Delirium In Older Medical Inpatients Research Articles

Results from a double blinded, randomised, placebo-controlled, feasibility trial of melatonin for the treatment of delirium in older medical inpatients.

Delirium is common in elderly inpatients, causing distress, cognitive decline and death. No known intervention improves the course of delirium; current treatments are symptomatic, and limited by lack of efficacy and adverse effects. There is an urgent need to find an effective treatment for delirium. To determine the feasibility of a trial of oral melatonin 5 mg nightly for five nights for the treatment of delirium in older medical inpatients, and determine the participants required to demonstrate a clinically and statistically significant decrease in severity of delirium in older medical inpatients treated with melatonin. This was a double blinded, randomised controlled trial in general internal medicine units of a tertiary teaching hospital. Older (≥70 years) inpatients with confusion assessment method positive hyperactive or mixed delirium were suitable for inclusion. Subjects received melatonin 5 mg oral nightly for five nights or matching placebo. The primary outcome was the Memorial Delirium Assessment Scale (MDAS) administered daily. No adverse effects occurred due to melatonin. In the treatment group, the mean change in MDAS from baseline during treatment period was 2.5 ± 5.0 points, in the placebo group, 2.1 ± 4.1 points, a non-significant difference. A power calculation accounting for drop-out (31.0%), suggests 120 participants would be required to demonstrate with 90% power that melatonin 5 mg reduces the severity of delirium by 3 points or more on MDAS. A trial of the hypothesis that 5 mg melatonin nightly for five nights reduces delirium severity in older medical inpatients would require 120 patients, and is feasible.

Risk Factors for Delirium in Older Medical Inpatients in Tanzania

Background: The risk factors for prevalent delirium in older hospitalised adults in Sub-Saharan Africa (SSA) remain poorly characterised. Methods: A total of 510 consecutive admissions of adults aged ≥60 years to acute medical wards of Kilimanjaro Christian Medical Centre in northern Tanzania were recruited. Patients were assessed within 24 h of admission with a risk factor questionnaire, physiological observations, neurocognitive assessment, and informant interview. Delirium and dementia diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) and DSM IV respectively, by an expert panel. Results: Being male, current alcohol use, dementia, and physiological markers of illness severity were significant independent risk factors for delirium on multivariable analysis. Conclusions: The risk factors for prevalent delirium in older medical inpatients in SSA include pre-existing dementia, and are similar to those identified in high-income countries. Our data could help inform the development of a delirium risk stratification tool for older adults in SSA.

The Association of Serum Levels of Brain-Derived Neurotrophic Factor with the Occurrence of and Recovery from Delirium in Older Medical Inpatients.

Limited studies of the association between BDNF levels and delirium have given inconclusive results. This prospective, longitudinal study examined the relationship between BDNF levels and the occurrence of and recovery from delirium. Participants were assessed twice weekly using MoCA, DRS-R98, and APACHE II scales. BDNF levels were estimated using an ELISA method. Delirium was defined with DRS-R98 (score > 16) and recovery from delirium as ≥2 consecutive assessments without delirium prior to discharge. We identified no difference in BDNF levels between those with and without delirium. Excluding those who never developed delirium (n = 140), we examined the association of BDNF levels and other variables with delirium recovery. Of 58 who experienced delirium, 39 remained delirious while 19 recovered. Using Generalized Estimating Equations models we found that BDNF levels (Wald χ2 = 7.155; df: 1, p = 0.007) and MoCA (Wald χ2 = 4.933; df: 1, p = 0.026) were associated with recovery. No significant association was found for APACHE II, dementia, age, or gender. BDNF levels do not appear to be directly linked to the occurrence of delirium but recovery was less likely in those with continuously lower levels. No previous study has investigated the role of BDNF in delirium recovery and these findings warrant replication in other populations.

The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial.

BackgroundDelirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients.Methods/DesignThe Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation.DiscussionLUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients.Trial registrationClinicalTrials.gov NCT01956604. EudraCT Number: 2013-000815-26

Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis

Background: delirium affects up to 40% of older hospitalised patients, but there has been no systematic review focussing on risk factors for incident delirium in older medical inpatients. We aimed to synthesise data on risk factors for incident delirium and where possible conduct meta-analysis of these.Methods: PubMed and Web of Science databases were searched (January 1987–August 2013). Studies were quality rated using the Newcastle-Ottawa Scale. We used the Mantel–Haenszel and inverse variance method to estimate the pooled odds ratio (OR) or mean difference for individual risk factors.Results: eleven articles met inclusion criteria and were included for review. Total study population 2338 (411 patients with delirium/1927 controls). The commonest factors significantly associated with delirium were dementia, older age, co-morbid illness, severity of medical illness, infection, ‘high-risk’ medication use, diminished activities of daily living, immobility, sensory impairment, urinary catheterisation, urea and electrolyte imbalance and malnutrition. In pooled analyses, dementia (OR 6.62; 95% CI (confidence interval) 4.30, 10.19), illness severity (APACHE II) (MD (mean difference) 3.91; 95% CI 2.22, 5.59), visual impairment (OR 1.89; 95% CI 1.03, 3.47), urinary catheterisation (OR 3.16; 95% CI 1.26, 7.92), low albumin level (MD −3.14; 95% CI −5.99, −0.29) and length of hospital stay (OR 4.85; 95% CI 2.20, 7.50) were statistically significantly associated with delirium.Conclusion: we identified risk factors consistently associated with incident delirium following admission. These factors help to highlight older acute medical inpatients at risk of developing delirium during their hospital stay.

Prognosis of delirium in hospitalized elderly: worse than we thought

Despite treatment of the associated condition, delirious persons do not always recover for unknown reasons. We sought to determine early prognostic indicators of poor recovery following an episode of delirium in older medical in-patients. Between October 2009 and July 2011, consecutively admitted older (≥70 years old) medical in-patients at the London Health Sciences Centre (Ontario) were screened for delirium. Delirious patients were followed. The primary outcome was poor recovery, in delirious patients, defined by death, long-term institutionalization, or functional decline (decreased activities of daily living), at discharge or 3 months after discharge, elicited from the medical chart or post-discharge caregiver telephone interviews. One thousand two hundred thirty-five in-patients (mean age 82.6 years, 42% men) were screened, delirium occurred in 355 (29%). Follow-up data was known on 342 (96%), and 237 (69%) had poor recovery: 55 died (54 in hospital and one after discharge), 136 were permanently institutionalized (86 directly from hospital and 50 after discharge), and 46 had functional decline (at a median of 103 days after discharge). Poor recovery was associated in the derivation sample with advanced age, lower baseline function, hypoxia, higher delirium severity scores, and acute renal failure; this was predictive of poor recovery in the validation sample (receiver operating characteristic area 0.68, 95% confidence interval: 0.57-0.79); however, even individuals with "low" risk had high (50%) poor recovery rates. Poor recovery after delirium is common and associated with certain characteristics. However, even "lower risk" delirious individuals do poorly. More research is needed to understand prognostic factors in delirium.

Relationship Between Cognitive Status at Admission and Incident Delirium in Older Medical Inpatients

Relationship Between Cognitive Status at Admission and Incident Delirium in Older Medical Inpatients

Relationship Between Cognitive Status at Admission and Incident Delirium in Older Medical Inpatients

To evaluate the relationship between cognitive status and incident delirium, 291 geriatric patients on internal medicine wards were evaluated on admission with the Mini-Mental State Examination (MMSE) and Confusion Assessment Method-Spanish. Those with incident delirium were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Delirium incidence was 11.7%, and 82 patients (28.2%) had cognitive deficits on MMSE. As cognitive impairment worsened, the risk for delirium increased linearly, and for each unit of MMSE worsening the DRS-R98 severity score worsened 0.4 points (F=5.39, df=1, p=0.027). Optimal MMSE cutoff score from receiver-operating characteristic curve analysis was 24.5. Even mild cognitive deficits increase delirium risk and severity.

