Confusion Assessment Method Criteria Research Articles

Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium.

Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). Data were from five independent study cohorts (N=1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.

Ascertainment of Delirium Status Using Natural Language Processing From Electronic Health Records.

Delirium is underdiagnosed in clinical practice and is not routinely coded for billing. Manual chart review can be used to identify the occurrence of delirium; however, it is labor-intensive and impractical for large-scale studies. Natural language processing (NLP) has the capability to process raw text in electronic health records (EHRs) and determine the meaning of the information. We developed and validated NLP algorithms to automatically identify the occurrence of delirium from EHRs. This study used a randomly selected cohort from the population-based Mayo Clinic Biobank (N = 300, age ≥65). We adopted the standardized evidence-based framework confusion assessment method (CAM) to develop and evaluate NLP algorithms to identify the occurrence of delirium using clinical notes in EHRs. Two NLP algorithms were developed based on CAM criteria: one based on the original CAM (NLP-CAM; delirium vs no delirium) and another based on our modified CAM (NLP-mCAM; definite, possible, and no delirium). The sensitivity, specificity, and accuracy were used for concordance in delirium status between NLP algorithms and manual chart review as the gold standard. The prevalence of delirium cases was examined using International Classification of Diseases, 9th Revision (ICD-9), NLP-CAM, and NLP-mCAM. NLP-CAM demonstrated a sensitivity, specificity, and accuracy of 0.919, 1.000, and 0.967, respectively. NLP-mCAM demonstrated sensitivity, specificity, and accuracy of 0.827, 0.913, and 0.827, respectively. The prevalence analysis of delirium showed that the NLP-CAM algorithm identified 12 651 (9.4%) delirium patients, the NLP-mCAM algorithm identified 20 611 (15.3%) definite delirium cases, and 10 762 (8.0%) possible cases. NLP algorithms based on the standardized evidence-based CAM framework demonstrated high performance in delineating delirium status in an expeditious and cost-effective manner.

Delirium in COVID-19: epidemiology and clinical correlations in a large group of patients admitted to an academic hospital

BackgroundDelirium incidence and clinical correlates in coronavirus disease-19 (COVID-19) pneumonia are still poorly investigated.AimTo describe the epidemiology of delirium in patients hospitalized for suspect COVID-19 pneumonia during the pandemic peak in an academic hospital of Northern Italy, identify its clinical correlations and evaluate the association with mortality.MethodsThe clinical records of 852 patients admitted for suspect COVID-19 pneumonia, defined as respiratory symptoms or fever or certain history of contact with COVID-19 patients, plus chest CT imaging compatible with alveolar-interstitial pneumonia, were retrospectively analyzed. Delirium was defined after careful revision of daily clinical reports in accordance with the Confusion Assessment Method criteria. Data on age, clinical presentation, comorbidities, drugs, baseline lab tests and outcome were collected. The factors associated with delirium, and the association of delirium with mortality, were evaluated through binary logistic regression models.ResultsNinety-four patients (11%) developed delirium during stay. They were older (median age 82, interquartile range, IQR 78–89, vs 75, IQR 63–84, p < 0.001), had more neuropsychiatric comorbidities and worse respiratory exchanges at baseline. At multivariate models, delirium was independently and positively associated with age [odds ratio (OR) 1.093, 95% confidence interval (CI) 1.046–1.143, p < 0.001], use of antipsychotic drugs (OR 4.529, 95% CI 1.204–17.027, p = 0.025), serum urea and lactate-dehydrogenase at admission. Despite a higher mortality in patients with delirium (57% vs 30%), this association was not independent of age and respiratory parameters.ConclusionsDelirium represents a common complication of COVID-19 and a marker of severe disease course, especially in older patients with neuropsychiatric comorbidity.

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.

The trajectory of C-reactive protein serum levels in older hip fracture patients with postoperative delirium.

