DELIRIUM SEVERITY AND COGNITIVE OUTCOMES

Abstract Delirium is heterogeneous and can vary by severity. The impact of its severity is unclear. This prospective cohort study enrolled emergency department (ED) patients who were > 65 years old and admitted to the hospital. Delirium severity was determined by the Confusion Assessment Method for the Intensive Care Unit Severity (CAM-ICU-S) Scale measured at enrollment. This scale ranges from 0 (no symptoms) to 7 (most severe). Premorbid and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine if delirium severity was associated with 6-month function and cognition adjusted for pre-illness IQCODE, baseline functional status, comorbidity burden, severity of illness, and central nervous system diagnosis. Two-factor interactions were incorporated to determine if pre-illness cognition modified the relationship between delirium severity as measured by the CAM-ICU-S and 6-month cognition. A total of 228 older patients were enrolled in the ED and of these, 105 were delirious. Median (interquartile range) CAM-ICU-S scores was 2 (0, 5). In patients with intact pre-illness cognition, a point increase in the CAM-ICU-S significantly increased the 6-month IQCODE by 0.06 (95%CI: 0.01 to 0.12) points. In patients with impaired pre-illness cognition, there was no significant association between the CAM-ICU-S and 6-month IQCODE. Thus delirium severity is associated with poorer 6-month cognition, but this association is more prominent in those with intact pre-illness cognition.

Download Full-text

Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients

International Psychogeriatrics ◽

10.1017/s1041610218000777 ◽

2018 ◽

Vol 31 (2) ◽

pp. 267-276 ◽

Cited By ~ 6

Author(s):

Jamie Cirbus ◽

Alasdair M. J. MacLullich ◽

Christopher Noel ◽

E. Wesley Ely ◽

Rameela Chandrasekhar ◽

...

Keyword(s):

Emergency Department ◽

Short Form ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Emergency Department Patients ◽

Factor Interactions

ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology.Objectives:We sought to determine how delirium subtyped by etiology affected six-month function and cognition.Design:Prospective cohort study.Setting:Tertiary care, academic medical center.Participants:A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED).Measurements:The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition.Results:In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = −2.9 points, 95%CI: −0.3 to −5.6) and organ dysfunction (β coefficient = −4.3 points, 95%CI: −7.2 to −1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20).Conclusions:Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.

Download Full-text

LO70: Functional & cognitive decline in older delirious adults after an emergency department visit

CJEM ◽

10.1017/cem.2019.113 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S33

Author(s):

M. Giroux ◽

M. Sirois ◽

A. Nadeau ◽

V. Boucher ◽

P. Carmichael ◽

...

Keyword(s):

Emergency Department ◽

Cognitive Decline ◽

Confusion Assessment Method ◽

Assessment Method ◽

Cognitive Status ◽

Cognitive Outcomes ◽

Negative Consequences ◽

Significant Difference ◽

The Impact

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Download Full-text

Pacemaker therapy in the elderly and very elderly: comorbidity-burden vs age, as prognostic factors for excess of length of in-hospital stay, complications and mortality

European Heart Journal ◽

10.1093/eurheartj/ehab724.2820 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

A Marschall ◽

H Del Castillo Carnevali ◽

F Goncalves Sanchez ◽

M Torres Lopez ◽

F A Delgado Calva ◽

...

Keyword(s):

