Presence Of Delirium Research Articles

Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study.

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.

Risk factors associated with the onset of delirium in a post-operative cardiac surgical ICU

Introduction Postoperative delirium is a disabling mental disorder in patients undergoing cardiac surgery. Post-cardiac surgery delirium is both a common and costly complication in the cardiac surgical ICU. Depending on the methodology, estimates of incidence have ranged from 3 to 70%. The potential consequences of delirium after cardiac surgery include increased morbidity, decreased functional status, cognitive decline and increased long-term mortality. Despite the impact of this condition, few studies exist in literature that help to identify risk factors associated with this condition in the specific setting of cardiac surgery. In this pilot, non-pharmacological, observational study we assessed the risk associated with the development of delirium in a cohort of patients who underwent cardiac surgery Methods We prospectively included 145 patients: women 42(28,9%) and 103men(71%) who underwent cardiac surgery between April and June 2018 at the cardiothoracic surgery department of the Tor Vergata University Hospital in Rome, Italy. Data about pre-intra and post-operatory period were collected. The presence of delirium was diagnosed if the CAM–ICU scale was positive when evaluated within the third post-operatory day. Univariate logistic regression was used to evaluate perioperative risk factors associated with delirium. Odds Ratio was used to estimate the importance of each factor in the genesis of delirium. Multivariate logistic regression was applied to the positive variables to assess the independent risk factors. A value p Results Among the 145 patients evaluated, 13 developed symptoms of delirium (5,09%). We found that the risk of Delirium was associated with pre-operatory EuroSCORE II (p = 0,028) and history of previous cardiac surgery (p = 0,042). Moreover, in the intra-operatory period the risk of Delirium was associated with red blood cell transfusion, intervention for Aortic Dissection (p = 0,013), HCA with ACP (p = 0,036). In the post-operatory period risk of Delirium was associated with levels of creatinine clearance (p = 0,035) and CRP (p = 0,029). Discussion Delirium is relatively frequent in the cardiac surgical ICU. High EuroScore correlates with the onset of delirium, suggesting that delirium is a multifactorial pathology linked with pre-operatory comorbidities. The complexity of surgery has a big influence on the development of delirium, especially in the cases of aortic dissection. Interestingly, the development of delirium was associated with intra-operatory blood transfusions in agreement with similar studies in literature. Finally, our data point to a bridge between post-operatory electrolytic disturbances, as well as inflammatory response to infections as factors potentially triggering delirium onset.

Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes.

To determine which findings on routine clinical EEGs correlate with delirium severity across various presentations and to determine whether EEG findings independently predict important clinical outcomes. We prospectively studied a cohort of nonintubated inpatients undergoing EEG for evaluation of altered mental status. Patients were assessed for delirium within 1 hour of EEG with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and 3D-CAM severity score. EEGs were interpreted clinically by neurophysiologists, and reports were reviewed to identify features such as theta or delta slowing and triphasic waves. Generalized linear models were used to quantify associations among EEG findings, delirium, and clinical outcomes, including length of stay, Glasgow Outcome Scale scores, and mortality. We evaluated 200 patients (median age 60 years, IQR 48.5-72 years); 121 (60.5%) met delirium criteria. The EEG finding most strongly associated with delirium presence was a composite of generalized theta or delta slowing (odds ratio 10.3, 95% confidence interval 5.3-20.1). The prevalence of slowing correlated not only with overall delirium severity (R 2 = 0.907) but also with the severity of each feature assessed by CAM-based delirium algorithms. Slowing was common in delirium even with normal arousal. EEG slowing was associated with longer hospitalizations, worse functional outcomes, and increased mortality, even after adjustment for delirium presence or severity. Generalized slowing on routine clinical EEG strongly correlates with delirium and may be a valuable biomarker for delirium severity. In addition, generalized EEG slowing should trigger elevated concern for the prognosis of patients with altered mental status.

Utility of FEV1/FEV6 index in patients with multimorbidity hospitalized for decompensation of chronic diseases.

Spirometry remains essential for the diagnosis of airway obstruction. Nevertheless, its performance in elderly hospitalized patients with multimorbidity can be difficult. The aim of this study is to assess the utility of the COPD-6 portable device in this population. We included all patients hospitalized for exacerbation of chronic diseases in a medical ward specialized in the care of multimorbidity patients, between September 2017 and May 2018. A questionnaire including sociodemographic, cognitive and functional impairment, among other variables, was completed the last day of admission. Subsequently, patients attempted to perform three valid respiratory manoeuvres with the COPD-6 device and then conventional spirometry. A total of 184 patients were included (mean age of 79.61 years, 55% men). Forty-seven (25.54%) patients were able to perform complete spirometric manoeuvres and 99 (53.8%) could perform a valid FEV1/FEV6 determination. The inability to perform a valid spirometry was related with the patient’s age, functional physical disability, cognitive impairment or the presence of delirium or dysphagia during admission. Only 9% of patients with a Mini Mental Cognitive Examination (MMEC) lower than 24 points could perform a valid spirometry. Of the patients with an MMEC < 24 points and unable to perform spirometry, 34% were able to complete the FEV1/FEV6 manoeuvres. No differences were found in the Charlson index, multimorbidity scale, number of domiciliary drugs, or length of stay between those patients able and those not able to perform respiratory manoeuvres. The agreement between the values for FEV1 measured with COPD-6 and those observed in the spirometry was good (r: 0.71; p<0.0001). Inability to perform a valid spirometry during hospitalization in elderly patients with multimorbidity is frequent and related with functional and cognitive impairment. FEV1/FEV6 determination using the COPD-6 portable device allows an important percentage of the patients with limitations to complete spirometric measurement.

Impact of a Premorbid Psychiatric Disorder on the Incidence of Delirium during ICU Stay, Morbidity, and Long-Term Mortality.

Introduction Delirium during ICU stay is a widespread problem with complex aetiology. A premorbid psychiatric disorder has been associated with an increased incidence of delirium in the general hospital population, but data on the impact of ICU delirium and consequences for morbidity and long-term mortality remain scarce. Methods In this single-centre retrospective analysis, 472 patients with an ICU stay >48 hours were included during a 2-year period. Postresuscitation and neurosurgical patients were not included. The primary aim of the study was to establish the incidence and duration of delirium during ICU stay in patients with (PS group) and without (NPS group) a premorbid psychiatric disorder. Data were analysed with applicable nonparametric tests. In a secondary analysis, patients were compared according to the presence or absence of delirium. Finally, a binary logistic regression model was constructed to correct for potential confounders. Results Of all patients, 19.7% were included in the PS group. Baseline characteristics with respect to severity of illness and type of admission did not differ between groups, but PS patients were significantly younger and more often female in comparison with NPS patients. The overall incidence of delirium during ICU was 57% and did not significantly differ between groups (65% in PS group vs. 56% in the NPS group, p=0.13). In a univariate analysis, the presence of a psychiatric history was also associated with prolonged mechanical ventilation, length of stay ICU, and hospital stay, but not with long-term all-cause mortality. The presence of delirium at any time during ICU admission was significantly associated with prolonged mechanical ventilation and prolonged ICU and hospital stay, but not with mortality. In a Kaplan–Meier analysis, 5-year all-cause mortality was clearly separated between groups, but the difference remained statistically insignificant (X2=3.01, p=0.08). In a binary logistic regression model, age, male sex, APACHE III score, and premorbid psychiatric disorder (OR 1.8, CI 1.1–3.0; p=0.023) were all independently associated with the presence of delirium. Conclusions In ICU patients with a length of stay >48 hours and a premorbid psychiatric disorder, the incidence of delirium was not significantly higher in comparison with patients without a premorbid psychiatric disorder.

