Prevalence and risk factors of delirium and subsyndromal delirium in older adults

Abstract Background Delirium is a common geriatric problem associated with poor outcomes. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium yet, not satisfying the definition of full-blown delirium, defined by categorical elements, and is usually referred to as the presence of one or more symptoms in the confusion assessment method (CAM). This study aimed to investigate the prevalence and risk factors of delirium and SSD in older adults admitted to the hospital. Five hundred eighty-eight elderly (above 65 years) Egyptian patients were recruited from January 2019 to February 2020. After explaining the purpose of the study and assuring the confidentiality of all participants, an informed consent was obtained from the participant or a responsible care giver for those who were not able to give consent. All patients were subjected ‘on admission’ to thorough history taking, clinical examination, and comprehensive geriatric assessment including confusion assessment tools, mini-mental state examination, and functional assessment using Barthel index score. Results The current study showed that 19.6% of patients had delirium and 14.1% of patients had SSD with combined prevalence of 33.7%. Most common causes included metabolic, infection, organic brain syndrome, and dehydration. The current study reported significant proportionate relation between cognitive assessment and functional ability, so patients with a score of 23 MMSE had good functional ability, while cognitive assessment using mini-mental score shows inversed relation to delirium and SSD using CAM score. Conclusion Delirium is independently associated with adverse short-term and long-term outcomes, including an increase in mortality, length of hospital stay, discharge to an institution, and functional decline on discharge. Subsyndromal delirium (SSD) is characterized by the presence of certain symptoms of delirium, not yet satisfying the definition of full-blown delirium but it can identify patients with early cognitive and functional disabilities, and because of high prevalence of delirium and SSD. Efforts to prevent or early detection may identify patients who warrant clinical attention.

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A Systematic Review and Pooled Prevalence of Paediatric Delirium in Critically Ill Children

International Journal of Pharmacy Practice ◽

10.1093/ijpp/riab015.038 ◽

2021 ◽

Vol 29 (Supplement_1) ◽

pp. i31-i32

Author(s):

D Semple ◽

M M Howlett ◽

J D Strawbridge ◽

C V Breatnach ◽

J C Hayden

Keyword(s):

Risk Factors ◽

Critical Care ◽

Critically Ill ◽

Observational Studies ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Critically Ill Children ◽

Confusion Assessment ◽

Pooled Prevalence

Abstract Introduction Paediatric Delirium (PD) is a neuropsychiatric complication that occurs during the management of children in the critical care environment (Paediatric Intensive Care (PICU) and Neonatal Intensive Care (NICU). Delirium can be classified as hypoactive (decreased responsiveness and withdrawal), hyperactive (agitation and restlessness), and mixed (combined) (1). PD can be assessed using a number of assessment tools. PD has been historically underdiagnosed or misdiagnosed, having many overlapping symptoms with other syndrome such as pain and iatrogenic withdrawal syndrome (2). An appreciation of the extent of PD would help clinicians and policy makers drive interventions to improve recognition, prevention and management of PD in clinical practice. Aim To estimate the pooled prevalence of PD using validated assessment tools, and to identify risk factors including patient-related, critical-care related and pharmacological factors. Methods A systematic search of PubMed, EMBASE and CINAHL databases was undertaken. Eligible articles included observational studies or trials that estimated a prevalence of PD in a NICU/PICU population using a validated PD assessment tool. Validated tools are the paediatric Confusion Assessment Method-ICU (pCAM-ICU), the Cornell Assessment of Pediatric Delirium (CAPD), the PreSchool Confusion Assessment Method for the ICU (psCAM-ICU), pCAM-ICU severity scale (sspCAM-ICU), and the Sophia Observation Withdrawal Symptoms scale Paediatric Delirium scale (SOS-PD) (1). Only full text studies were included. No language restrictions were applied. Two reviewers independently screened records. Data was extracted using a pre-piloted form and independently verified by another reviewer. Quality was assessed using tools from the National Institutes of Health. A pooled prevalence was calculated from the studies that estimated PD prevalence using the most commonly applied tool, the CAPD (1). Results Data from 23 observational studies describing prevalence and risk factors for PD in critically ill children were included (Figure 1). Variability in study design and outcome reporting was found. Study quality was generally good. Using the validated tools prevalence ranged from 10–66% of patients. Hypoactive delirium was the most prevalent sub-class identified. Using the 13 studies that used the CAPD tool, a pooled prevalence of 35% (27%-43% 95%CI) was calculated. Younger ages, particularly less than two years old, sicker patients, particularly those undergoing mechanical and respiratory ventilatory support were more at risk for PD. Restraints, the number of sedative medications, including the cumulative use of benzodiazepines and opioids were identified as risk factors for the development of PD. PD was associated with longer durations of mechanical ventilation, longer stays and increased costs. Data on association with increased mortality risk is limited and conflicting. Conclusion PD affects one third of critical care admissions and is resource intense. Routine assessment in clinical practice may facilitate earlier detection and management strategies. Modifiable risk factors such as the class and number of sedative and analgesic medications used may contribute to the development of PD. Early mobility and lessening use of these medications present strategies to prevent PD occurrence. Longitudinal prospective multi-institutional studies to further investigate the presentations of the different delirium subtypes and modifiable risk factors that potentially contribute to the development of PD, are required. References 1. Semple D (2020) A systematic review and pooled prevalence of PD, including identification of the risk factors for the development of delirium in critically ill children. doi: 10.17605/OSF.IO/5KFZ8 2. Ista E, te Beest H, van Rosmalen J, de Hoog M, Tibboel D, van Beusekom B, et al. Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU. Australian Critical Care. 2018;31(5):266–73