Prognostic Factors ◽

Elderly Patients ◽

Hospital Stay ◽

The Elderly ◽

Very Elderly ◽

Pacemaker Therapy ◽

Clinical Scenarios ◽

Comorbidity Burden ◽

The Impact ◽

Complications And Mortality

Abstract Background The number of elderly patients undergoing pacemaker (PM) implantation is constantly growing. However, information on survival and prognostic factors of this particular patient group is scarce. Recent studies suggest that comorbidity burden may have an equal, if not greater, effect on length of in-hospital stay (LOS), complications and mortality, as age in a variety of clinical scenarios. Objective The objective of this study was to determine the survival of elderly and very elderly patients undergoing PM implantation, as well as to investigate the impact of comorbidities, as compared to age, on excess of length of in-hospital stay and mortality. Methods This is a retrospective observational study of a single centre. Patients that underwent (both elective and non-elective) PM implantation between June 2016 and December 2018 in our centre, were included for chart review. Elderly patients were defined as those with age 80–89 years, whereas very elderly patients were defined as those with ≥90 years of age. Excess in LOS was defined as an in-hospital stay >3 days. Results A total of 507 patients were included in the study with a mean age of 80.6 (±8.5) years. 255 elderly and 60 very elderly patients were included. Median follow-up time was 24 months. Baseline clinical characteristics are presented in Table 1. The mortality rate for elderly patients was 18.8% for the elderly and 36.7% for the very elderly (p=0.002). The presence of ≥2 comorbidities (defined in Table 1) resulted to be a significant predictor for the excess of LOS, whereas age did not significantly predict excess of LOS (HR: 7.1 (4.4–11.4), p<0.001); HR: 1.01 (0.9–1.1), p=0.56, respectively). Neither age, nor comorbidity burden predicted the appearance of device related complications. Both comorbidites and age predicted mortality. However, the association was stronger for the presence of comorbidites, than for age (HR: 1.9 (1.1–3.1), p=0.002 vs HR: 1.1 (1.1–1.2), p<0.001, respectively). Elderly patients with low comorbidity burden (<2 comorbidities) showed no significant differences with regards to LOS and mortality when compared to younger patients (2 (2–4) vs 3 (2–5) days, p=0.529 and 18.3% vs 17.4%, p=0.702; respectively). Conclusions Our study shows a good life expectancy of elderly and very elderly patients, that underwent PM implantation, with a survival rate that is comparable to the general population. Comorbidity burden, rather than age, significantly predicts excess of LOS and should therefore be the driving factor in the approach of patients undergoing new PM implantation. FUNDunding Acknowledgement Type of funding sources: None.

Download Full-text

A multifaceted intervention package to improve the diagnosis and management of delirium

International Psychogeriatrics ◽

10.1017/s1041610214001938 ◽

2014 ◽

Vol 27 (2) ◽

pp. 337-342 ◽

Cited By ~ 1

Author(s):

J. Fleet ◽

S. Chen ◽

F.C. Martin ◽

T. Ernst

Keyword(s):

Confusion Assessment Method ◽

Assessment Method ◽

Multifaceted Intervention ◽

Junior Doctors ◽

Intervention Package ◽

Post Intervention ◽

Convenience Sample ◽

Pharmacological Management ◽

Hospital Patients ◽

The Impact

ABSTRACTBackground:Delirium is a major cause of morbidity and mortality amongst hospital patients. Previous studies have shown that it is often poorly recognized and managed. We wanted to assess the impact of a multifaceted intervention on delirium management.Methods:A pre/post-intervention design was used. The local hospital delirium guideline was adapted into A7 sized cards and A3/A2 posters. Cards were distributed to junior doctors and teaching sessions were held. Computer screen savers were displayed and delirium promotion days held. The pre/post-intervention data were used to audit the following: delirium knowledge through questionnaires, documented use of the confusion assessment method (CAM) and identification and management of eight common precipitating factors. Re-audit was four months post baseline with interventions within this period. χ2 tests were used for statistical analysis.Results:A convenience sample of randomly selected doctors in postgraduate training posts completed 100 questionnaires and 25 clinical notes were selected via retrospective identification of delirium. Results from questionnaires demonstrated significant improvements in: recognizing CAM as the diagnostic tool for delirium (24% vs. 71%, p < 0.01); identifying haloperidol as first line in pharmacological management (55% vs. 98%, p <0.01) and its correct dose (40% vs. 67%, p <0.01). In clinical practice, there was significant improvement in documentation of CAM for inpatient delirium assessments (0% vs. 77%, p <0.01). Trainees found the delirium card “very helpful” (82%) and carried it with them at all times (70%).Conclusion:This multifaceted intervention increased CAM use in delirium recognition and improved the knowledge of pharmacological management. The delirium card was highly popular.

Download Full-text

Twelve-Month Mortality Among Delirium Subtypes

Clinical Nursing Research ◽

10.1177/1054773811419497 ◽

2011 ◽

Vol 20 (4) ◽

pp. 404-421 ◽

Cited By ~ 11

Author(s):

Susan K. DeCrane ◽

Kennith R. Culp ◽

Bonnie Wakefield

Keyword(s):

Statistical Significance ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Term Care ◽

International Classification Of Disease ◽

Subsyndromal Delirium ◽

Icd 10 ◽

Underlying Cause Of Death ◽

State Examination

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using “days of survival” did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

Download Full-text

Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) completion on an acute care ward for the elderly: a brief study of informant characteristics