Important precipitating risk factors for delirium such as infections, vascular disorders, and surgery are accompanied by a systemic inflammatory response. Systemic inflammatory mediators can induce delirium in susceptible individuals. Little is known about the trajectory of systemic inflammatory markers and their role in the development and outcome of delirium. This is a prospective cohort study of older patients undergoing acute surgery for hip fracture. Baseline characteristics were assessed preoperatively. During hospital admission, presence of delirium was assessed daily according to the Confusion Assessment Method criteria. This study compared the trajectory of serum levels of the C-reactive protein (CRP) between people with and without postoperative delirium. Blood samples were taken at baseline and at postoperative day 1 through postoperative day 5. Forty-one out of 121 patients developed postoperative delirium after hip fracture surgery. Longitudinal analysis of the trajectory of serum CRP levels using the Generalized Estimating Equations (GEE) method identified that higher CRP levels were associated with postoperative delirium. CRP levels were higher from postoperative day 2 through postoperative day 5. No significant differences in serum CRP levels were found when we compared patients with short (1-2 days) and more prolonged delirium (3 days or more). Delirium is associated with an increased systemic inflammatory response, and our results suggest that CRP plays a role in the underlying (inflammatory-vascular) pathological pathway of postoperative delirium.

Parkinson's disease-related non-motor features as risk factors for post-operative delirium in spinal surgery

BackgroundThe clinical features of postoperative delirium are similar to the core features of alpha synuclein-related cognitive disorders, such as Parkinson’s disease dementia (PDD) or dementia with Lewy bodies (DLB). Therefore, we hypothesized that the non-motor symptoms (NMSs) in Parkinson’s disease (PD), which precede the cardinal motor features of PD, are likely to be risk factors for developing postoperative delirium. We investigated the association between PD-related NMSs and postoperative delirium in old people undergoing elective spinal surgery.MethodsThis study was a prospective study. Participants were aged 65 years and older and scheduled to undergo elective spinal surgery. During the enrollment period, 338 individuals were screened, 104 participants were included in the analysis. We assessed eight easily-assessed and representative PD-related NMSs 1 day before the scheduled surgery using tests or questionnaires for each symptom. The presence of delirium was determined by using the short version of the Confusion Assessment Method (CAM).ResultsFifteen (14.4%) of the 104 participants (age, 71.7 ± 4.7 years; men, 34.6%) met the CAM criteria for post-operative delirium. Multivariate logistic analysis showed that decreased olfactory function (odds ratio [OR] 0.63, 95% CI 0.44–0.91) and exhibiting rapid eye movement sleep behavior disorder (RBD, OR 1.45, 95% CI 1.09–1.93) were significantly independent predictors of postoperative delirium.ConclusionsOur study shows that hyposmia and RBD are significantly independent risk factors for postoperative delirium in general elderly population. Considering that NMSs may represent burden of alpha synuclein deposit, we postulate that an underlying alpha synucleinopathy may correlates with postoperative delirium.SignificanceThis study gives a novel insight for the risk factor of postoperative delirium.

Observational cohort study examining apolipoprotein E status and preoperative neuropsychological performance as predictors of post-operative delirium in an older elective arthroplasty population.

delirium following surgery is common and is associated with negative outcomes. Preoperative cognitive impairment has been shown to be a risk factor for post-operative delirium. Often the cognitive tests used are cumbersome. This study tests the hypothesis that the quantification of brain vulnerability, using Apolipoprotein E (ApoE) status and neuropsychological tests, both traditional and more easily administered, can quantify the risk of post-operative delirium following elective primary arthroplasty surgery. this observational cohort study recruited participants aged 65 years or older admitted prior to elective primary hip or knee arthroplasty. Baseline data was collected and participants underwent neuropsychological testing and had blood taken for ApoE genotyping preoperatively. Post-operatively participants were assessed daily for delirium using the Confusion Assessment Method (CAM) and charts were reviewed where possible for reports of delirium. Univariate and multivariate analyses of preoperative factors were undertaken to identify independent predictors of delirium. between March 2012 and October 2014, 315 participants completed the study with an overall incidence of post-operative delirium of 40/315 (12.7%). Of these 18 fulfilled the CAM criteria for delirium and 22 were deemed delirious by consensus decision based on chart review. ApoE genotype was not associated with post-operative delirium in this cohort. Time taken to complete Colour Trails 2, errors in mini mental state examination and level of pain preoperatively were independent predictors of post-operative delirium. this study challenges the assertion that ApoE4 genotype predicts post-operative delirium. It replicates previous work suggesting cognitive impairment predicts post-operative delirium and shows for the 1st time that simple cognitive tests can be as effective as more detailed tests.

