Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults

Donna M Fick, Melinda R Steis, Jennifer L Waller, Sharon K Inouye, Donna M Fick, Melinda R Steis, Jennifer L Waller, Sharon K Inouye

Abstract

Background: Current literature does not identify the significance of underlying cognitive impairment and delirium in older adults during and 30 days following acute care hospitalization.

Objective: Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia.

Design: A 24-month prospective cohort study.

Setting: Community hospital.

Patients: A total of 139 older adults (>65 years) with dementia.

Methods: This prospective study followed patients daily during hospitalization and 1 month posthospital. Main measures included dementia (Modified Blessed Dementia Rating score, Informant Questionnaire on Cognitive Decline in the Elderly), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3, and significance was an α level of 0.05. Logistic regression, analysis of covariance, or linear regression was performed controlling for age, gender, and dementia stage.

Results: The overall incidence of new delirium was 32% (44/139). Those with delirium had a 25% short-term mortality rate, increased length of stay, and poorer function at discharge. At 1 month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium, and for every 1 unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium.

Conclusions: Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital.

Copyright © 2013 Society of Hospital Medicine.

References

    1. Krumholz HM. Post-hospital syndrome - an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100–102.
    1. Alzheimer's Association Alzheimer's disease facts and figures. Alzheimers Dement. 2012;8(2):131–168.
    1. Steis MR, Fick DM. Delirium superimposed on dementia: accuracy of nurse documentation. J Gerontol Nurs. 2012;38(1):32–42. doi:10.3928/00989134-20110706-01.
    1. Fick D, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2002;50(10):1723–1732.
    1. Fong TG, Jones RN, Shi P, et al. Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 2009;72(18):1570–1575. doi:10.1212/WNL.0b013e3181a4129a.
    1. Fong TG, Jones RN, Marcantonio ER, et al. Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Intern Med. 2012;156(12):848–856. W296. doi:10.7326/0003-4819-156-12-201206190-00005.
    1. Fick D, Kolanowski A, Waller JL, Inouye SK. Delirium superimposed on dementia in a community-dwelling managed care population: A 3-year retrospective study of occurrence, costs, and utilization. J Gerontol. 2005;60A(6):748–753.
    1. Voyer P, Richard S, Doucet L, Carmichael PH. Factors associated with delirium severity among older persons with dementia. J Neurosci Nurs. 2011;43(2):62–69.
    1. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care. 2008;12(Suppl 3):S3. doi:10.1186/cc6149.
    1. Uhlmann RF, Larson EB, Buchner DM. Correlations of Mini-Mental State and Modified Rating Scale to Measures of Transitional Health Status in Dementia. Jnl Of Gerontology. 1987;42(1):33–36.
    1. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993;269(18):2386–2391.
    1. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922–935.
    1. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–572.
    1. Auer S, Reisberg B. The GDS/FAST staging system. Int Psychogeriatr. 1997;9(Suppl 1):167–171.
    1. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948.
    1. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N. Validation of the Delirium Rating Scale-Revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci. 2001;13(2):229–242.
    1. Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The confusion assessment method: a systematic review of current usage. J Am Geriatr Soc. 2008;56(5):823–830. doi:10.1111/j.1532-5415.2008.01674.x.
    1. American Society of Health-System Pharmacists . AHFS Drug Information. American Society of Health-System Pharmacists; Bethesda, MD: 2005.
    1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–2724. Erratum in: Arch Intern Med 2004;164(3):298.
    1. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry. 1988;23(3):271–284.
    1. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. JAGS. 1983;31(12):721–726.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383.
    1. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9–15.
    1. Andrew MK, Freter SH, Rockwood K. Prevalence and outcomes of delirium in community and non-acute care settings in people without dementia: a report from the Canadian Study of Health and Aging. Br Med J. 2006;4(15) doi:10.1186/1741-7015-4-15.
    1. Pitkala KH, Laurila JV, Strandberg TE, Tilvis RS. Prognostic significance of delirium in frail older people. Dementia. 2005;19(2–3):158–163. 10.1159/000082888.
    1. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304(4):443–451. doi:10.1001/jama.2010.1013.
    1. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–1762.
    1. Bellelli G, Speciale S, Barisione E, Trabucchi M. Delirium subtypes and 1-year mortality among elderly patients discharged from a post-acute rehabilitation facility. J Gerontol. 2007;62A(10):1182–1183.
    1. Edlund A, Lundstrom M, Karlsson S, Brannstrom B, Bucht G, Gustafson Y. Delirium in older patients admitted to general internal medicine. J Geriatr Psychiatry Neurol. 2006;19(2):83–90.
    1. Kiely DK, Jones RN, Bergmann MA, Marcantonio ER. Association between psychomotor activity delirium subtypes and mortality among newly admitted postacute facility patients. J Gerontol. 2007;62A(2):174–179.
    1. Leslie DL, Zhang Y, Holford TR, Bogardus ST, Leo-Summers LS, Inouye SK. Premature death associated with delirium at 1-year follow-up. Arch Intern Med. 2005;165:1657–1662.
    1. McAvay GJ, Van Ness PH, Bogardus ST, et al. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc. 2006;54(8):1245–1250. 10.1111/j.1532-5415.2006.00815.x.
    1. Voyer P, McCusker J, Cole MG, Khomenko L. Influence of prior cognitive impairment on the severity of delirium symptoms among older patients. J Neurosci Nurs. 2006;38(2):90–101.
    1. Voyer P, McCusker J, Cole MG, St. Jacques S, Khomenko L. Factors associated with delirium severity among older patients. J Clin Nurs. 2007;16:819–831.
    1. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30–39. doi:10.1056/NEJMoa1112923.
    1. Wright RM, Roumani YF, Boudreau R, et al. Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: Findings from the Health, Aging And Body Composition Study. J Am Geriatr Soc. 2009;57(2):243–250. doi:JGS2127 [pii]10.1111/j.1532-5415.2008.02127.x.
    1. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel