C International Psychogeriatric Association 2014 International Psychogeriatrics: page 1 of 10 doi:10.1017/S1041610214002658
Poor functional recovery after delirium is associated with other geriatric syndromes and additional illnesses ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Monidipa Dasgupta1,2 and Chris Brymer1 1
Division of Geriatric Medicine, Department of Medicine, Shulich School of Medicine, University of Western Ontario, University Hospital, 339 Windermere Road, London, On, Canada, N6A 5A5 2 Lawson Health Research Institute, London, Ontario, Canada
ABSTRACT
Background: Delirious individuals are at increased risk for functional decline, institutionalization and death. Delirium is also associated with other geriatric syndromes, behavioral care issues, and new illnesses. The objectives of this study were to determine how often certain geriatric syndromes, care issues, and additional diagnoses occur in delirious individuals, and to see whether they correlate with worse functional recovery. Methods: Consecutive delirious older medical in-patients (n = 343) were followed for the occurrence of geriatric syndromes (falls, pressure ulcers, poor oral intake, and aspiration), care issues (refusing treatments or care, need for sitters, security services, physical restraints, and new neuroleptic medications) and additional diagnoses occurring after the third day of admission. Poor functional recovery was defined by any one of death, permanent institutionalization or increased dependence for activities of daily living (ADLs) at discharge or three months after discharge from hospital, elicited through chart review or a follow-up telephone interview. Results: Poor functional recovery was seen in 237 (69%) delirious patients. Geriatric syndromes and additional illnesses were common and associated with poor functional recovery (falls in 21%, adjusted OR 2.27; possible aspiration in 26%, adjusted OR 3.06; poor oral intake in 49%, adjusted OR = 2.31; additional illnesses in 38%, adjusted OR 3.54). Care issues were also common (range 9%–54%) but not associated with poor recovery. Conclusions: Geriatric syndromes, behavioral care issues and additional illnesses are common in delirium. Future studies should assess whether monitoring for and intervening against geriatric syndromes and additional illnesses may improve functional outcomes after delirium. Key words: delirium, activities of daily living, aged care, adverse events
Introduction Delirium is a cognitive-behavioral syndrome seen in 11%–42% (Siddiqi et al., 2006) of medically hospitalized, acutely ill individuals. It is associated with increased length of stay, cost, functional decline, institutionalization and death, even with treatment of the underlying associated illness(es) (Inouye, 2006; Siddiqi et al., 2006) Although some delirious individuals recover, many have persistent delirium symptoms which are associated with poorer functional outcomes and death (Levkoff et al., 1992; McCusker et al., 2003; Kiely et al., Correspondence should be addressed to: Monidipa Dasgupta, Associate Professor, Geriatric medicine-B9-103, University Hospital, 339 Windermere Road, London, ON, Canada N6A 5A5. Phone: 519-685-8500, ext. 33922#; Fax: 519-663-3472. Email: [email protected]. Received 6 Sep 2014; revision requested 5 Oct 2014; revised version received 23 Oct 2014; accepted 13 Nov 2014.
2006; Speciale et al., 2007; Kiely et al., 2009). Some delirium may be preventable, but once delirium develops, little is known about how to improve patient outcomes (Young and George, 2003). Delirious patients are also at increased risk for having geriatric syndromes, new acute illnesses and needing repeat hospitalizations (George et al., 1997; Marcantonio et al., 2005). These geriatric syndromes can include falls, pressure sores, immobility, incontinence, malnutrition or weight loss, and dehydration (Fick and Forman, 2000; Marcantonio et al., 2005; Speciale et al., 2007; Lakatsos et al., 2009). Behavioral symptoms, possibly resulting in restraint use or pulling out intravenous lines, can also accompany delirium and may be associated with increased length of hospital stay (Fick and Forman, 2000; Saravay et al., 2004). However, there is sparse data on how often these complicating factors occur in delirium,
2
M. Dasgupta and C. Brymer
and how they may impact ultimately on functional recovery. We recently completed a prospective study on older medical in-patients with delirium. Consecutive medical admissions were actively screened for delirium. Delirious patients were followed throughout their hospitalization and information was collected on the occurrence of certain geriatric syndromes (e.g. falls, pressure ulcers, poor oral intake), other care issues (e.g. refusal of treatments or care, need for physical restraints or hospital security services), new neuroleptic medication use, and any additional diagnoses made after admission. A three month follow-up telephone interview was conducted on delirious patients who were discharged to the community from hospital, and information was collected on functional recovery as well as the need for re-hospitalizations or emergency room visits. The objectives of the present study were to determine how often delirious individuals have certain geriatric syndromes, care issues or additional diagnoses made (after admission), and whether these are associated with poor functional recovery (defined by functional decline, need for new permanent institutionalization or death). It was hypothesized that the occurrence of geriatric syndromes, care issues or additional diagnoses would be associated with adverse functional recovery in delirious individuals.