Partial and No Recovery from Delirium in Older Hospitalized Adults: Frequency and Baseline Risk Factors.

To determine the frequency and baseline risk factors for partial and no recovery from delirium in older hospitalized adults. Cohort study with assessment of recovery status approximately 1 and 3 months after enrollment. University-affiliated, primary, acute-care hospital. Medical or surgical inpatients aged 65 and older with delirium (N = 278). The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), and activities of daily living (ADLs) were completed at enrollment and each follow-up. Primary outcome categories were full recovery (absence of CAM core symptoms of delirium), partial recovery (presence of ≥1 CAM core symptoms but not meeting criteria for delirium), no recovery (met CAM criteria for delirium), or death. Secondary outcomes were changes in MMSE, DI, and ADL scores between the baseline and last assessment. Potential risk factors included many clinical and laboratory variables. In participants with dementia, frequencies of full, partial, and no recovery and death at first follow-up were 6.3%, 11.3%, 74.6%, and 7.7%, respectively; in participants without dementia, frequencies were 14.3%, 17%, 50.9%, and 17.9%, respectively. In participants with dementia, frequencies at the second follow-up were 7.9%, 15.1%, 57.6%, and 19.4%, respectively; in participants without dementia, frequencies were 19.2%, 20.2%, 31.7%, and 28.8%, respectively. Frequencies were similar in participants with prevalent and incident delirium and in medical and surgical participants. The DI, MMSE, and ADL scores of many participants with partial and no recovery improved. Independent baseline risk factors for delirium persistence were chart diagnosis of dementia (odds ratio (OR) = 2.51, 95% confidence interval (CI) =1.38, 4.56), presence of any malignancy (OR = 5.79, 95% CI = 1.51, 22.19), and greater severity of delirium (OR =9.39, 95% CI = 3.95, 22.35). Delirium in many older hospitalized adults appears to be much more protracted than previously thought, especially in those with dementia, although delirium symptoms, cognition, and function improved in many participants with partial and no recovery. It may be important to monitor the longer-term course of delirium in older hospitalized adults and develop strategies to ensure full recovery.

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

Background The frequency of full syndromal and subsyndromal delirium is understudied. Aims We conducted a point prevalence study in a general hospital. Method Possible delirium identified by testing for inattention was evaluated regarding delirium status (full/subsyndromal delirium) using categorical (Confusion Assessment Method (CAM), DSM-IV) and dimensional (Delirium Rating Scale-Revised-98 (DRS-R98) scores) methods. Results In total 162 of 311 patients (52%) screened positive for inattention. Delirium was diagnosed in 55 patients (17.7%) using DSM-IV, 52 (16.7%) using CAM and 58 (18.6%) using DRS-R98⩾12 with concordance for 38 (12.2%) individuals. Subsyndromal delirium was identified in 24 patients (7.7%) using a DRS-R98 score of 7-11 and 41 (13.2%) using 2/4 CAM criteria. Subsyndromal delirium with inattention (v. without) had greater disturbance of multiple delirium symptoms. Conclusions The point prevalence of delirium and subsyndromal delirium was 25%. There was modest concordance between DRS-R98, DSM-IV and CAM delirium diagnoses. Inattention should be central to subsyndromal delirium definitions.

Can dementia be diagnosed during hospitalisation?

