Incidence, predictors and health outcomes of delirium in very old hospitalized patients: a prospective cohort study

Risk of drug-induced delirium in older patients- a pharmacovigilance study of FDA adverse event reporting system database

BACKGROUND

Drug-induced delirium is known risk factors associated with increased morbidity and mortality in older patients. The objective was to evaluate the risk of drug-related delirium in older patients based on the FDA Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

Delirium reports in older patients (age ≥65) extracted from the FAERS database using Open Vigil 2.1. The reported odds ratio and the proportional reported ratio were calculated to detect the adverse reaction signal of delirium. Combined with published evidence, suspected drugs were categorized as known, possible, or new potential delirium-risk-increasing drugs.

RESULTS

Of the 130,885 reports (including 28,850 delirium events and 1,857 drugs) analyzed for this study, 314 positive signal drugs were detected. Positive signal drugs are mainly concentrated on the drug of nervous system, cardiovascular system , alimentary tract and metabolism and anti-infectives for systemic use. Of the positive signal drugs, 26.11% (82/314) were known delirium-risk increasing drugs, 44.90% (141/314) were possible and 28.98% (91/314) were new potential.

CONCLUSION

Drug-induced delirium risk is prevalent in older patients, according to the FAERS. The risk level of drug-induced delirium should be taken into account to optimize drug therapy in clinical practice.

The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'

BACKGROUND

Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes.

AIM

To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults.

METHODS

A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge.

RESULTS

The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up.

CONCLUSION

Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.

Nomogram to predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection

Objective

To construct and validate nomogram models that predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection.

Methods

Elderly patients (≥65y) tested positive for SARS-CoV-2 infection at the hospital were included. We used the 3-min diagnostic Confusion Assessment Method for delirium diagnosis. Least absolute shrinkage and selection operator (LASSO) logistical regression analysis was performed to explore potential independent influencing factors of delirium. A predict model visualized by nomogram was constructed based on the confirmed variables. The predictive accuracy and clinical value of the model were evaluated using receiver operating characteristic (ROC) curves.

Results

The data of 311 elderly patients were analyzed, of whom 73 (23.47%) patients were diagnosed with delirium. Three independent influencing factors of delirium were confirmed: age (OR1.16,1.11-1.22), Glomerular filtration rate (OR 0.98,0.97-0.99), platelet-large cell ratio (1.06,1.02-1.10). These parameters were used to create a nomogram to predict the development of delirium, which showed good predictive accuracy confirmed by the ROC curves (AUC 0.82,0.76-0.88).

Conclusion

We construct a credible nomogram to predict the development of delirium in elderly patients with Non-severe SARS-CoV-2 infection. Our finding may be useful to physicians in early prevention and treatment of delirium.

Delirium Severity and Physical Function in Hospitalized Persons Living With Dementia: Moderation by Age, Sex, and Race

OBJECTIVE

This study investigated whether demographic characteristics (age, sex, and race) moderated delirium severity as a predictor of physical function in hospitalized persons living with dementia.

METHODS

The sample consisted of 351 patients enrolled in a randomized controlled trial (Function Focused Care for Acute Care Using the Evidence Integration Triangle). Preliminary analysis was conducted to assess the main effect, and multiple linear regression was used to examine the moderating effect of demographic characteristics between delirium severity and physical function.

RESULTS

Both age and sex were found to have significant moderating effects on the relationship between delirium severity and physical function (β = 2.22; P = 0.02 and β = 1.34; P = 0.04, respectively). Older adults aged 85 years or older with higher levels of delirium severity reported lower levels of physical function compared with older adults aged 65 to 84 years. Males with higher levels of delirium severity reported lower levels of physical function compared with females. Race did not significantly moderate the association between delirium severity and physical function (β = 0.22; P = 0.90).

CONCLUSIONS

Our findings suggest that age and sex may have differential effects on physical function across different levels of delirium severity in hospitalized persons living with dementia.

Family-centered delirium prevention and treatment using video calls: the FACE Delirium trial

PURPOSE

In the FACE Delirium trial, we investigated the feasibility of a structured FAmily-CEntered delirium prevention and treatment during the corona pandemic.

METHODS

Patients hospitalized in a German geriatric medicine department were included in this single-center, prospective, single-arm feasibility study. Their relatives received a short training on delirium and volunteers or paid staff members facilitated video calls. The primary endpoint was reached when contact between patients and their relatives occurred on ≥ 80% of treatment days, either via video call or visit.

RESULTS

38 patients were included (age 83.0 ± 5.9 years; 73.7% women). 76.3% reached the primary endpoint. Due to the pandemic, 99.3% of the contacts were video calls with a duration of 24.8 ± 16.3 min.

CONCLUSION

Family-centered delirium prevention and treatment using video calls is feasible among hospitalized geriatric patients. Daily implementation in clinical practice poses challenges and requires motivated and qualified staff.

Non-pharmacological interventions to prevent and treat delirium in older people: An overview of systematic reviews

BACKGROUND

As advanced age is a major risk factor for confusion status, delirium has become prevalent in the older population, contributing to longer hospital stays, cognitive impairment, and higher risks of complications and mortality. Compared with pharmacological methods, non-pharmacological interventions are preferred and are recommended by the National Institute for Health and Care Excellence for the prevention of delirium. Numerous systematic reviews and meta-analyses have been carried out to investigate the effects of non-pharmacological interventions. However, the outcomes were diverse and the quality varied widely, making it challenging to draw firm conclusions from the evidence.

OBJECTIVE

To summarize the contents and evaluate the effects of non-pharmacological interventions to prevent and treat delirium among older people.

DESIGN

Overview of systematic reviews.