Ultra-brief Screeners for Detecting Delirium Superimposed on Dementia

ObjectiveDelirium superimposed on dementia (DSD) is common, morbid, and costly, yet frequently undiagnosed. Our study aimed to develop a brief screening test to improve health care worker recognition of DSD. Design/Setting/ParticipantsOlder hospitalized adults with dementia were prospectively enrolled from medical and surgical inpatient units of 3 hospitals (2 in Pennsylvania, 1 in Tennessee). MeasuresThe reference standard delirium assessment used Confusion Assessment Method (CAM) criteria and was based on a structured interview including the Mini-Mental State Examination, interviewer observations, and medical record review. To develop the screening test, 1-, 2-, and 3-item combinations from the reference standard assessment were analyzed to determine their sensitivity and specificity in diagnosing delirium presence in a dementia population compared to the reference standard. For multiple-item screeners, error on 1 or more items was considered a positive screen. ResultsOverall, 391 older adults with dementia were enrolled (mean age: 83.9 years, 71.1% female), and 95 (24.4%) developed DSD during their hospitalization, based on the reference standard. The best single-item screen for DSD was “What day of the week is it?” with 84% sensitivity [95% confidence interval (CI): 0.75, 0.91] and 41% specificity (CI: 0.35, 0.47). The best 2-item screen was “list the days of the week backwards” and “What day of the week is it?” with 93% sensitivity (CI: 0.85, 0.97) and 30% specificity (CI: 0.25, 0.36). The best 3-item screen was “list the days of the week backwards,” “What type of place is this? [hospital]” and “Does the patient appear sleepy?” with 94% sensitivity (CI: 0.87, 0.98) and 42% specificity (CI: 0.36, 0.48). Conclusions/ImplicationsWe identified a 3-item DSD screener with excellent sensitivity but limited specificity. This screener can be used to quickly rule out DSD in populations with a high prevalence of dementia and is a promising step toward developing efficient tools for DSD recognition among care providers.

Effect of Melatonin on Incidence Rate of Delirium in Elderly Patients Undergoing Open-Heart Surgery without a Pump: A Clinical Trial

Introduction: Delirium has been considered as the most common cognitive disorder after major surgery. Melatonin therapy is effective in reducing the incidence of delirium after open heart surgery with pain relief mechanism and adjustment of the sleep cycle and the absence of specific side effects. This study was conducted to determine the effectiveness of melatonin on prevention of delirium after coronary artery bypass surgery. Methods: The double blind randomized controlled clinical trial recruited 140 patients, equally decided, who underwent coronary artery bypass surgery in Afshar Hospital, Yazd city, 2016. All participants of the two groups were evaluated for the presence of delirium on the day of surgery and three days after by the Confusion Assessment Method for ICU (CUM-ICU). Respectively, The intervention and control group received 3 mg melatonin and 3 mg placebo orally before and after the operation. Data were analyzed by Chi-square, T-test, paired t-test and Cochran tests. Results: The incidence of delirium in the melatonin and the control group was 35.7% and 5.7% on the day of operation, 68.6% and 31.4% three days after the operation, respectively. The results showed that there was a significant difference in the frequency of cognitive test of CAM-ICU on day of surgery and three days after surgery between the two groups (p &lt;0.001). Conclusion: Despite the efficacy of melatonin therapy in reducing delirium, further studies on the effects of other effective drugs on the treatment of delirium, such as antipsychotics and receptor blockers, should be considered.

The Experience of Acute Mechanical Ventilation From the Patient's Perspective.

The Pain, Agitation, and Delirium guidelines influenced practice to support targeted, light sedation for the mechanically ventilated patient. This practice is associated with improved clinical outcomes, but it remains unclear how it impacts the patient experience. The objective was to determine the pervasive patient experience components and how the experience may have been influenced by targeted, light sedation practices. A prospective observational study using mixed methodology and a convenience sample was conducted after institutional review board approval was obtained. Inclusion criteria were the following: acute mechanical ventilation of less than 14 days, 18 years or older and able to provide consent, English speaking, and delirium-free. Exclusion criteria were the presence of delirium or intravenous opioids/sedatives within 24 hours prior to the interview. The quantitative component included simple yes or no questions and identification of quantitative adjectives describing the mechanical ventilation experience. Every 10th patient was invited to participate in an expanded qualitative interview. Data were collected for 12 months with a total sample size of 130 patients participating in the quantitative component and a subset of 15 patients also participating in the qualitative interview. Sixty percent of the total sample consisted of cardiothoracic surgery patients, and 40% were mixed intensive care unit patient populations. Descriptive statistics include the following averaged values: Richmond Agitation Sedation Scale scores -1.7 throughout mechanical ventilation, aged 59.9 years, days mechanically ventilated 1.4, intensive care unit length of stay 4.6 days, and Acute Physiology and Chronic Health Evaluation II score 16.1. The most significant finding was that 56.2% of patients who could not communicate reported feeling afraid, whereas 32.5% of those who could communicate reported feeling afraid (P < .027). The themes identified in the qualitative component of the study reinforced these quantitative findings; 10 of the 15 patients interviewed reported experiencing fear, and all of the patients reported issues with communication. The clinical implications of this research study primarily affect critical care nursing. Changes in nursing practice can address these findings to improve and more effectively acknowledge the patient experience.