IntroductionAcute hospitalisation can be an opportunity to diagnose dementia if it can be guaranteed that confounding factors are taken into account. ObjectiveTo study the validity of systematic criteria for the detection of cognitive impairment and of a standardised diagnostic protocol of dementia in elderly patients hospitalised in a geriatric service. MethodsPatients were included if they met any of the following criteria: a) previous score on the Red Cross Mental Scale (RCMS)≥2, b) Pfeiffer Questionnaire score≥5 errors and/or c) presence of delirium (Confusion Assessment Method criteria). A geriatrician conducted a cognitive history and physical examination and the following diagnostic protocol was applied: DSM-IV criteria for dementia, Mini Mental State Examination, Clock Drawing Test, Informant Questionnaire, Clinical Dementia Rating Scale, Pfeffer Scale of Instrumental Activities and Laboratory and neuroimaging tests. Each diagnosis was confirmed by another independent geriatrician. ResultsSeven hundred and fifty-five patients were hospitalised, of which 156 (21%) met the inclusion criteria. The study could be completed during hospitalization in 114 patients (73%). The definitive diagnosis was Alzheimer's disease or mixed dementia in 63 cases (40%), vascular dementia in 17 (11%), mild cognitive impairment in 6 (4%) and delirium without previous decline in 28 (18%). Treatment recommendations were given in all cases. ConclusionsApplication of systematic detection criteria and a standardised diagnostic protocol made it possible to discover unknown cognitive problems in one of every five hospitalised elders and to diagnose 73% of them. Most of the diagnosis were for established dementia.

BIS-guided Anesthesia Decreases Postoperative Delirium and Cognitive Decline

Previous clinical trials and animal experiments have suggested that long-lasting neurotoxicity of general anesthetics may lead to postoperative cognitive dysfunction (POCD). Brain function monitoring such as the bispectral index (BIS) facilitates anesthetic titration and has been shown to reduce anesthetic exposure. In a randomized controlled trial, we tested the effect of BIS monitoring on POCD in 921 elderly patients undergoing major noncardiac surgery. Patients were randomly assigned to receive either BIS-guided anesthesia or routine care. The BIS group had anesthesia adjusted to maintain a BIS value between 40 and 60 during maintenance of anesthesia. Routine care group had BIS measured but not revealed to attending anesthesiologists. Anesthesia was adjusted according to traditional clinical signs and hemodynamic parameters. A neuropsychology battery of tests was administered before and at 1 week and 3 months after surgery. Results were compared with matched control patients who did not have surgery during the same period. Delirium was measured using the confusion assessment method criteria. The median (interquartile range) BIS values during the maintenance period of anesthesia were significantly lower in the control group, 36 (31 to 49), compared with the BIS-guided group, 53 (48 to 57), P<0.001. BIS-guided anesthesia reduced propofol delivery by 21% and that for volatile anesthetics by 30%. There were fewer patients with delirium in the BIS group compared with routine care (15.6% vs. 24.1%, P=0.01). Although cognitive performance was similar between groups at 1 week after surgery, patients in the BIS group had a lower rate of POCD at 3 months compared with routine care (10.2% vs. 14.7%; adjusted odds ratio 0.67; 95% confidence interval, 0.32-0.98; P=0.025). BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

594 - Clerking in confusion

Introduction Delirium is common but often under-diagnosed. Early detection and diagnosis are vital for better prognosis, placing emphasis on the quality of the admission clerking. NICE recommends using the Confusion Assessment Method (CAM) when assessing such patients. For a delirium diagnosis patients have to fulfill the CAM criteria. Aim To establish if the CAM is a useful tool in clerking patients presenting with confusion. Objectives 1. Assess uptake of the CAM 2. Identify how many patients presenting with confusion fulfill diagnosis criteria 3. Determine if the CAM results in a lower number of amended diagnoses 4. Describe associations between clinical findings and diagnosis 5. Evaluate junior doctor knowledge about the CAM Methods A prospective audit was performed to assess the quality of clerking in fifty patients presenting with “confusion’. The second phase involved a qualitative questionnaire to assess junior doctor knowledge of the CAM. Results CAM was not used to make any diagnosis. Only 4% of clerkings fulfilled diagnosis criteria. Patients diagnosed with delirium, who then had their diagnosis amended, did not fulfill CAM criteria on admission. Junior doctor knowledge of delirium diagnosis was poor. Conclusions The CAM is a useful and valuable tool, resulting in fewer unnecessary investigations and a reduced hospital stay. Junior doctor knowledge of it is inadequate explaining why it is not currently being used in practice. We recommend that the CAM should be included in the teaching curriculum. This study shows that further investigation of the aim, and its objective, is warranted and justified.

