Environmental risk factors for delirium in hospitalized older people

OBJECTIVES: To evaluate the relationship of environmental risk factors in hospitals to changes over time in delirium symptom severity scores. DESIGN: Observational prospective clinical study with repeated measurements, several times during the first week of hospitalization and then weekly during hospitalization. SETTING: University-affiliated general community hospital. PARTICIPANTS: Four hundred forty-four patients age 65 and older admitted to the medical wards: 326 with delirium and 118 without delirium. Patients with prior cognitive impairment were oversampled. MEASUREMENTS: The severity of delirium symptoms was measured with the Delirium Index, a scale developed and validated by our group, based on the Confusion Assessment Method. Potential environmental risk factors assessed included isolation, hospital unit, room changes, levels of sensory stimulation, aids to orientation, and presence of medical (e.g., intravenous) or physical restraints. RESULTS: Controlling for initial severity of delirium and patient characteristics, variables significantly related to an increase in delirium severity scores included hospital unit (intensive care or long-term care unit), number of room changes, absence of a clock or watch, absence of reading glasses, presence of a family member, and presence of medical or physical restraints. CONCLUSION: The associations of intensive care and medical and physical restraints with severity of delirium symptoms may be due to uncontrolled confounding by indication. However, the other factors identified suggest potentially modifiable risk factors for symptoms of delirium in hospitalized older people.     

Consequences of preventing delirium in hospitalized older adults on nursing home costs

OBJECTIVES: To determine whether costs of long-term nursing home (NH) care for patients who received a multicomponent targeted intervention (MTI) to prevent delirium while hospitalized were less than for those who did not receive the intervention. DESIGN: Longitudinal follow-up from a randomized trial. SETTING: Posthospital discharge settings: community-based care and NHs. PARTICIPANTS: Eight hundred one hospitalized patients aged 70 and older. MEASUREMENTS: Patients were followed for 1 year after discharge, and measures of NH service use and costs were constructed. Total long-term NH costs were estimated using a two-part regression model and compared across intervention and control groups. RESULTS: Of the 400 patients in the intervention group and 401 patients in the matched control group, 153 (38%) and 148 (37%), respectively, were admitted to a NH during the year, and 54 (13%) and 51 (13%), respectively, were long-term NH patients. The MTI had no effect on the likelihood of receiving long-term NH care, but of patients receiving long-term NH care, those in the MTI group had significantly lower total costs, shorter length of stay and lower cost per survival day. Adjusted total costs were $50,881 per long-term NH patient in the MTI group and $60,327 in the control group, a savings of 15.7% (P=.01). CONCLUSION: Active methods to prevent delirium are associated with a 15.7% decrease in long-term NH costs. Shorter length of stay of patients receiving long-term NH services was the primary source of these savings.     

Participation in activity and risk for incident delirium

OBJECTIVES: To examine the mediating role between educational attainment and risk for incidence delirium of activity participation and to examine the contribution of participation in specific activities to the development of delirium. DESIGN: Prospective cohort study. SETTING: Urban teaching hospital in New Haven, Connecticut. PARTICIPANTS: Participants were drawn from two prospective cohort studies of 779 newly hospitalized patients aged 70 and older without dementia. MEASUREMENTS: The main outcome was delirium, measured using the full Confusion Assessment Method (CAM) algorithm, which consisted of acute onset and fluctuating course, inattention, and disorganized thinking or altered level of consciousness, as rated by trained clinical interviewers. RESULTS: Bivariable results indicated a significant relationship between education and the development of delirium (odds ratio (OR)=0.92, 95% confidence interval (CI)=0.88–0.97) and between activity and delirium (OR= 0.60, 95% CI=0.46–0.79). In multivariable analysis, activity mediated the relationship between education and risk for delirium. Considering each activity separately, multivariable logistic regression analysis showed that regular exercise significantly lowered the risk for developing delirium (OR=0.76, 95% CI=0.60–0.96). CONCLUSION: In older persons without dementia, activity participation before hospitalization is a mediator between education and incidence of delirium. Specifically, it was found that participation in regular exercise was found to be significantly protective against delirium.     