International Psychogeriatrics ◽

10.1017/s1041610212000415 ◽

2012 ◽

Vol 24 (10) ◽

pp. 1700-1701 ◽

Cited By ~ 1

Author(s):

K. Bloomfield ◽

N. John

Keyword(s):

Cognitive Impairment ◽

Cognitive Decline ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Cognitive Screening ◽

Screening Algorithm ◽

Drawing Task ◽

The Uk ◽

State Examination

Over recent years in the UK, emphasis has been placed on appropriate diagnosis and referral of patients with dementia. In guidelines published by the British Geriatrics Society (BGS) and Faculty of Old Age Psychiatrists consensus group (Forsyth et al., 2006), a cognitive screening algorithm was developed, which consists of initial screening for cognitive impairment with the Mini-Mental State Examination (MMSE) and CLOX1 (an executive clock drawing task). If the scores meet cut-off points indicated in the algorithm (MMSE <24 or CLOX1 <11), further assessments with the Confusion Assessment Method (CAM) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) are applied with the aim to differentiate between delirium (CAM positive, IQCODE negative), delirium and chronic impairment (CAM positive, IQCODE positive), or chronic cognitive impairment (CAM negative, IQCODE positive).

Download Full-text

Decisional capacity in patients with acute delirium. A Rawlsian approach

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.872 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S581-S581

Author(s):

S. Hostiuc ◽

I. Negoi ◽

E. Drima

Keyword(s):

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Ethical Principle ◽

Point Of View ◽

Practical Implementation ◽

Decisional Capacity ◽

Confusion Assessment ◽

Competing Interest ◽

Proper Analysis

Delirium is characterized by a temporary, usually reversible, cause of mental alteration; it can occur at any age, but affect most often the elderly. Delirium patients may also present acute psychotic episodes, which might make them decisionally incompetent. In order to assess decisional capacity, Fan et al developed a two-stage approach, which tries to analyse:– the presence of delirium, using the Confusion Assessment Method;– a proper analysis of the decisional capacity.Often, in patients with decreased decisional capacity, physicians must assess which ethical principle should respect first – the principle of autonomy, whose practical implementation is informed consent, or beneficence – the good of the patient, irrespective of the its declared wishes. In this poster, we will look at the issue of decisional capacity in patients with acute delirium from a Rawlsian point of view, and will try to give an answer based on what is just – to respect the autonomy of the patient, or the moral duty to do good to the patient.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Download Full-text

A study of etiological profile of acute confusional state

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20195661 ◽

2019 ◽

Vol 7 (1) ◽

pp. 138

Author(s):

Jaspreet Kaur ◽

Gurinder Mohan ◽

S. B. Nayyar ◽

Ranjeet Kaur

Keyword(s):

Hospital Stay ◽

The Elderly ◽

Final Diagnosis ◽

Confusion Assessment Method ◽

Assessment Method ◽

Acute Confusional State ◽

Provisional Diagnosis ◽

Metabolic Encephalopathy ◽

Common Diagnosis ◽

One Year

Background: ACS (Acute confusional states) are on the rise taking the shape of an epidemic. These states are common among the elderly, but young individuals are also not spared. Prompt diagnosis and management of these states can decrease the associated morbidity and mortality.Methods: In this prospective observational study, etiological profile of ACS was evaluated in a total 100 patients, selected over a period of one year, after they fulfilled the CAM (Confusion Assessment Method) criteria.Results: Among 100 patients of ACS, mean age was 54.77±18.50 years, males were 66% and 34% were females. The most common diagnosis provisionally made on the basis of history and clinical examination was metabolic encephalopathy in 37% patients, meningoencephalitis (24%), CVA (Cerebrovascular accident) (18%), seizures (9%), sepsis (6%), poisoning (6%). Whereas the final diagnosis made after subjecting the patients to relevant investigations, was metabolic encephalopathy in 37% of patients, meningoencephalitis (20%), CVA (18%), sepsis (12%), unprovoked seizures (6%), poisoning (6%) and undetermined in 1%. The final diagnosis matched the provisional diagnosis in most of the patients except sepsis as a provisional diagnosis was underdiagnosed. The mean duration of hospital stay was 7.6±3.67days and the hospital stay was most commonly complicated by aspiration pneumonia and acute kidney injury.Conclusions: This study emphasizes that the ACS is an emergency medical situation, where prompt identification, workup and treatment should be done parallelly and urgently to prevent the morbidity and mortality.