Anesthesia and Postoperative Delirium in Older Adults Undergoing Hip Surgery

To examine the effects of general anesthesia on the risk of incident postoperative delirium in older adults undergoing hip surgery. Secondary analysis of haloperidol prophylaxis for delirium clinical trial data. Predefined risk factors for delirium were assessed prior to surgery. Primary outcome was postoperative delirium. Study outcome was compared across patient groups who received either general or regional anesthesia, and for individuals receiving various perioperative medications (benzodiazepines, anticholinergics, and opioids), using multivariable logistic regression after controlling for potential confounders. Subgroup analyses based on baseline cognitive impairment and delirium risk were also undertaken. Large medical school-affiliated general hospital in Alkmaar, the Netherlands. Five hundred twenty-six adults aged 70 and older undergoing hip surgery. The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Sixty participants (11.4%) had incident postoperative delirium. One hundred eighty-nine (35.9%) received general anesthesia, 18 (9.5%) of whom developed postoperative delirium, and 337 (64.1%) received regional anesthesia, 42 (12.5%) of whom developed postoperative delirium (adjusted odds ratio=0.81, 95% confidence interval=0.43-1.52, P=.51). Results were stratified for baseline cognitive impairment, age, acute admission, perioperative medication and other delirium risk factors. Delirium was not independently associated with specific drugs or the medication classes opioids, benzodiazepines, and anticholinergics. General anesthesia has no distinct effect on incident postoperative delirium in older adults undergoing hip surgery. This also holds for individuals suffering from cognitive impairment or who are otherwise at risk for postoperative delirium. Perioperative use of narcotics, benzodiazepines, and anticholinergic agents was not associated with incident delirium in this cohort of older adults undergoing hip surgery.

Prevalence of Delirium on Admission to Postacute Care is Associated With a Higher Number of Nursing Home Deficiencies

To examine the association between the prevalence of delirium among patients admitted to postacute care and the quality of nursing home care as reflected in deficiency counts. Analysis of screening data from a randomized controlled trial (RCT) of a delirium abatement program. We screened 4744 of 6352 RCT-eligible persons admitted to 1 of 8 skilled nursing facilities in the Boston area over a 3-year period. Quality of care was operationalized with the count of deficiencies noted by state surveyors. Prevalence of Confusion Assessment Method (CAM) diagnoses of delirium as completed by trained research interviewers at each facility. About 1 in 7 persons admitted to postacute care met CAM criteria for delirium, but this varied from 1 in 15 to 1 in 4 across facilities. The correlation of deficiency count per 100 beds and the prevalence of CAM delirium was strong (r=0.45) and significant (95% Confidence interval =0.07, 0.71). Although this study is limited by small sample size, limited geographic scope, and crude assessment of quality with deficiency counts, we have found that facilities with more deficiencies admit more persons that satisfy CAM criteria for delirium. It is possible that good facilities often choose to admit and/or are referred good candidates for rehabilitation, whereas facilities with more deficiencies are not able to be so selective. The end result may be that delirious patients are being preferentially admitted to poorer quality facilities, increasing their likelihood of poor postacute outcomes.

