematic review presents an overview of the existing dementia care models in various ambulatory care settings under three categories (i.e., home- and community-based care models, partnership between health systems and community-based resources, and consultation models) and their impact on hospitalization among Persons Living with Dementia (PLWD). PRISMA guidelines were applied, and our search resulted in a total of 13 studies focusing on 11 care models. Seven studies reported that utilization of dementia care models was associated with a modest reduction in hospitalization among community-residing PLWD. Only two studies reported statistically significant results. Dementia care models that were utilized in specialty ambulatory care settings such as memory care showed more promising results than traditional primary care. To develop a better understanding of how dementia care models can be improved, future studies should explore how confounders (e.g., stage of dementia) influence hospitalization.

Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression

Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.

Cerebrospinal Fluid Concentration of Neurogranin in Hip Fracture Patients with Delirium

BACKGROUND

Delirium is associated with an increased risk of incident dementia and accelerated progression of existing cognitive symptoms. Reciprocally, dementia increases the risk of delirium. Cerebrospinal fluid (CSF) concentration of the dendritic protein neurogranin has been shown to increase in early Alzheimer's disease (AD), likely reflecting synaptic dysfunction and/or degeneration.

OBJECTIVE

To elucidate the involvement of synaptic dysfunction in delirium pathophysiology, we tested the association between CSF neurogranin concentration and delirium in hip fracture patients with different AD-biomarker profiles, while comparing them to cognitively unimpaired older adults (CUA) and AD patients.

METHODS

The cohort included hip fracture patients with (n = 70) and without delirium (n = 58), CUA undergoing elective surgery (n = 127), and AD patients (n = 46). CSF was collected preoperatively and diagnostically in surgery and AD patients respectively. CSF neurogranin concentrations were analyzed in all samples with an in-house ELISA. Delirium was assessed pre-and postoperatively in hip fracture patients by trained investigators using the Confusion Assessment Method. Hip fracture patients were further stratified based on pre-fracture dementia status, delirium subtype, and AD fluid biomarkers.

RESULTS

No association was found between delirium and CSF neurogranin concentration (main analysis: delirium versus no delirium, p = 0.68). Hip fracture patients had lower CSF neurogranin concentration than AD patients (p = 0.001) and CUA (p = 0.035) in age-adjusted sensitivity analyses.

CONCLUSION

The findings suggest that delirium is not associated with increased CSF neurogranin concentration in hip fracture patients, possibly due to advanced neurodegenerative disease and age and/or because synaptic degeneration is not an important pathophysiological process in delirium.

Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis

Objective

To determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older.

Methods

The protocol for this systematic review and meta‐analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta‐analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle‐Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I² tests. The effects of potential moderators were investigated by both subgroup and meta‐regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test.

Results

Twenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12–3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57–4.65; p = 0.37). All included studies were of moderate quality.

Conclusion

The results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.

Effectiveness of a Geriatric Emergency Medicine Unit for the Management of Neurocognitive Disorders in Older Patients: Results of the MUPACog Study

INTRODUCTION

The prevalence of neurocognitive disorders (NCDs) increases with age and is associated with cognitive impairment. Older patients with NCD admitted to the emergency department (ED) are readmitted after discharge to home more often than those without NCD. Comprehensive geriatric assessment (CGA) is effective for improving clinical outcomes in older patients; however, the usefulness of CGA for older patients with NCD admitted to the ED has not been investigated. The main objective of our study is to assess the effectiveness of a geriatric emergency medicine unit (GEMU) for elderly patients with NCD admitted to the ED.

METHODS

This historical cohort study included patients aged 75 years and older with NCD admitted to the ED of Limoges University Hospital in France over a 4-year period. We compared patients treated in our hospital's GEMU, the MUPA unit (exposed group), and patients who received standard care by emergency physicians (control group). The primary end point was the incidence of 30-day readmissions.

RESULTS

The study included 801 patients admitted to the ED between January 1, 2015, and December 31, 2018 (400 in the exposed group). Of those, 72.5% were female, and the mean age was 87 ± 5 years. After adjusting for confounding factors, the 30-day readmission rate was significantly associated with the MUPA unit intervention.

CONCLUSION

CGA in a GEMU improved health outcomes in elderly patients with NCD in the ED. We recommend that all EDs include a geriatric team, such as the MUPA unit, to treat all patients with NCD admitted to the ED.

Incidence, characteristics, and outcomes of delirium in patients with noninvasive ventilation: a prospective observational study

Background

Factors that may increase the risk for delirium and the firm knowledge around mechanism for delirium in noninvasive ventilation (NIV) patients is lacking. We investigated the incidence, characteristics, and outcomes of delirium in NIV patients.