Cortisol, insulin, and glucose and the risk of delirium in older adults with hip fracture

OBJECTIVES: To determine the relationship between perioperative delirium and cortisol, glucose, and insulin in older adults acutely admitted for hip fracture. DESIGN: Prospective cohort study. SETTING: Tertiary university center. PARTICIPANTS: Consecutive individuals aged 65 and older acutely admitted for hip fracture were invited to participate. MEASUREMENTS: All participants were repeatedly examined to determine presence and severity of delirium. Blood samples for cortisol, glucose, and insulin were drawn at 11:00 a.m. Differences in characteristics of participants with and without delirium were evaluated using t‐tests and Mann‐Whitney tests. A logistic regression analysis was performed to correct for other important risk factors for delirium. RESULTS: One hundred forty‐three participants, 70 (49%) with delirium and 73 (51%) without, were included. In univariate analyses, there was a trend toward higher cortisol levels (odds ratio=1.003 (95% confidence interval=1.001–1.004, P=.004), but this association was not statistically significant after multivariable analysis and may reflect an association between high cortisol and preexisting cognitive and functional impairment, and there was no association with insulin or glucose levels. Adjusting for sex and prefracture cognitive and functional impairment made the trend with cortisol and delirium statistically nonsignificant. CONCLUSION: Delirium in older adults acutely admitted for hip fracture may be linked with higher cortisol concentrations, but it may be that this association reflects an association between higher cortisol and preexisting cognitive and functional impairment.     

Anesthesia and postoperative delirium in older adults undergoing hip surgery

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

Depressive symptoms and 3-year mortality in older hospitalized medical patients

BACKGROUND: Depressive symptoms are common in hospitalized older persons. However, their relation to long-term mortality is unclear because few studies have rigorously considered potential confounders of the relation between depression and mortality, such as comorbid illness, functional impairment, and cognitive impairment. OBJECTIVE: To measure the association between depressive symptoms and long-term mortality in hospitalized older persons. DESIGN: Prospective cohort study. SETTING: General medical service of a teaching hospital. PATIENTS: 573 patients 70 years of age or older. MEASUREMENTS: Depressive symptoms (Geriatric Depression Scale score), severity of acute illness (Acute Physiology and Chronic Health Evaluation II score), burden of comorbid illness (Charlson comorbidity index score), physical function (a nurse assessed dependence in six activities of daily living), and cognitive function (modified Mini-Mental State Examination) were measured at hospital admission. Mortality over the 3 years after admission was determined from the National Death Index. Mortality rates among patients with six or more depressive symptoms were compared with those among patients with five or fewer symptoms. RESULTS: The mean age of the patients was 80 years; 68% of patients were women. Patients with six or more depressive symptoms had greater comorbid illness, functional impairment, and cognitive impairment at admission than patients with fewer depressive symptoms. Three-year mortality was higher in patients with six or more depressive symptoms (56% compared with 40%; hazard ratio, 1.56 [95% CI, 1.22 to 2.00]; P < 0.001). After adjustment for age, acute illness severity, comorbid illness, functional impairment, and cognitive impairment at the time of admission, patients with six or more depressive symptoms continued to have a higher mortality rate during the 3 years after admission (hazard ratio, 1.34 [CI, 1.03 to 1.73]). Although depressive symptoms contributed less to the mortality rate than did the total burden of comorbid medical illnesses, the excess mortality rate associated with depressive symptoms was greater than that conferred by one additional comorbid medical condition. CONCLUSIONS: Depressive symptoms are associated with long-term mortality in older patients hospitalized with medical illnesses. This association is not fully explained by greater levels of comorbid illness, functional impairment, and cognitive impairment in patients with more depressive symptoms.     

合并视力障碍的老年内科住院病人谵妄发生率及影响因素

目的 了解视力障碍的老年内科疾病病人住院期间谵妄发生率和相关影响因素.方法 采用前瞻性队列研究方法,入选2016年3月至2017年1月四川大学华西医院老年科存在视力障碍的老年住院病人.入院48 h内对病人进行视力检查和谵妄相关危险因素评估,从住院当天至住院第13天每隔一天对病人进行谵妄评估,记录住院期间有无发生谵妄,并...     

Depressive symptoms among African American and white older adults

Guided by a stress and coping model, we explored determinants of depressive symptoms among community samples of older African Americans (n=255) and older Whites (n=452). We gave focus to the effects of demographic variables, physical health constraints (chronic conditions and functional disability), and psychosocial attributes (sense of mastery, religiosity, social support, and satisfaction with support), along with their interactive roles. We identified lower education, greater functional disability, lower sense of mastery, and poorer satisfaction with support as common risk factors for depressive symptoms in both groups; in contrast, the effects of age, gender, and religiosity were race specific. In addition, we obtained significant interactions among predictor variables in each group, identifying risk-reducing and risk-enhancing factors within each group.