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Do we know if our Patients are Delirious?

Journal of the Intensive Care Society ◽

10.1177/175114370800900322 ◽

2008 ◽

Vol 9 (3) ◽

pp. 269-269

Author(s):

Callum Kaye

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Confusion Assessment Method ◽

Assessment Method ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Critically Ill Patient ◽

Confusion Assessment ◽

Surgical Icu ◽

Symptoms And Signs

Delirium in the intensive care unit (ICU) setting is a significant cause of morbidity, mortality and increases ICU, as well as hospital length of stay1,2. Furthermore, with so many of the risk factors being present in the critically ill patient in the ICU environment, it's not surprising that other studies have found that up to 80% of patients will be delirious at some point during admission3,4. We performed a small study in a Toronto Medical-Surgical ICU using the Confusion Assessment Method for the ICU (CAM-ICU)5 to determine the prevalence of delirium in this unit. We concurrently reviewed medical and nursing notes to identify documentation of symptoms and signs that could indicate possible delirium during routine clinical assessment of the patient.

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Postoperative Delirium after Urological Surgery: A Literature Review

Current Urology ◽

10.1159/000499280 ◽

2019 ◽

Vol 13 (3) ◽

pp. 133-140 ◽

Cited By ~ 2

Author(s):

Ioannis Leotsakos ◽

Ioannis Katafigiotis ◽

Ofer N. Gofrit ◽

Mordechai Duvdevani ◽

Dionysios Mitropoulos

Keyword(s):

Risk Factors ◽

Literature Search ◽

Postoperative Delirium ◽

Mini Mental State Examination ◽

Confusion Assessment Method ◽

Assessment Method ◽

Factors Associated ◽

Confusion Assessment ◽

Urological Surgery ◽

State Examination

Purpose: We aimed to thoroughly search and identify studies referring to risk factors associated with postoperative delirium (POD) in patients undergoing open as well as en-doscopic urological surgery. Methods: The review after a systematic literature search included 5 studies. Results: The incidence of POD was reported to be between 7.8 and 30% depending on the type of the urologic surgery, while in the majority of the studies the onset happened on the first postoperative day and the symptoms lasted 3 ± 0.8 days. Seventeen different risk factors for POD were identified and presented in detail. Conclusion: The Mini-Mental State Examination score and older age were significantly associated with the development of POD. However, the Confusion Assessment Method is very well validated against the diagnosis of delirium from the specialists.

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Prevalence and risk factors of delirium and subsyndromal delirium in Chinese older adults

Geriatrics and Gerontology International ◽

10.1111/ggi.13545 ◽

2018 ◽

Vol 18 (12) ◽

pp. 1625-1628 ◽

Cited By ~ 3

Author(s):

Ka‐Keung Yam ◽

Yat‐Fung Shea ◽

Tuen‐Ching Chan ◽

Ka‐Chun Chiu ◽

James Ka‐Hei Luk ◽

...

Keyword(s):

Risk Factors ◽

Older Adults ◽

Chinese Older Adults ◽

Subsyndromal Delirium

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Delirium in Hospitalized Older Patients: Recognition and Risk Factors

Journal of Geriatric Psychiatry and Neurology ◽

10.1177/089198879801100302 ◽

1998 ◽

Vol 11 (3) ◽

pp. 118-125 ◽

Cited By ~ 142

Author(s):

Sharon K. Inouye

Keyword(s):

Risk Factors ◽

High Risk ◽

Older Patients ◽

Confusion Assessment Method ◽

Assessment Method ◽

Precipitating Factors ◽

Acute Confusional State ◽

Confusional State ◽

Confusion Assessment ◽

Simplified Algorithm

Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.

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Sedation in the Intensive Care Setting

10.2310/7ccsp.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

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Cognitive Assessment Tools for Screening Older Adults With Low Levels of Education: A Critical Review

Frontiers in Psychiatry ◽

10.3389/fpsyt.2019.00878 ◽

2019 ◽

Vol 10 ◽

Cited By ~ 1

Author(s):

José Wagner Leonel Tavares-Júnior ◽

Ana Célia Caetano de Souza ◽

Gilberto Sousa Alves ◽

Janine de Carvalho Bonfadini ◽

José Ibiapina Siqueira-Neto ◽

...