Examination of the Multifactorial Model of Delirium Among Long-Term Care Residents with Dementia

The multifactorial model of delirium was developed to explain the interrelationship between predisposing and precipitating factors for delirium. Although validated among hospitalized patients, this model has never been tested among long-term care residents with dementia. We undertook this secondary data analysis to investigate the combined effect of predisposing and precipitating factors on the likelihood of having delirium among this population. Delirium was defined as meeting the Confusion Assessment Method criteria for definite or probable delirium. Risk factors considered in the study were those found significantly associated with delirium in the original study. Participants (N=155) were classified into risk groups. Prevalence of delirium for the low, moderate, and high predisposing risk groups were 32%, 78.4%, and 98.1%, respectively, and 37.9%, 67.2%, and 86.8% for the precipitating factors risk groups. When both variables were included in the same model, only predisposing factors remained statistically associated with delirium. Predisposing factors play a key role in the likelihood of having delirium among this population. Increased awareness of these factors among nurses could improve the care of these residents by targeting modifiable risk factors.

Risk Factors and Prediction of Postoperative Delirium in Elderly Hip‐Surgery Patients: Implementation and Validation of a Medical Risk Factor Model

To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model. Prospective cohort study. Medical school-affiliated general hospital in Alkmaar, the Netherlands. Six hundred three hip-surgery patients aged 70 and older screened for risk factors for postoperative delirium. Predefined risk factors for delirium were assessed on admission. One point was assigned for each of four risk factors present, resulting in three groups: low, intermediate, and high risk. Baseline screening and assessment included the Mini-Mental State Examination, the standardized Snellen test for visual impairment, chart review to determine Acute Physiological and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine ratio. The primary outcome was postoperative delirium, as defined using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria. All patients were screened daily for delirium. Incidence of delirium was 3.8% in the low-risk group (P<.001), 11.1% in the intermediate-risk group (P=.27, relative risk (RR)=3.0), and 37.1% in the high-risk group (P<.001, RR=9.8). Cognitive impairment at admission had the highest predictive value for postoperative delirium (coefficient of determination=0.15). Contrary to previous findings, age was an independent predictive factor for delirium. Moreover, postoperative delirium was four times as frequent in acute patients as in elective hip-replacement patients. The medical risk factor model is valid for elderly hip-surgery patients. Cognitive impairment, age, and type of admission are important risk factors for delirium in this surgical population.

OUTCOMES OF OLDER PEOPLE ADMITTED TO POSTACUTE FACILITIES WITH DELIRIUM

Objectives: To compare outcomes of patients admitted to postacute skilled nursing facilities with delirium, subsyndromal delirium, and no delirium. Design: Observational cohort study. Setting: Seven skilled nursing facilities that specialize in postacute care within a single metropolitan region. Participants: Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and older who underwent mental status testing within 5 days of admission to the participating facilities. Subjects who met full Confusion Assessment Method (CAM) criteria were classified as delirious, those with one or more CAM criteria were classified as having subsyndromal delirium, and those with no CAM features were classified as having no delirium. All subjects with delirium and with available medical records were included. A random subset of subjects with no delirium and subsyndromal delirium with available medical records was included. Measurements: The medical records of all subjects underwent a structured review by trained research nurses who were masked to the subjects' initial delirium status. Records were reviewed for the development of new complications within the postacute setting and to determine whether the subjects were discharged within 30 days and, if so, the discharge destination. The National Death Index was used to assess 6-month mortality. Results: Subjects with delirium were more likely to experience one or more complications than subjects with no delirium (73% vs 41%, P < .01). Within 30 days of postacute admission, subjects with delirium were more than twice as likely to be rehospitalized (30% vs 13%), and less than half as likely to be discharged to the community (30% vs 73%) than subjects without delirium (differences P < .01). Subjects with subsyndromal delirium had outcomes intermediate between those with and without delirium. Finally, subjects admitted to the postacute setting with delirium experienced a 6-month mortality rate of 25.0%, compared with 5.7% in subjects admitted without delirium. Subjects with subsyndromal delirium had a 6-month mortality rate of 18.3%. Conclusion: Patients admitted to postacute skilled nursing facilities with delirium are more likely to experience complications, rehospitalization, and death than patients without delirium. These findings support the need for improved case finding and management of delirium in postacute care.

