Probable Delirium Research Articles

Long-term cognitive impairment after probable delirium in long-term care residents: A population-based retrospective cohort study.

The impact of delirium on cognition has not been well-studied in long-term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia. We conducted a population-based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument-Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0-6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models. Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval [CI] 1.35-1.99), 1.56 (95% CI 1.34-1.85), 1.57 (95% CI 1.32-1.86) and 1.50 (95% CI 1.25-1.80) after 1-3, 4-6, 7-9, and 10-12 months of follow-up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79-6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%). Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

ObjectivesThis study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada. DesignPopulation-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument–Minimum Dataset version 2.0 (RAI-MDS 2.0). Setting and ParticipantsLTC residents in Ontario between January 1, 2016, and December 31, 2019. MethodsWe used residents’ first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. ResultsThe study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non–CNS-related PIP criteria. Conclusions and ImplicationsThis population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

172 Using the early identification and management of delirium to optimise memory pathway referrals and resources

Abstract Background Priority actions within the National Dementia Strategy are to ensure early diagnosis of dementia and to develop appropriate referral pathways and interventions to support patients. One element is the consideration of referral to memory services for patients who develop delirium within the acute hospital setting, which may suggest possible underlying cognitive impairment. We examined the effect of early identification and diagnosis of delirium via an inpatient frailty service on this process. Methods Over a 9-month period (September 2022–May 2023), patients >75 years admitted to the acute medical floor were screened with the Rockwood Clinical Frailty Scale (CFS) by a multi-disciplinary in-patient frailty team. Those with a CFS score of 5–6 (mild to moderate frailty) were prioritised for Comprehensive Geriatric Assessment (CGA), which included the 4AT delirium screening tool. Patients presenting with a 4AT of 1–3 indicating cognitive vulnerability and those with a 4AT of >4 suggesting a probable delirium with possible dementia were identified for assessment. Results 3,200 patients >75 years were admitted to the medical floor during the 9 months. Over 2,100 patients were screened for mild to moderate frailty and 495 CGA’s were completed. 105 patients presented with a 4AT of >4 with 44% not having a formal diagnosis of cognitive impairment. 74% of this cohort were referred onward to memory streams. 143 patients presented with a 4AT of 1–3. 66% did not have a formal diagnosis of cognitive impairment, of which 61% were referred onward to memory services. Conclusion The development of delirium in the acute hospital setting is an important opportunity to assess for the presence of an underlying neurodegenerative process. Early identification and management pathways for delirium can allow timely initiation of referral to specialist memory streams to aid prompt diagnosis of dementia, facilitating optimisation of care, supports, and advanced planning.

253 DELIRIUM IDENTIFICATION AT INITIAL TRIAGE IN AN IRISH EMERGENCY DEPARTMENT SETTING

Abstract Background Over 10% of older adults are affected by delirium on presentation to Emergency Departments (ED), with many more developing it during a prolonged ED stay. Early detection is key to delirium management, but the diagnosis is often missed, with over 50% of delirium going undetected in the ED. In 2019 the HSE guideline on Early Identification and Management of Delirium in the ED recommended that all those over 65 years be screened on presentation to ED using the 4AT, a validated instrument in delirium screening. Through our ED’s delirium working group, we conducted a baseline audit on current rates of screening for delirium, ahead of a quality improvement project on management of patients with, or at risk of delirium in our ED. Methods A retrospective review was conducted of consecutive patients >65yrs who presented to ED in one month with the following terms mentioned in the presenting complaint at triage: confusion/delirium/memory/speech/language disturbance/agitation i.e. terms that could indicate possible delirium as considered by the triage practitioner. We also recorded whether a 4AT was recorded. An additional 50 charts from the consecutive series were randomly selected and examined for probable delirium on presentation which was not captured at triage. Results n=23/1,597 (<1%) had possible delirium recorded at triage as per our criteria. In-depth case note review supported the diagnosis of delirium in 20 of the 23 initially identified at triage. Only 5 of these had a documented 4AT score. Of the additional 50 charts screened, a further 6 had likely delirium of whom n=3 had a 4AT score completed. N=16 required hospital admission. Conclusion Delirium screening and detection rates at ED triage are less than expected, and below the 2019 national screening recommendations. Implementing same in any busy ED is challenging. We are developing a multifaceted educational program to address this and plan a repeat audit following implementation.