METHODS

A comprehensive literature search was conducted in Medline, Cochrane Library, EMBASE, CINAHL, PsycINFO, JBI EBP Database, China's SinoMed, CNKI, and Wangfang databases from inception to 2nd December 2022. Two reviewers performed the study selection, quality appraisal, and data extraction independently. The AMSTAR 2 tool was used to appraise the methodological quality of eligible reviews. The results were presented in narrative synthesis based on types of intervention, including multicomponent and single-component interventions.

RESULTS

Twenty-four systematic reviews were included in this overview, of which four reviews were of high quality. Multicomponent interventions were the most widely disseminated non-pharmacological strategy, which were effective in preventing delirium with 27 %-54 % reduction in delirium incidence. Additionally, the multicomponent strategy also reduced the incidence of falls and pressure ulcers, and showed trends toward shortening the length of stay and improving cognitive function. Among single-component interventions, physical training, geriatric risk assessment, and reorientation protocol revealed positive effects in delirium prevention. However, the effectiveness of non-pharmacological interventions for treating delirium was limited, and while multicomponent methods had inconsistent impacts on the duration and severity of delirium, single-component methods showed no significant impact.

CONCLUSION

Non-pharmacological interventions are effective in reducing the incidence of delirium and improving other health outcomes among older patients. However, the effects on the duration and severity of delirium need more evidence to confirm.

REGISTRATION NUMBER

CRD42022376651 in PROSPERO.

Inflammatory biomarkers and delirium: a Mendelian randomization study

Background

The association between inflammatory biomarkers and individual delirium symptoms remains controversial in observational studies. We investigated the relationship between inflammatory biomarkers and the risk of developing delirium.

Methods

A bidirectional two-sample Mendelian randomization (MR) was performed. Genetic instruments associated with peripheral tumor necrosis factor-a (TNF-a) C-reactive protein (CRP), interleukin (IL)-1α, IL-1β, IL-2, IL-8, IL-6, soluble IL-6 receptor alpha (sIL-6Rα), and soluble gp130 were identified in three different large summary genome-wide association studies (GWAS) conducted in the European population. Summary-level statistics for delirium not induced by alcohol and other psychoactive substances were obtained from the FinnGen consortium (2,612 cases and 325,306 controls). The estimated causal effects were performed using instruments' variants at the genome-wide significant level (P < 5e-8 and P < 5e-6), applying a linkage disequilibrium clumping approach with a threshold of r2 < 0.001 for each of the exposures. Reverse causation was also performed. The inverse-variance weighted method (IVW), MR-Egger method, weighted median method, MR-Egger regression, and MR Pleiotropy RESidual Sum were used for MR analyses.

Results

At the genome-wide significant level (P < 5e-8, r2 < 0.001), genetically predicted sIL-6Rα was significantly associated with a decreased risk of delirium with less than three single-nucleotide polymorphisms (SNPs) in all three GWAS data sources (ORWaldratio = 0.89, 95% CI: 0.79-0.96, PWaldratio = 0.0016; ORIVW = 0.88, 95% CI: 0.79-0.97, PIVW = 0.008; ORIVW = 0.88, 95% CI: 0.80-0.96, PIVW = 0.004). The causal relationship between sIL-6Rα and delirium became non-significant when a more liberal threshold of P of < 5e-6 was applied (all PIVW > 0.05). At the two genome-wide significance levels (P < 5e-8 and P < 5e-6), we found no evidence for the causal effects of peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, IL-8, and soluble gp130 on delirium (all P > 0.05). The MR-Egger intercept and MR-PRESSO results indicated that no SNP had possible pleiotropy (all P > 0.05). Regarding the reverse, no evidence for an effect of delirium on these inflammatory biomarkers could be found (all P > 0.05).

Conclusion

The results of this MR analysis did not support that peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, sIL-6Rα, soluble gp130, and IL-8 were causally associated with delirium. More research is needed to explore the role of inflammatory factors in the pathogenesis of delirium.

Clinical Risk Group as a predictor of mortality in delirious older adults in the emergency department

BACKGROUND

In older people, chronicity is associated with delirium, which in turn increases the risk of developing poor clinical outcomes like nursing home admission and death. The aim is to determine whether chronicity, as assessed by Clinical Risk Groups (CRG), is an independent predictor of mortality in older adults with delirium seen in the emergency department (ED).

METHODS

Prospective study with 18-month follow-up. Included patients were aged 65 years or older, admitted from 1 January to 31 December 2020, and diagnosed and coded for delirium in the ED of a secondary hospital. Patients were followed for 18 months. A survival analysis was performed using the Kaplan-Meier method and a multivariate Cox proportional hazards model.

RESULTS

The study included 125 patients (56 % men, mean age 81.2 years, standard deviation [SD] 7.5). At baseline, level 0 chronicity was present in 4.7 % of the patients; level 1, 23.4 %; level 2, 32.8 %; and level 3, 39.1 %. By study end, 29.68 % (n = 38) had died. Mean survival in the total sample was 176.6 (standard error 25.8) days. Level 3 chronicity was associated with a significantly higher risk of mortality (hazard ratio 3.41, 95 % confidence interval 1.31-8.96).

CONCLUSIONS

Level 3 chronicity, as assessed by Clinical Risk Groups, is an independent predictor of mortality in older ED patients with delirium. Delirium leads to an increased level of chronicity over the following months.

Falls in Senior Adults Part II: Management, Treatment, Prevention, and Therapy Plans

In this follow up to our Falls in Senior Adults Part I article,1 we address further management of falls after fall risk has been identified. This review will focus on the current literature on the treatment, therapy plans, and prevention of falls in senior adults.