Methods

A prospective observational study was performed in an intensive care unit (ICU) of a teaching hospital. Patients in whom NIV was used as a first-line intervention were enrolled. During NIV intervention, delirium was screened using the Confusion Assessment Method for the ICU each day. The association between delirium and poor outcomes (e.g., NIV failure, ICU and hospital mortality) was investigated using forward stepwise multivariate logistic regression analyses.

Results

We enrolled 1083 patients. Of these, 196 patients (18.1%) experienced delirium during NIV intervention. Patients with delirium had higher NIV failure rates (37.8% vs. 21.0%, p < 0.01), higher ICU mortality (33.2% vs. 14.3%, p < 0.01), and higher hospital mortality (37.2% vs. 17.0%, p < 0.01) than subjects without delirium. They also had a longer duration of NIV (median 6.3 vs. 3.7 days, p < 0.01), and stayed longer in the ICU (median 9.0 vs. 6.0 days, p < 0.01) and the hospital (median 14.5 vs. 11.0 days, p < 0.01). These results were confirmed in COPD and non-COPD cohorts. According to subtype, compared to hyperactive delirium patients, hypoactive and mixed delirium patients spent more days and many more days on NIV (median 3.4 vs. 6.5 vs. 10.1 days, p < 0.01). Similar outcomes were found for length of stay in the ICU and hospital. However, NIV failure, ICU mortality, and hospital mortality did not differ among the three subtypes.

Conclusions

Delirium is associated with increases in poor outcomes (NIV failure, ICU mortality, and hospital mortality) and the use of medical resources (duration of NIV, and lengths of stay in the ICU and hospital). Regarding subtype, hypoactive and mixed delirium are associated with higher, and much higher, consumption of medical resources, respectively, compared to hyperactive delirium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01517-3.

Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.

Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) in a skilled nursing facility and comparison to the 4 'A's test (4AT)

OBJECTIVE

To validate the Delirium Diagnostic Tool (DDT-Pro) in a SNF and compare its performance to the 4 A's Test (4AT) in real life conditions.

METHODS

Prospective cross-sectional study of 262 consecutively admitted adults to a SNF, independently assessed by psychiatrists using DSM-5 delirium criteria and by geriatricians using the DDT-Pro (0-9 points) and 4AT (0-12 points).

RESULTS

141 (53.8%) participants had dementia and 79 (30.1%) had delirium. DDT-Pro and 4AT were moderately correlated (-0.59). Accuracies against DSM-5 diagnosis ranged from 80 to 85% and were comparable between tools regardless of dementia. Recommended delirium cutoff for the DDT-Pro (≤6) had 77.2% sensitivity, 84% specificity, and NPV = 89.5% and 4AT (≥4) had 54.4% sensitivity and 92.9% specificity, with lower specificity in the dementia subsample. DDT-Pro sensitivity increased (84.8%) at ≤7cutoff. Sensitivity and specificity of all DDT-Pro and 2/4 4AT items displayed gradients along severity levels, but two dichotomously rated 4AT items had low positivity. The tools had low concordance (p < 0.05) for delirium positivity.

CONCLUSIONS

DDT-Pro is valid to detect delirium in SNF population where simple, structured tools with high sensitivity are needed. DDT-Pro items assess the three core domains of delirium as a continuous measure and may have advantages over the 4AT.

Down syndrome and congenital heart disease: perioperative planning and management

Approximately 50% of newborns with Down syndrome have congenital heart disease. Non-cardiac comorbidities may also be present. Many of the principles and strategies of perioperative evaluation and management for patients with congenital heart disease apply to those with Down syndrome. Nevertheless, careful planning for cardiac surgery is required, evaluating for both cardiac and noncardiac disease, with careful consideration of the risk for pulmonary hypertension. In this manuscript, for children with Down syndrome and hemodynamically significant congenital heart disease, we will summarize the epidemiology of heart defects that warrant intervention. We will review perioperative planning for this unique population, including anesthetic considerations, common postoperative issues, nutritional strategies, and discharge planning. Special considerations for single ventricle palliation and heart transplantation evaluation will also be discussed. Overall, the risk of mortality with cardiac surgery in pediatric patients with Down syndrome is no more than the general population, except for those with functional single ventricle heart defects. Underlying comorbidities may contribute to postoperative complications and increased length of stay. A strong understanding of cardiac and non-cardiac considerations in children with Down syndrome will help clinicians optimize perioperative care and long-term outcomes.