Delirium en pacientes de la Unidad de Cuidados Intensivos de una institución de salud en Montería, Colombia

IntroductionDelirium, in addition to causing suffering to patients, relatives and caregivers, is associated with increases in morbidity, mortality and hospital complications, which leads to high costs for the health system. ObjectiveTo determine the incidence of delirium and related factors in patients admitted to an intensive care unit of a health institution in the city of Monteria, Colombia. MethodsA descriptive, longitudinal study with a quantitative approach that includes the correlation of variables of interest with the incidence of delirium. For the collection of information and subsequent analysis, the CAM-ICU scale –which allowed the identification of the presence of delirium– and the APACHE II severity scale were used. Likewise, a data card was prepared based on clinical and epidemiological variables of interest. ResultsThe patients were mostly men (50.5%) with an average age of 60 years. The incidence of delirium was 22% with hyperactive presentation in 62% of cases. There was no relationship between the presence of delirium and the variables of age, sex and APACHE II, although correlation was observed with the use of mechanical ventilation and with the days of stay in the health centre. ConclusionsPatients who developed delirium, the hyperactive form being the most common, were characterized either by having spent several days in the Intensive Care Unit or having undergone mechanical ventilation.

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.

Distinguishing characteristics of delirium in a skilled nursing facility in Spain: Influence of baseline cognitive status.

Mild cognitive impairment (MCI) and dementia (DEM) are prevalent in skilled nursing facilities (SNFs), confounding delirium detection. We report characteristics of delirium in an SNF to ascertain distinguishing features for delirium diagnosis, despite challenges of comorbidity with MCI and DEM. Cross-sectional study of 200 consecutive patients from an SNF in Catalunya, Spain, assessed within the first 24 to 48 admission hours by independent experts with Spanish-Informant Questionnaire on Cognitive Decline in the Elderly (for MCI-DEM), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) delirium criteria, and Delirium Rating Scale Revised-98 (DRS-R98) for delirium phenomenology. Delirium characteristics were modeled in successive steps, according to the presence of delirium and MCI-DEM, with analysis of variance (ANOVA), receiver operator characteristic analyses, and conditional logistic regression. The final model produced symptoms that represented each of the three delirium core domains (ie, cognitive, higher order thinking, and circadian). The DRS-R98 items rated these symptoms as moderate-severe attention/vigilance, mild-severe language, and moderate-severe sleep-wake cycle alterations. The delirium discriminant accuracy of the three symptoms together was high: 84.6% in the MCI-DEM group to 92.8% in the No MCI-DEM group. Impairments of attention, language, and sleep-wake cycle indicate delirium in SNF patients regardless of the underlying MCI-DEM status. Because delirium is underdetected in SNFs, where nursing staff/patient ratios are low, brief simple tools that measure these symptoms could potentially enhance delirium detection.

Antipsychotic Treatment of Delirium in Critically Ill Children: A Retrospective Matched Cohort Study.

To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically. The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium. Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported. No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.

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

The aim of this double-blinded randomised placebo-controlled trial was to investigate the efficacy of clonidine for delirium in medical inpatients greater than 65years. Acutely admitted medical patients greater than 65years with delirium or subsyndromal delirium were eligible for inclusion. Included patients were given a loading dose of either placebo or clonidine; 75μg every third hour up to a maximum of four doses to reach steady state and further 75μg twice daily until delirium free for 2days, discharge or a maximum of 7days of treatment. The primary endpoint was the trajectory of the Memorial Delirium Assessment Scale (MDAS) for the 7days of treatment. Presence of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and severity measured by MDAS were assessed daily until discharge or a maximum of 7days after end of treatment. Because of slower enrolment than anticipated, the study was halted early. Ten patients in each group were studied. The low recruitment rate was mainly due to the presence of multiple patient exclusion criteria for patient safety. There was no significant difference between the treatment group in the primary endpoint comparing the trajectory of MDAS for the 7days of treatment using mixed linear models with log transformation, (P=.60). The treatment group did not have increased adverse effects. No effect of clonidine for delirium was found, although the study was under powered. Further studies in less frail populations are now required.