Potentially inappropriate prescribing in long-term care residents and its association with probable delirium.

Objective: Medications can increase the risk of delirium due to drug toxicities, polypharmacy, and drug interactions. This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care residents. Approach: We conducted a cross-sectional study of long-term care residents in Ontario, Canada between January 1, 2016 and December 31, 2019. Routinely collected long-term care resident assessment data from the Resident Assessment Instrument – Minimum Dataset (RAI-MDS) was linked to prescription claims data to ascertain probable delirium and medication use in the two weeks preceding the index assessment. PIP was measured via the STOPP/START criteria and Beers criteria, with residents classified as having 0, 1, 2, or 3+ PIPs. Associations between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. ResultsThe study population included 171,190 long-term care residents. The mean age was 84.5 years, 66.8% were female, and 62.9% had dementia. Probable delirium was documented on 3.7% of resident assessments. Over half (51.8%) of residents had 1+ PIP and 21% had 3+ PIPs according to the STOPP/START criteria. The odds of probable delirium increased as the number of PIPs increased. Probable delirium was 1.86 times more likely (95% confidence interval 1.74-1.98) in residents with 3+ PIPs compared to those with no PIPs after confounder adjustment. Similar findings were observed when PIP was evaluated using the Beers criteria. ConclusionThis population-based study highlighted that potentially inappropriate medication prescribing was highly prevalent and was significantly associated with the increased likelihood of probable delirium among long-term care residents.

Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study.

To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium. Population-based cross-sectional study using routinely collected administrative health data. All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217). Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with theoutcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for highvs low instability). There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.

144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts

IntroductionCOVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults.MethodsObservational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over; unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322); (ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020; self-report or report-by-proxy data; reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough.ResultsHospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough.ConclusionsThis study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.

Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions

Objectives The aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care. Methods A prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 ‘A’s test (4AT), with a score >0 indicating cognitive impairment (1–3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire. Results In all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers. Conclusions Cognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers. What is known about the topic? Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment. What does this paper add? This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care. What are the implications for practitioners? Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.

Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU).

OBJECTIVETo adapt and validate a chart‐based delirium detection tool for use in critically ill adults.DESIGNValidation study.SETTINGMedical‐surgical intensive care unit (ICU) in an academic hospital.MEASUREMENTSA chart‐based delirium detection tool (CHART‐DEL) was adapted for use in critically ill adults (CHART‐DEL‐ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM‐ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART‐DEL tool was adapted to include physician‐reported ICDSC score (for probable delirium) and Richmond‐Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium‐related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence).RESULTSCharts were manually abstracted for delirium‐related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART‐DEL‐ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3–72.3%) and specificity was 82.1% (95% CI = 78.0–85.7%), with a cut‐point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART‐DEL‐ICU alone is 74.1% (95% CI = 70.4–77.8%) compared with the addition of the CAM‐ICU and ICDSC (CAM‐ICU/CHART‐DEL‐ICU: 80.9% (95% CI = 77.8–83.9%), P = .01; ICDSC/CHART‐DEL‐ICU: 79.2% (95% CI = 75.9–82.6%), P = .03).CONCLUSIONA chart‐based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM‐ICU and ICDSC), compared to a chart‐based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.

Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults.

BackgroundFrailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification.ObjectiveTo assess how frailty affects presenting COVID-19 symptoms in older adults.DesignObservational cohort study of hospitalised older patients and self-report data for community-based older adults.SettingAdmissions to St Thomas’ Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application.SubjectsHospital cohort: patients aged 65 and over (n = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020.MethodsMultivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19.ResultsHospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath.ConclusionsThis is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium.

Prevalence and risk factors of delirium in psychogeriatric outpatients.