Haloperidol Prophylaxis for Elderly Hip‐Surgery Patients at Risk for Delirium: A Randomized Placebo‐Controlled Study

To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium. Randomized, double-blind, placebo-controlled trial. Large medical school-affiliated general hospital in Alkmaar, The Netherlands. A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium. Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay. The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6-1.3); the mean highest DRS-R-98 score+/-standard deviation was 14.4+/-3.4 and 18.4+/-4.3, respectively (mean difference 4.0, 95% CI=2.0-5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI=4.0-8.0; P<.001); and the mean number of days in the hospital was 17.1+/-11.1 and 22.6+/-16.7, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). No haloperidol-related side effects were noted. Low-dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated.

Outcomes of Older People Admitted to Postacute Facilities with Delirium

To compare outcomes of patients admitted to postacute skilled nursing facilities with delirium, subsyndromal delirium, and no delirium. Observational cohort study. Seven skilled nursing facilities that specialize in postacute care within a single metropolitan region. Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and older who underwent mental status testing within 5 days of admission to the participating facilities. Subjects who met full Confusion Assessment Method (CAM) criteria were classified as delirious, those with one or more CAM criteria were classified as having subsyndromal delirium, and those with no CAM features were classified as having no delirium. All subjects with delirium and with available medical records were included. A random subset of subjects with no delirium and subsyndromal delirium with available medical records was included. The medical records of all subjects underwent a structured review by trained research nurses who were masked to the subjects' initial delirium status. Records were reviewed for the development of new complications within the postacute setting and to determine whether the subjects were discharged within 30 days and, if so, the discharge destination. The National Death Index was used to assess 6-month mortality. Subjects with delirium were more likely to experience one or more complications than subjects with no delirium (73% vs 41%, P < .01). Within 30 days of postacute admission, subjects with delirium were more than twice as likely to be rehospitalized (30% vs 13%), and less than half as likely to be discharged to the community (30% vs 73%) than subjects without delirium (differences P < .01). Subjects with subsyndromal delirium had outcomes intermediate between those with and without delirium. Finally, subjects admitted to the postacute setting with delirium experienced a 6-month mortality rate of 25.0%, compared with 5.7% in subjects admitted without delirium. Subjects with subsyndromal delirium had a 6-month mortality rate of 18.3%. Patients admitted to postacute skilled nursing facilities with delirium are more likely to experience complications, rehospitalization, and death than patients without delirium. These findings support the need for improved case finding and management of delirium in postacute care.

Detection of Delirium in the Intensive Care Unit: Comparison of Confusion Assessment Method for the Intensive Care Unit with Confusion Assessment Method Ratings

To compare the Confusion Assessment Method (CAM) and CAM for the Intensive Care Unit (CAM-ICU) methods for detecting delirium in alert, nonintubated older ICU patients. Comparison study. Fourteen-bed medical ICU of an 800-bed university teaching hospital. Twenty-two patients aged 65 and older admitted to the ICU. Two blinded, trained clinician-researchers who had undergone interrater reliability testing interviewed patients separately, usually within 10 minutes of each other (up to 120 minutes). Each researcher examined patients for the four key CAM criteria: acuteness, inattention, disorganized thinking, and altered level of consciousness. One researcher used the CAM method with the Mini-Mental State Examination and Digit Span; the other researcher used the CAM-ICU method with nonverbal cognitive and attention tasks. Rates of delirium were 68% according to CAM and 50% according CAM-ICU. Comparing the two methods, agreement was 82%, with a kappa of 0.64. Using the CAM as the reference standard, the CAM-ICU had a sensitivity of 73% (95% confidence interval (CI)=60-86) and specificity of 100% (95% CI=56-100). There were four false-negative ratings using the CAM-ICU. Reasons for disparate results were that the CAM used more-detailed cognitive testing that detected more deficits (3 patients) and the time elapsed (90 minutes) between ratings in one patient with markedly fluctuating symptoms. CAM and CAM-ICU agreement was moderately high. Although the CAM-ICU is recommended for ICU patients because of its brevity and ease of use, the standard CAM method may detect more subtle cases of delirium in nonintubated, verbal ICU patients.