Delirium in elderly general medical inpatients: a prospective study

More than 49% of all US hospital days are spent caring for patients with delirium. There are few Australian data on this important condition. The aim of the study was to determine the prevalence and incidence of delirium in older medical inpatients in a metropolitan teaching hospital, the incidence of known risk factors and current practice in identifying and managing patients at risk of this condition. Patients aged 65 years or more, and admitted to a general medical unit, were eligible for study inclusion. Participants were screened with an Abbreviated Mental Test Score (AMTS) and chart review. Confusion Assessment Method was used to diagnose delirium if confusion was documented or AMTS < 8. Barthel Index (BI), demographics, delirium risk factors and management were recorded. Prevalent delirium was diagnosed in 19 of 104 (18%) and incident delirium in 2 of 85 (2%) participants. Pre-existing cognitive impairment and admission AMTS < 8 were strongly associated with prevalent delirium (P-values < 0.01). Age > 80 years, Barthel Index < or = 50, use of high-risk medications and electrolyte disturbance were also associated with prevalent delirium. Prevalent delirium was not recognized by the treating unit in 4 of 19 cases (21%). Five of 104 (4.8%) of participants had a formal cognitive assessment on admission. One of 19 patients (5.3%) with prevalent delirium had an orientation device in their room. Pre-existing cognitive impairment and admission AMTS are strong predictors of delirium. Despite this, formal cognitive assessment is not routinely carried out in elderly medical patients. Recognition of delirium may be improved by routine cognitive assessment in elderly medical patients.

An Exploratory Study of Diagnostic Criteria for Delirium in Older Medical Inpatients

The poor prognosis of delirium in older medical inpatients has generated controversy about the diagnostic criteria for delirium in this population. The goal of the present study was to explore the presenting symptoms of delirium among older medical inpatients who did or did not recover from delirium. Patients 65 years or older admitted from the emergency department to medical services were screened with the Confusion Assessment Method (CAM). Patients with delirium were assessed at enrollment, several times during the first week, then weekly for 4 weeks using the Delirium Index (DI). Measures at baseline included demographics, dementia and severity of physical illness. Recovery was defined as a decline of three points or more on the DI and a final DI score of less than 5 or 4 points in patients with or without dementia, respectively. Of 290 patients who met DSM-IV criteria for delirium, 65 recovered and 225 did not. Three symptoms (orientation to person, hyperactivity, and inattention) were associated with recovery from delirium in older medical inpatients. These results suggest it may be necessary to place increased emphasis on these presenting symptoms when diagnosing delirium in this population.

Diagnosing dementia in long-term care facilities.

SUMMARY Detection and accurate diagnosis of cognitive impairmentand dementia in LTCF remains deficient. Failure to recognizedementia can lead to failure to protect the patient from theirown poor decision-making, and produce misunderstandingsbetween residents and caregivers who are not aware of howdementia is influencing the resident’s behavior. Failure toassess and document dementia and related problems can de-crease reimbursement under the skilled nursing facility pro-spective payment system and lead to survey citations. Failureto accurately diagnosis dementia in LTCFs deprives the resi-dent the advantages of early treatment and can increase therisk of medication errors, falls, delirium, and other dementia-related problems. Failure to prepare staff to provide necessaryphysical and emotional care will lead to unnecessary sufferingof LTCF residents with dementia, from entry into the facilityto end-of-life. REFERENCES 1. Roe C, Anderson M, Spivack B. Use of anticholinergic medications byolder adults with dementia. J Am Geriatr Soc 2002;50:836 –842.2. Jantti P, Pyykko V, Hervonen A. Falls among elderly nursing homeresidents. Am J Public Health 1993;107:89–96.3. Jensen J, Nyberg L, Gustafson Y, Lundin-Olsson L. Fall and injuryprevention in residential care—Effects in residents with higher and lowerlevels of cognition. J Am Geriatr Soc 2003;51:627–635.4. McNicoll L, Pisani MA, Zhang Y, et al. Delirium in the intensive careunit: Occurrence and clinical course in older patients. J Am Geriatr Soc2003;51:591–598.5. Rahkonen T, Luukkainen-Markkula R, Paanila S, et al. Delirium episodeas a sign of undetected dementia among community dwelling elderlysubjects: A two-year follow-up study. J Neurol Neurosurg Psychiatry2000;69:519–521.6. McCusker J, Cole M, Dendukuri N, et al. Delirium in older medicalinpatients and subsequent cognitive and functional status: A prospectivestudy. Can Med Assoc J 2001;165:575–583.7. Fick D, Foreman M. Consequences of not recognizing delirium superim-posed on dementia in hospitalized elderly individuals. J Gerontol Nurs2000;26:30–40.8. Fick D, Agostini J, Inouye S. Delirium superimposed on dementia: Asystematic review. J Am Geriatr Soc 2002;50:1723–1732.9. Cohen-Mansfield J, Creedon M. Nursing staff members’ perceptions ofpain indicators in persons with severe dementia. Clin J Pain 2002;18:64–73.

The course of delirium in older medical inpatients: a prospective study.

To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium. Prospective cohort study. Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal. Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital. Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the in-hospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality. Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.