BackgroundDelirium is a serious neuropsychiatric syndrome, which requires timely treatment. However, it is easily missed, especially in older patients with premorbid cognitive disorders.ObjectivesThe aim of this study is to investigate the prevalence and risk factors of delirium in older outpatients with and without dementia.MethodWe assessed 444 patients referred to the memory clinic of a psychiatric hospital between March 2013 and March 2014. Demographic information, medical history, impairments in daily living activities and referral information were registered. Patients underwent a psychiatric examination using the Delirium Rating Scale‐Revised‐98 and cognitive tests, a physical examination and laboratory tests. We recorded medication use and changes before and after the onset of symptoms.ResultsAmong the 444 outpatients, 85 had probable delirium (prevalence of 19%), and 10 had subsyndromal delirium (2%). The most common triggers were infection (42%), drug‐intoxication or withdrawal (22%), and metabolic/endocrine disturbance (12%). Age (OR 1.07, 95% CI 1.02‐1.11) and prior delirium (OR 3.34, 95% CI 1.28‐8.69) were independent non‐modifiable factors associated with an increased risk of delirium. The only independent modifiable risk factor was infection (OR 17.31, 95% CI 8.44‐35.49).ConclusionsA delirium was detected in one of five patients referred for dementia screening. Most patients could be treated at home. Age and prior delirium were predictive of an increased risk of delirium.

Fluctuations of consciousness after stroke: Associations with the confusion assessment method for the intensive care unit (CAM-ICU) and potential undetected delirium

PurposeTo examine associations between fluctuating consciousness and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessments in stroke patients compared to non-neurological patients. Materials and methodsWe linked all recorded CAM-ICU assessments with corresponding Richmond Agitation Sedation Scale (RASS) measurements in patients with stroke or sepsis from a single-center ICU database. Fluctuating consciousness was defined by RASS variability using standard deviations (SD) over 24-h periods; regression analyses were performed to determine associations with RASS variability and CAM-ICU rating. ResultsWe identified 16,509 paired daily summaries of CAM-ICU and RASS measurements in 546 stroke patients and 1586 sepsis patients. Stroke patients had higher odds of positive (OR 4.2, 95% CI 3.3–5.5) and “unable to assess” (UTA; OR 5.2, 95% CI 4.0–6.8) CAM-ICU ratings compared to sepsis patients, and CAM-ICU-positive and UTA assessment-days had higher RASS variability than CAM-ICU-negative assessment-days, especially in stroke patients. Based on model-implied associations of RASS variability (OR 2.0 per semi-IQR-difference in RASS-SD, 95% CI 1.7–2.2) and stroke diagnosis (OR 2.7, 95% CI 2.0–3.7) with CAM-ICU-positive assessments, over one-third of probable delirium cases among stroke patients were potentially missed by the CAM-ICU. ConclusionsPost-stroke delirium may frequently go undetected by the CAM-ICU, even in the setting of fluctuating consciousness.

IDENTIFYING PATIENTS WITH PROBABLE DELIRIUM AND DEMENTIA FROM ROUTINE HOME HEALTH CARE ASSESSMENTS

Timely education of patients and their family caregivers on dementia disease management and health behavior changes and referral to additional resources is an essential part of age-friendly and high quality care. Nearly one out-of-three home health care patients has been diagnosed with dementia, however, family members and front-line health care providers are frequently unaware that a diagnosis of dementia has made, and what to do. The aim of this study was to identify a small set of questions that are routinely collected during home health care assessment which can be used to rapidly identify patients with suspected dementia, who may benefit from additional screening and services. We developed the preliminary model from 100% national home health care assessment data from 2014 (4.1 million people). We validated the model with a sample of nearly 27,000 patients who received a new (start-of-care) home health assessment in 2016, from four home health agencies that share a common data warehouse. The final model consisting of five questions, performed well in national data (AUC 0.85) predicting any diagnosis of dementia contained in the Medicare Chronic Conditions warehouse or home health record. The final model performed similarly (AUC 0.87) in the validation sample, predicting a diagnosis of dementia or history of dementia medication during a 3-year window of time from clinical data warehouse. The potential applications of this model have the potential to accelerate timely identification of patients with probable dementia or delirium, patient and family caregiver education, and referral to rehabilitative and supportive services.

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] <13) with early WLST (defined as <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 <13, 9/66 with GCS 13-15). After adjusting for ICH severity, admission GCS <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 >80; OR 8.4, 95% CI 1.7-40.7 for size >30cc; intraventricular hemorrhage and infratentorial location were not significant). Of 92 patients who survived >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<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 <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.

Longitudinal patterns of delirium severity scores in long-term care settings.

The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents. A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores. During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks. The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors.