Delirium in geriatric urology patients

Delirium is acommon but often undiagnosed complication in geriatric patients following amajor or minor operation. With 14-56% in patients over 70 years of age, it is one of the most frequent complications seen in hospitals. The link between the prescription of drugs with antimuscarinic effects and cognitive disturbance is also well known. Recognizing the presence of delirium and the criteria to establish the diagnosis of delirium will improve aclinician's ability to detect this complication. Treating delirium with non-pharmacologic, reduces the incidence and side effects of postoperative delirium. The purpose of this article is to describe the diagnosis and treatment of postoperative delirium. Asudden rise following fluctuating symptoms with decreased attentiveness, awareness and thinking are typical symptoms of delirium. The organic origin is not focused and must be considered. Transurethral resection (TUR) of the prostate and the bladder can increase the risk of bleeding, delirium and TUR syndrome. As simple instruments to assess signs and symptoms, the Clinical Assessment Method (CAM) and the Nurses Delirium Screening Scale (Nu-DESC) in the clinical setting are well examined. Preoperatively screening and execution of ageriatric assessment to detect vulnerable elderly could be afirst step in reduction of complication. Regularly screening for delirium reduces the pre-, post-, and perioperative complications in patients with delirium.

PREDICTION OF DELIRIUM, MORTALITY, AND FALL RISK IN INPATIENTS USING BISPECTRAL EEG

Introduction Delirium is a prevalent yet under-diagnosed and under-treated condition. Although questionnaire instruments are capable of detecting delirium if implemented rigorously, they have not been effectively used due to their lack of efficiency in busy hospital workflows. Their subjective nature is also a drawback. Electroencephalography (EEG) can objectively detect the “diffuse slowing” of brain waves that is characteristic of delirium. While standard EEG is not suitable for mass screening due to its size, cost, and the expertise required for lead placement and interpretation, simplified two channel EEG devices can still be used to measure frontal EEG changes. Our goal was to investigate if frontal EEG activity could be used to detect delirium and to predict fall risk and mortality among elderly inpatients. Methods A single center, prospective design was used to collect frontal EEG activity (Fp1 and Fp2 EEG signals) from elderly patients (>55 yo) after admission or at the time of an emergency room visit. EEG features (band powers and different combinations of frequency bands) were calculated for both channels and averaged. A bispectral EEG score (“BSEEG score”) was calculated based on the distribution of the scores from the study participants, and normalized with a mean value of zero and one standard deviation (SD) above the mean as 1. The top 9 EEG features were selected using machine learning methods, Random Forest. Subjects were assessed for the clinical presence of delirium and the primary outcomes measured were fall history, and mortality. K-nearest neighbors, logistic regression, support vector machine (SVM), kernelized SVM, and neural network approaches were used to assess the ability of bispectral EEG to predict delirium status, falls and survival. Results EEG features and outcome data for 274 patients was available for analysis. Clinical presence of delirium and BSEEG score were significantly associated (P = 6.14 × 10-6; unadjusted, P= 1.17 × 10-5; adjusted). Of all the classification methods, kernelized SVM yielded the highest prediction accuracies of 69%, 89%, and 81%, for delirium status, falls and mortality, respectively. Hazard ratio (HR) for survival controlling for age, gender, CCI and delirium status based on one SD change of BSEEG score at the time of admission was 1.32, (CI = 1.03 to 1.70, P=0.026). Conclusions In our study, bispectral EEG in delirious elderly inpatients was able to predict patient outcomes including mortality and fall risks. Bispectral EEG monitoring may also be applicable in settings including the primary care clinic, emergency department, and in nursing home or home-care settings. Delirium is particularly dangerous when patients experience it outside of hospitals because they do not have medical attention available on site. The simple, noninvasive nature of a simplified EEG test makes it potentially ideal for routine screening. Potentially it can be used as a next vital sign to monitor the risk of delirium, mortality, and falls among elderly patients. As the aging population is expanding rapidly, such a test would be in high demand. This research was funded by This study was supported by the University of Iowa Research Foundation GAP funding award for Gen Shinozaki. Gen Shinozaki has grant support from NSF1664364 and K23 MH107654.

Functional mobility trajectories of hospitalized older adults admitted to acute geriatric wards: A retrospective observational study in an English university hospital.