Download Full-text

Cerebrospinal Fluid Apolipoprotein E Levels in Delirium

Dementia and Geriatric Cognitive Disorders Extra ◽

10.1159/000477847 ◽

2017 ◽

Vol 7 (2) ◽

pp. 240-248 ◽

Cited By ~ 3

Author(s):

Gideon A. Caplan ◽

JIan Tai ◽

Fazrul Mohd Hanizan ◽

Catherine L. McVeigh ◽

Mark A. Hill ◽

...

Keyword(s):

Risk Factors ◽

Cerebrospinal Fluid ◽

Apolipoprotein E ◽

Late Onset ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Apolipoprotein A1 ◽

Ε4 Allele ◽

State Examination

Background/Aims: Delirium and the apolipoprotein E ε4 allele are risk factors for late-onset Alzheimer disease (LOAD), but the connection is unclear. We looked for an association. Methods: Inpatients with delirium (n = 18) were compared with LOAD outpatients (n = 19), assaying blood and cerebrospinal fluid (CSF) using multiplex ELISA. Results: The patients with delirium had a higher Confusion Assessment Method (CAM) score (5.6 ± 1.2 vs. 0.0 ± 0.0; p < 0.001) and Delirium Index (13.1 ± 4.0 vs. 2.9 ± 1.2; p = 0.001) but a lower Mini-Mental State Examination (MMSE) score (14.3 ± 6.8 vs. 20.8 ± 4.6; p = 0.003). There was a reduction in absolute CSF apolipoprotein E level during delirium (median [interquartile range]: 9.55 μg/mL [5.65–15.05] vs. 16.86 μg/mL [14.82–20.88]; p = 0.016) but no differences in apolipoprotein A1, B, C3, H, and J. There were no differences in blood apolipoprotein levels, and no correlations between blood and CSF apolipoprotein levels. CSF apolipoprotein E correlated negatively with the CAM score (r = –0.354; p = 0.034) and Delirium Index (r = –0.341; p = 0.042) but not with the Acute Physiology and Chronic Health Evaluation (APACHE) index, or the MMSE or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Conclusion: Reduced CSF apolipoprotein E levels during delirium may be a mechanistic link between two important risk factors for LOAD.

Download Full-text

Postoperative Delirium Is Associated with Long-term Decline in Activities of Daily Living

Anesthesiology ◽

10.1097/aln.0000000000002849 ◽

2019 ◽

Vol 131 (3) ◽

pp. 492-500 ◽

Cited By ~ 16

Author(s):

Zhongyong Shi ◽

Xinchun Mei ◽

Cheng Li ◽

Yupeng Chen ◽

Hailin Zheng ◽

...

Keyword(s):

Activities Of Daily Living ◽

Daily Living ◽

Postoperative Delirium ◽

Postoperative Mortality ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Lost To Follow Up

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Postoperative delirium is one of the most common complications in the elderly surgical population. However, its long-term outcomes remain largely to be determined. Therefore a prospective cohort study was conducted to determine the association between postoperative delirium and long-term decline in activities of daily living and postoperative mortality. The hypothesis in the present study was that postoperative delirium was associated with a greater decline in activities of daily living and higher mortality within 24 to 36 months after anesthesia and surgery. Methods The participants (at least 65 yr old) having the surgeries of (1) proximal femoral nail, (2) hip replacement, or (3) open reduction and internal fixation under general anesthesia were enrolled. The Confusion Assessment Method algorithm was administered to diagnose delirium before and on the first, second, and fourth days after the surgery. Activities of daily living were evaluated by using the Chinese version of the activities of daily living scale (range, 14 to 56 points), and preoperative cognitive function was assessed by using the Chinese Mini-Mental State Examination (range, 0 to 30 points). The follow-up assessments, including activities of daily living and mortality, were conducted between 24 and 36 months after anesthesia and surgery. Results Of 130 participants (80 ± 6 yr, 24% male), 34 (26%) developed postoperative delirium during the hospitalization. There were 32% of the participants who were lost to follow-up, resulting in 88 participants who were finally included in the data analysis. The participants with postoperative delirium had a greater decline in activities of daily living (16 ± 15 vs. 9 ± 15, P = 0.037) and higher 36-month mortality (8 of 28, 29% vs. 7 of 75, 9%; P = 0.009) as compared with the participants without postoperative delirium. Conclusions Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.

Download Full-text