To investigate patterns and predictors of use of antipsychotics in hospitalized adults. Retrospective cohort study. Academic medical center. Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder. Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use. The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk (RR) = 1.4, 95% confidence interval (CI) = 1.2-1.7), male sex (RR = 1.2, 95% CI = 1.1-1.4), black race (RR = 0.8, 95% CI = 0.6-0.96), delirium (RR = 4.8, 95% CI = 4.2-5.7), dementia (RR = 2.1, 95% CI = 1.7-2.6), admission to a medical service (RR = 1.2, 95% CI = 1.1-1.4), intensive care unit stay (RR = 2.1, 95% CI = 1.8-2.4), and mechanical ventilation (RR = 2.0, 95% CI = 1.7-2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older (RR = 0.6, 95% CI = 0.4-0.7), discharge to any location other than home (RR = 2.5, 95% CI = 1.8-3.3), and class of in-hospital antipsychotic exposure (RR = 1.6, 95% CI = 1.1-2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9-3.8 for both vs typical). Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity.

Validation of a consensus method for identifying delirium from hospital records.

BackgroundDelirium is increasingly considered to be an important determinant of trajectories of cognitive decline. Therefore, analyses of existing cohort studies measuring cognitive outcomes could benefit from methods to ascertain a retrospective delirium diagnosis. This study aimed to develop and validate such a method for delirium detection using routine medical records in UK and Ireland.MethodsA point prevalence study of delirium provided the reference-standard ratings for delirium diagnosis. Blinded to study results, clinical vignettes were compiled from participants' medical records in a standardised manner, describing any relevant delirium symptoms recorded in the whole case record for the period leading up to case-ascertainment. An expert panel rated each vignette as unlikely, possible, or probable delirium and disagreements were resolved by consensus.ResultsFrom 95 case records, 424 vignettes were abstracted by 5 trained clinicians. There were 29 delirium cases according to the reference standard. Median age of subjects was 76.6 years (interquartile range 54.6 to 82.5). Against the original study DSM-IV diagnosis, the chart abstraction method gave a positive likelihood ratio (LR) of 7.8 (95% CI 5.7–12.0) and the negative LR of 0.45 (95% CI 0.40–0.47) for probable delirium (sensitivity 0.58 (95% CI 0.53–0.62); specificity 0.93 (95% CI 0.90–0.95); AUC 0.86 (95% CI 0.82–0.89)). The method diagnosed possible delirium with positive LR 3.5 (95% CI 2.9–4.3) and negative LR 0.15 (95% CI 0.11–0.21) (sensitivity 0.89 (95% CI 0.85–0.91); specificity 0.75 (95% CI 0.71–0.79); AUC 0.86 (95% CI 0.80–0.89)).ConclusionsThis chart abstraction method can retrospectively diagnose delirium in hospitalised patients with good accuracy. This has potential for retrospectively identifying delirium in cohort studies where routine medical records are available. This example of record linkage between hospitalisations and epidemiological data may lead to further insights into the inter-relationship between acute illness, as an exposure, for a range of chronic health 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.

Detecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents

To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents. Descriptive study. LTC settings in Quebec City, Canada. Participants were 155 individuals aged 65 and older, with dementia. (1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies. Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed. Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

Temporal association between hospitalization and rate of falls after discharge.

Evidence suggests that acute illness and hospitalization may increase the risk for falls. To evaluate the rate of falls, and associated risk factors, for 90 days following hospital discharge. We consecutively enrolled 311 patients, aged 65 years and older, discharged from the hospital after an acute medical illness and receiving home-nursing services. Patients were assessed within 5 days of discharge for prehospital and current functioning by self-report, and balance, vision, cognition, and delirium by objective measures. Patients were followed up weekly for 13 weeks for falls, injuries, and health care use. The rate of falls was significantly higher in the first 2 weeks after hospitalization (8.0 per 1000 person-days) compared with 3 months later (1.7 per 1000 person-days) (P =.002). Fall-related injuries accounted for 15% of all hospitalizations in the first month after discharge. Independent prehospital risk factors significantly associated with falls included dependency in activities of daily living, use of a standard walker, 2 or more falls, and more hospitalizations in the year prior. Posthospital risk factors included use of a tertiary amine tricyclic antidepressant, probable delirium, and poorer balance, while use of a cane was protective. The rate of falls is substantially increased in the first month after medical hospitalization, and is an important cause of injury and morbidity. Posthospital risk factors may be potentially modifiable. Efforts to assess and modify risk factors should be integral to the hospital and posthospital care of older adults (those aged >/=65 years).