The mobility trajectories of hospitalized older people are heterogeneous, and there is a need to understand patient groups with similar trajectories. Our aims were to identify mobility trajectories of older patients admitted to geriatric wards in an English university hospital, and describe patient characteristics and outcomes associated with different mobility groups. A retrospective observational study of first admissions to geriatric wards for 3 months starting 1 May 2016 was carried out. Anonymized routinely collected clinical data was extracted from the electronic patient records: age, sex, Clinical Frailty Scale score, presence of delirium (yes/no), diagnosis of dementia (yes/no), Charlson Comorbidity Index, falls in the past year and the highest recorded Modified Early Warning Score in the Emergency Department. Physiotherapists routinely collected the Elderly Mobility Scale on admission and discharge; this information was entered in a K-means cluster analysis to identify mobility trajectory groups. We compared clinical characteristics and outcomes between these groups and used logistic regression models to determine independent predictors of group membership. The overall functional trajectory was improvement, from a median Elderly Mobility Scale of 11 on admission to 14 on discharge. Cluster analysis identified five mobility trajectory groups: low-low (n = 117), intermediate-intermediate (n = 95), intermediate-high (n = 205), low-high (n = 89) and high-high (n = 209). Higher frailty and the presence of cognitive impairment were associated with the low-low and intermediate-intermediate group membership, and negatively associated with the high-high group membership. The majority of hospitalized patients experienced functional improvement. Frailty and cognitive impairment might be associated with poorer mobility trajectories and hence require early identification. Geriatr Gerontol Int 2019; 19: 305-310.

Factors Associated with Length of Stay in Hospital Patients with and Without Dementia.

Hospital care of older adults, especially of those with dementia, is associated with a high risk of complications and increased mortality. Adverse events are often triggered by hospital-related factors, hence the time spent in hospitals should be limited. There is little knowledge of the specific factors influencing hospitalizations of older persons. To assess the duration of length of stay (LOS) and risk factors of increased LOS, and, specifically, the role of delirium and neuropsychiatric symptoms (NPS) among a large sample of older adults with and without dementia in Germany. A claims data based dynamic retrospective cohort study from 2004 to 2015 was conducted. People with dementia (PWD) were identified using ICD-10 codes and the application of diagnostic measures. A control group without diagnosis of dementia (CG) were matched in a 3: 1 ratio. Multivariate methods were used to investigate the factors associated with LOS. 7,139 PWD and 21,417 controls were included. PWD had longer hospitalizations (first LOS: +4.3 days; second LOS: +0.2 days) than the CG. Diagnosis of delirium was associated with LOS, both for PWD (first LOS: +9.6 days; second LOS: +5.3 days) and CG (first LOS: +13.7 days; second LOS: +7.2 days). Major determinants of LOS were similar in PWD and the CG. The strongest association was found for the presence of delirium and NPS. Future research should focus on prevention and intervention strategies that may reduce the impact of delirium as well as NPS on the length of stay especially for PWD.

Abstract WP443: The Impact of Delirium and Impaired Consciousness on Withdrawal of Life-Sustaining Treatment After Spontaneous Intracerebral Hemorrhage

Introduction: Established predictors for outcome after intracerebral hemorrhage (ICH) may be subject to self-fulfilling prophecy, as studies examining their effects on mortality have generally not considered changes in code status leading to withdrawal of life-sustaining treatment (WLST). We aimed to identify factors specifically associated with WLST, and hypothesized that impaired consciousness and delirium would be especially implicated. Methods: We analyzed data from consecutive patients admitted with ICH from February-June 2018. ICH score and other clinical predictors were prospectively adjudicated, and most patients had delirium assessments performed by an expert clinician; for those who did not, we established the presence of probable delirium via chart review. Using logistic regression models that adjusted for ICH severity, we determined the association of impaired consciousness on admission (Glasgow Coma Scale [GCS] &lt;13) with early WLST (defined as &lt;24 hours from admission), and the presence of delirium on subsequent assessments with WLST after 24 hours. Results: Of 106 patients in our cohort (mean age 68.7 [SD 17.8], median ICH score 1.5 [IQR 1-2]), WLST occurred in 29% (22/40 with admission GCS &lt;13, 9/66 with GCS 13-15). After adjusting for ICH severity, admission GCS &lt;13 was more strongly associated with early WLST (OR 26.8, 95% CI 2.8-255.8) than other components of the ICH score (OR 9.9, 95% CI 1.5-67.0 for age &gt;80; OR 8.4, 95% CI 1.7-40.7 for size &gt;30cc; intraventricular hemorrhage and infratentorial location were not significant). Of 92 patients who survived &gt;24 hours without early WLST, 52% had delirium. We found that delirious patients were significantly more likely than patients without delirium to have subsequent WLST (33% vs. 2%, p&lt;0.001; OR 18.8, 95% CI 2.1-165.5 after adjusting for ICH severity). Finally, we found that a composite predictor—initial GCS &lt;13 or subsequent delirium—was strongly associated with WLST at any time during hospitalization (OR 19.0, 95% CI 2.3-158.0 after adjusting for ICH severity). Conclusion: Impaired consciousness and delirium likely play a significant role in WLST after ICH. However, whether this phenomenon is due to effects on clinician or surrogate decision-making remains unclear.