[Descriptive study of delirium in the emergency department]

Objetivo

Conocer mejor las variables clínicas, funcionales y analíticas que se asocian al síndrome confusional agudo (SCA) en urgencias y la evolución de las mismas con el fin de obtener una mejora en el abordaje terapéutico del paciente anciano previniendo así la morbimortalidad en este tipo de pacientes.

Diseño

Se trata de un estudio descriptivo prospectivo de SCA en urgencias.

Emplazamiento

Hospital General Universitario de Ciudad Real.

Participantes

Se incluyó, en el intervalo de las 24 h siguientes al ingreso en el Servicio de Geriatría, a todos los pacientes procedentes del Servicio de Urgencias con diagnóstico de SCA.

Mediciones principales

Se realizó un análisis de las variables del conjunto de datos (variables sociodemográficas y clínicas), calculando tablas de frecuencias para variables de tipo cualitativo y estadísticos descriptivos para las variables cuantitativas. Posteriormente, se han empleado técnicas de inferencia estadística.

Resultados

El antecedente médico más frecuente fueron la enfermedad neurológica y la HTA, seguida de las enfermedades reumatológicas. Los motivos de consulta principales fueron el deterioro del estado general, la disnea, la disminución del nivel de consciencia y la fiebre. Se debe destacar la incidencia de la polifarmacia, especialmente de fármacos como los diuréticos, benzodiacepinas o hipnóticos. En relación con la etiología principal, destaca el papel de las infecciones de tipo urinario y respiratorio.

Conclusiones

Se destaca el papel fundamental de las enfermedades neurológicas (especialmente la demencia), la HTA, la polifarmacia (uso inadecuado de benzodiacepinas e hipnóticos) y las infecciones urinarias y respiratorias como factores tratables o prevenibles del delirium en el paciente de Atención Primaria en nuestro medio.

Ultrasound-guided cannulation of the superficial femoral vein for central venous access

BACKGROUND

In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also-as suggested by few recent studies-by puncture of the superficial femoral vein at mid-thigh.

METHODS

We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications.

RESULTS

From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis.

CONCLUSIONS

The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions

OBJECTIVE

Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs.

DESIGN

Exploratory cohort study.

SETTING AND PARTICIPANTS

Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics.

MEASURES

We compared setting, characteristics, and outcomes between patients admitted to the 2 units.

RESULTS

Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH).

CONCLUSIONS AND IMPLICATIONS

These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.

How a Barcelona Post-Acute Facility became a Referral Center for Comprehensive Management of Subacute Patients With COVID-19

The COVID-19 pandemic's greatest impact is among older adults. Management of the situation requires a systemic response, and post-acute care (PAC) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in post-COVID-19 recovery. In the region of Catalonia, Spain, selected PAC centers have become sites to treat older patients with COVID-19. Referrals come from the emergency department or COVID-19 wards of the acute reference hospitals, nursing homes, or private homes. We critically review the actions taken by Parc Sanitari Pere Virgili, a PAC facility in Barcelona, to manage the pandemic, including its administration, health care, communication, psychological support, and ethical frameworks. We believe that the strategies we used and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

Incidence of and risk factors for postoperative delirium in older adult patients undergoing noncardiac surgery: a prospective study

Background

To identify the incidence of, risk factors for, and outcomes associated with postoperative delirium (POD) in older adult patients who underwent noncardiac surgery.

Methods

This prospective study recruited patients aged ≥ 60 years who were scheduled to undergo noncardiac surgery at Siriraj Hospital (Bangkok, Thailand). Functional and cognitive statuses were assessed preoperatively using Barthel Index (BI) and the modified Informant Questionnaire on Cognitive Decline in the Elderly, respectively. POD was diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition criteria. Incidence of POD was reported. Univariate and multivariate analyses were used to identify risk factors for POD.

Results

Of the 249 included patients, 29 (11.6%) developed POD. Most patients (61.3%) developed delirium on postoperative day 1. Univariate analysis showed age ≥ 75 years, BI score ≤ 70, pre-existing dementia, preoperative use of opioid or benzodiazepine, preoperative infection, and hematocrit < 30% to be significantly associated with POD. Multivariate logistic analysis revealed pre-existing dementia (adjusted risk ratio [RR]: 3.95, 95% confidence interval [CI]: 1.91–8.17; p < 0.001) and age ≥ 75 years (adjusted RR: 2.54, 95% CI: 1.11–5.80; p = 0.027) to be independent risk factors for POD. Median length of hospital stay was 10 (range: 3–36) days for patients with POD versus 6 (range: 2–76) days for those without delirium (p < 0.001).