Keyword(s):

Older Adults ◽

Critical Review ◽

Cognitive Assessment ◽

Assessment Tools ◽

Low Levels

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

Geriatrics ◽

10.3390/geriatrics4030052 ◽

2019 ◽

Vol 4 (3) ◽

pp. 52

Author(s):

Khor ◽

Ong ◽

Tan ◽

Low ◽

Saedon ◽

...

Keyword(s):

Older Patients ◽

Altered Mental Status ◽

Confusion Assessment Method ◽

Assessment Method ◽

Assessment Tools ◽

University Hospital ◽

Cognitive Screening ◽

Cross Sectional ◽

Confusion Assessment ◽

Severity Scores

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.

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Linking the Scores of the Montreal Cognitive Assessment 5-min and the interRAI Cognitive Performance Scale in Older Adults With Mild Physical or Cognitive Impairment

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.705188 ◽

2021 ◽

Vol 12 ◽

Author(s):

Björn Andersson ◽

Hao Luo ◽

Gloria H. Y. Wong ◽

Terry Y. S. Lum

Keyword(s):

Older Adults ◽

Hong Kong ◽

Cognitive Impairment ◽

Cognitive Performance ◽

Cognitive Assessment ◽

Assessment Tools ◽

Montreal Cognitive Assessment ◽

Cognitive Performance Scale ◽

Mild Impairment ◽

Performance Scale

Background: Bridging scores generated from different cognitive assessment tools is necessary to efficiently track changes in cognition across the continuum of care. This study linked scores from the Montreal Cognitive Assessment-5 min (MoCA 5-min) to the interRAI cognitive Performance Scale (CPS), commonly adopted tools in clinical and long-term care settings, respectively.Methods: We included individual-level data from persons who participated in a home- and community-based care program for older people with mild impairment in Hong Kong. The program used the interRAI-Check Up instrument for needs assessment and service matching between 2017 and 2020. Each participant's cognitive performance was assessed using CPS, CPS Version 2 (CPS2), and MoCA 5-min. We performed equipercentile linking with bivariate log-linear smoothing to establish equivalent scores between the two scales.Results: 3,543 participants had valid data on both scales; 66% were female and their average age was 78.9 years (SD = 8.2). The mean scores for MoCA 5-min, CPS, and CPS2 were 18.5 (SD = 5.9), 0.7 (SD = 0.7), and 1.3 (SD = 1.1), respectively. A CPS or CPS2 score of 0 (intact cognition) corresponds to MoCA 5-min scores of 24 and 25, respectively. At the higher end, a CPS score of 3 (moderately impaired) and a CPS2 score of 5 (moderately impaired Level-2) corresponded to MoCA 5-min scores of 0 and 1, respectively. The linking functions revealed the floor and ceiling effects that exist for the different scales, with CPS and CPS2 measuring more-severe cognitive impairment while the MoCA 5-min was better suited to measure mild impairment.Conclusions: We provided score conversions between MoCA 5-min and CPS/CPS2 within a large cohort of Hong Kong older adults with mild physical or cognitive impairment. This enabled continuity in repeated assessment with different tools and improved comparability of cognitive scores generated from different tools from diverse populations and research cohorts.

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Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults

Journal of Hospital Medicine ◽

10.12788/jhm.3410 ◽

2020 ◽

Vol 15 (9) ◽

pp. 544-547

Author(s):

Andrea Yevchak Sillner ◽

Long Ngo ◽

Yoojin Jung ◽

Sharon Inouye ◽

Marie Boltz ◽

...

Keyword(s):

Older Adults ◽

Postoperative Delirium ◽

Elective Surgery ◽

Confusion Assessment Method ◽

Assessment Method ◽

Reference Standard ◽

Patient Reports ◽

Confusion Assessment ◽

Overall Performance ◽

Cognitively Intact

The authors’ sought to develop an ultrabrief screen for postoperative delirium in cognitively intact patients older than 70 years undergoing major elective surgery. All possible combinations of one-, two- and three-item screens and their sensitivities, specificities, and 95% confidence intervals were calculated and compared with the delirium reference standard Confusion Assessment Method (CAM). Among the 560 participants (mean age, 77 years; 58% women), delirium occurred in 134 (24%). We considered 1,100 delirium assessments from postoperative days 1 and 2. The screen with the best overall performance consisted of three items: (1) Patient reports feeling confused, (2) Months of the year backward, and (3) “Does the patient appear sleepy?” with sensitivity of 92% and specificity of 72%. This brief, three-item screen rules out delirium quickly, identifies a subset of patients who require further testing, and may be an important tool to improve recognition of postoperative delirium.

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