Abstract TP358: Delirium is Associated With Increased Readmissions and Mortality in Patients With Acute Ischemic Stroke

Background: Delirium is characterized by a fluctuating level of awareness and cognition. It is frequently seen in patients hospitalized with strokes. Despite delirium being a temporary condition it can lead to worsened outcomes. We sought to examine the effect of delirium during hospitalizations for acute ischemic strokes (AIS) using the Nationwide Readmission Database. Methods: We utilized Nationwide Readmissions Database (NRD) to identify AIS using appropriate ICD-9CM codes in primary diagnosis field and delirium was identified by appropriate ICD-9CM in secondary diagnosis field. Predictors to assess the association between baseline characteristics and 30-day readmission were analyzed using multivariable logistic regression model. Results: We identified 1958231 patients with hospitalizations for AIS between 2010-2014. Patients had an average age of 70.9 years, 48.3% were male and 51.7% female. 58738 (3%)of patients had a concurrent diagnosis of delirium. Patients with delirium were older (75.4 vs. 70.7 years; p&lt;0.0001), and had a higher comorbidity index (p&lt;0.0001). They were less likely to have received thrombolysis or mechanical thrombectomy (p&lt;0.0001). Patients with delirium and AIS were less likely to be discharged home (42% vs. 63.4%; p&lt;0.0001). The presence of delirium was also associated with a longer median length of stay (6 vs. 4 days; p&lt;0.0001), and increased 30-day readmission (15.4% vs 11.8%; p&lt;0.0001). Delirium in AIS patients increases 30-day readmission by 28% (OR 1.28, 95% CI, (1.24-1.33); p &lt;0.0001). Etiologies of readmission were most commonly neurological (25.3%), with 12.8% being ischemic stroke. This was followed by readmission for infection (14.7%), kidney or urinary complications (12.6%), pulmonary (10.3%), and cardiac causes (10.2%). Presence of delirium was associated with a significantly higher mortality compared to AIS alone (10.3 % vs 5%; p&lt;0.0001). Conclusion: In conclusion, the concurrent diagnosis of delirium during acute stroke hospitalization leads to markedly worse outcomes with increased rate of readmission and mortality. Protocols to prevent delirium should be implemented during hospitalizations for AIS.

Prolonged hospitalization is a risk factor for delirium onset: one-day prevalence study in Slovenian INTENSIVE CARE UNITS.

SUMMARYDelirium is a clinical syndrome often underestimated in the intensive care units (ICU). The aim of this study was to determine the prevalence and factors that influence the onset of delirium. A questionnaire was sent to intensivists in Slovenian ICUs, who estimated the prevalence of delirious patients. The questionnaire consisted of demographic data, type of ICU, diagnosis, reason for admission to the ICU, type of anesthesia and surgery, clinical condition, type of supportive therapy, presence of delirium, data on discharge, transfers between departments or patient outcome on day 30. Patient consciousness was assessed by the Richmond Agitation-Sedation Scale (RASS) and the presence of delirium by the validated delirium-screening Confusion Assessment Method for the ICU (CAM-ICU). Replies received from intensivists included data on 103 patients. According to RASS ≥-3, the prevalence of delirium was 9.5% (7 out of 74 patients). There was no difference in the prevalence of delirium between surgical and medical ICU patients (p=0.388). Delirious patients had longer hospital stay (p=0.002) and ICU stay (p=0.032) compared to patients without delirium. All delirious patients survived until day 30, whereas 19 patients without delirium died (p=0.092). Logistic regression analysis dismissed any association of delirium with patient mortality (p=0.998). Age, gender, anesthesia, mechanical ventilation, and type of surgical procedure could not be evaluated as risk factors for delirium. In Slovenian ICUs, a lower proportion of delirium was observed, as reported from similar studies. Risk factors such as gender, age, mechanical ventilation, sedation, anesthesia, or department could not predict delirium. However, prolonged hospitalization of ICU patients could predict the onset of delirium, but the presence of delirium did not increase patient mortality.