Conclusions

POD remains a common surgical complication, with an incidence of 11.6%. Patients with pre-existing dementia and age ≥ 75 years are the most vulnerable high-risk group. A multidisciplinary team consisting of anesthesiologists and geriatricians should implement perioperative care to prevent and manage POD.

Diagnosing delirium in patients with dementia, a great challenge

Delirium, despite its high incidence, serious consequences and potential reversibility, remains an underdiagnosed syndrome. In patients with dementia, the healthcare professional may find significant difficulties in differentiating whether the patient presents cognitive alterations and behavioural disorders characteristic of dementia or, on the contrary, is faced with a delirium superimposed on dementia (DSD). In view of this difficulty, many tools have been proposed in recent years to improve the diagnosis of DSD in these highly complex patients. The aim of these tools is to be easy and quick to apply, and although focusing on assessing cognitive aspects such as attention or level of consciousness, some of them have also incorporated the assessment of other more novel aspects, such as the ability to respond to external stimuli (Arousal) or the degree of mobility.

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

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

Preventing Delirium Takes a Village: Systematic Review and Meta-analysis of Delirium Preventive Models of Care

BACKGROUND

Each hospital day of delirium incurs greater healthcare costs, higher levels of care, greater staff burden, and higher complication rates. Accordingly, administrators are incentivized to identify models of care that reduce delirium rates and associated costs.

PURPOSE

We present a systematic review and meta-analysis of delirium prevention models of care.

DATA SOURCES

Ovid MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, and PsycINFO.

STUDY SELECTION

Eligible models of care were defined as provider-oriented interventions involving revision of professional roles, multidisciplinary teams, and service integration. Included studies implemented multidomain, multicomponent interventions, used a validated delirium instrument, and enrolled a control group to evaluate efficacy or effectiveness.

DATA EXTRACTION

We extracted data on study design; Population, model of care, outcomes, and results.

DATA SYNTHESIS

A total of 15 studies were included. All but two studies reported reduction in delirium or its duration, and 11 studies reported statistically significant improvements. Using random effects models, the pooled odds ratios of delirium incidence were 0.56 (95% CI: 0.37-0.85) from three randomized controlled trials, 0.63 (95% CI 0.37-1.07) from four pre-post intervention studies, and 0.79 (95% CI: 0.46-1.37) from three additional nonrandomized studies.

CONCLUSIONS

Several models of care can prevent delirium. In general, higher quality studies were more likely to demonstrate statistical significance of an effect. The diverse models of care included here explored interventions adapted to specific care settings, especially by addressing setting-specific delirium risk factors. These care models illustrate a range of promising strategies that deserve growing recognition, refinement, and implementation.

Characteristics of Hospitalized Patients Screening Positive for Delirium

BACKGROUND

Delirium in the hospitals leads to worse outcomes for patients. There were no previous studies that characterize patients with delirium from multiple hospital locations.

OBJECTIVE

To describe patient characteristics screening positive for delirium and identify any correlations with hospital location and medication use.

DESIGN, SETTINGS, PATIENTS

Retrospective chart review of 227 hospitalized patients from a large, academic, tertiary referral, 2-campus health system. Patients were ≥18 years old and had delirium for at least ≥24 hours. Validated delirium screening tools were utilized.

MEASUREMENTS

Patients' demographics, inpatient stay information, delirium episodes characteristics, drugs, and palliative and psychiatry teams' involvement.

RESULTS

Most patients were older with a mean age of 64.1 years. The most common primary diagnoses were infection, cardiac, and pulmonary. Average length of delirium was 7.2 days (standard deviation [SD] = 8.2), and average length of stay (LOS) was 18.7 days (median = 10.5, SD = 35.1, 95% confidence interval = 14.1-23). Thirty-day readmission rate was 24.8% (65/262 hospitalizations); 12.8% of patients died in the hospital (29/227). Around one-third of hospitalizations had involvement of palliative care, palliative psychiatry, or general psychiatry team. There was a decrease in the number of medications administered 24 hours after the first recording of delirium compared to the immediate preceding 48 hours. Those hospitalizations where delirium first occurred in the intensive care unit (ICU) did have a longer LOS (average = 22.9, SD = 45.7) than those where delirium first occurred outside the ICU (average = 14.8, SD = 20.5). Patients were likely to have received an opioid within 48 hours in 51% of hospitalizations and to have received benzodiazepines in 16% of hospitalizations.

CONCLUSION

In our study, we found that delirium significantly impacted length of delirium episode, number of episodes of delirium, length of hospital admission, and mortality. The population most sensitive to the impacts of delirium were elderly patients.