Volume 1, Issue 2

 

Assessing Risk Factors and Outcomes of interests in Hospitalized Elderly patients with Delirium

July 28, 2010

Background

Delirium is frequently found in the elderly hospitalized patient, particularly in the frail elderly.  In the acute care setting, delirium can be found in greater than 30% of elderly patients, more than 50% in postoperative elderly patients.

Greater length of stays, higher morbidity and mortality are found among geriatric patients. These adverse outcomes can be far reaching given that delirium can last weeks to months. Thus, contributing to decline in functional status and admission to long term care facilities. The health care cost, more importantly, impairment in quality of life can be devastating.

There are multiple risk factors associated with the development of delirium, such as age, cognitive deficits, sensory impairment, and infection.

Predictive models, such as the one devised by Sharon Inouye and colleagues can be used to stratify the elderly patient's risk of developing delirium(1). Yet, such models are not widely used.

Should we apply such models at our health center? In order, to get more idea of the prevalence of delirium in our health care center, we did a retrospective chart review , looking at elderly patients admitted to  medical/surgical  service.  

 

Objectives

  •  To identify elderly patients who developed delirium during acute hospitalization at Brooklyn Hospital Center, a community teaching health center. 
  •  Assess risk factors for the development of delirium in our study population.
  •  Two outcomes of interest are length of stay and mortality.

 

Methods

Retrospective study.

Reviewed charts of patients of age of 65 years and older, admitted to The Brooklyn Hospital Center in a three month  period, from 10/1/2008-12/31/2008.

300 patient charts were randomly selected.

Presence of delirium was determined by reviewing the charts for such keywords: delirium, delirious, acute confusion, agitation, acute agitation, use of restraints, orders written for companion for direct observation, use of benzodiazepines and psychoactive medications due to acute change in behavior.

Exclusion criteria- admission of acute confusion, delirium or stroke.

 Results

  Mean Patient Age: Delirium vs. Non-Delirium                      

 

  Dementia was a significant factor among delirium patients,  p < 0.0001

  A significantly greater number of delirium patients were more likely to expire,  p < 0.0001

 

  p < 0.0001

Discussion

  •  Delirium is found  in 65 of 300 patients(21.6%), p<0.0001. Findings consistent with other studies on delirium. Some findings were surprising. 
  •  Patients in the delirium were significantly older, had dementia, and were less likely discharged to the community.
  •  Surprising findings, were that pain, # of meds, and use of narcotics were not significant between the two groups. Given, that a large number of elderly in the delirium group had cognitive impairment, pain could have been under-reported.
  •  Significantly more patients with delirium were found that have hearing impairment. No significant difference in visual impairment between the groups.  There could be more under reporting of visual impairment. 
  •  Surgical procedures were significantly higher in the group

With delirium.  This could be related to the use of general anesthesia or  a group with a higher burden of illness.

  •  Foley Catheter use was significant in the acute confusion group. Thus, the higher infection rate and longer LOS,and higher mortality rate in this group.
  • Mean length of Stay for delirium patients was 17.4 days while non delirious patients LOS is 5.8 days. A tremendous difference, with associated great monetary cost.
  •  There were significantly more deaths in patients who developed delirium( 21.5% vs 1.72%). Delirium is very difficult to treat, with a poor prognosis.
  • For older patients with or without dementia functional status is independent risk factor for delirium, study shows 49% patients who developed delirium were non ambulatory.
  •  This study underscores the need for institution of intervention

Models to identify patients at risk of delirium, with the goal of prevention.

  •  In conclusion it is more cost effective to prevent than treat delirium.