Methods One thousand two hundred and thirty five consecutive medical in-patients admitted to the London Health Sciences Centre (a tertiary care academic teaching hospital), in London, Ontario, Canada, who were 70 years of age or older, were screened for delirium, using a structured interview as previously described (Dasgupta and Brymer, 2014). Eligible and consenting patients were screened every two days after enrollment, three times in total or until discharge (whichever occurred first), and classified as delirious if they met confusion assessment method criteria (Inouye et al., 1990) for delirium. Exclusion criteria included lack of a willing caregiver or substitute decision maker, transfer to a non-medical unit within seven days of admission, admission solely for palliation or institutionalization, inability to communicate in English, pre-hospitalization long-term residence in a nursing home, complete dependence for ADLs (Fillenbaum, 1978), transfers from other inpatient units, or enrollment in other intervention studies. For cognitively impaired participants (and all delirious participants), consent was required
from both the participant and a substitute-decision maker. The study was approved by the Health Sciences Research Ethics Board of the University of Western Ontario. As the primary purpose of this study was to assess indicators of poor recovery in delirious patients, participants could be approached more than once for the study if both of the following occurred: (i) a participant was admitted to hospital and discharged within 72 h and (ii) if the participant was not delirious during the initial admission. If this occurred, data from only one of the admissions was included in the dataset (the admission during which the participant was delirious, or the longer admission). Three hundred and fifty five individuals were classified as being delirious and followed during their hospitalization. Delirious individuals were followed by the research assistant (RA) in hospital, every two days for the first week, bi-weekly for the subsequent two weeks, weekly thereafter for two months and monthly thereafter until study participants were discharged from hospital. Data were collected on demographics, baseline function using the OARS questionnaire (Fillenbaum, 1978) on ADLs (eating, dressing, grooming, walking, transferring, bathing, toileting, and incontinence), whether there was history of a known neurodegenerative disorder (any one of dementia, Parkinson’s disease, being on a cholinesterase inhibitor, possible mild cognitive impairment, traumatic brain injury or normal pressure hydrocephalus), baseline cognitive function, measured with the informant questionnaire of cognitive decline in the elderly, IQCODE (Jorm, 2004), co-morbidity using the cumulative illness rating scale (Parmalee et al., 1995), and admitting diagnoses. Delirium severity was also measured using the memorial delirium assessment scale (MDAS) (Breitbart et al., 1997). Delirious individuals were interviewed to assess for delirium at each visit by the RA, using a structured interview, and their charts were also monitored for any new medications that were started, the occurrence of certain geriatric syndromes, behavioral issues affecting the provision of care (hereafter referred to as care issues) and any additional diagnoses made after the third day of admission. The RA also noted if any lap or limb restraints were applied, and if security or sitter services were present. If patients were readmitted within one week of discharge for the same diagnosis, because of inability to manage at home, data from the second admission was also collected (as a continuation of the first hospitalization) and included as part of the participant’s hospital data. The presence of certain geriatric syndromes was based upon whether they were noted to have been
Functional recovery after delirium
present in the hospital chart. All parts of the hospital chart were assessed including the orders section, the medication administration records, and clinical progress notes by all care providers. Data on the following syndromes was collected: (1) pressure sores (documentation of ulcers, skin breakdown or need for wound care consult); (2) decreased oral intake; (3) concerns about trouble swallowing and (4) in-hospital falls. The following care issues were assessed (chart documentation or if present when seen by the RA): (1) notes of patients refusing vital signs, investigations, treatments or other care; (2) use of physical limb or waist restraints (excluding bedrails, geri chairs or other tethering devices such as intravenous lines or foley catheters); (3) use of observational sitter services (sitters are ordered for safety concerns); (4) use of hospital security services (for safety concerns) and (5) use of new neuroleptic medications. The latter was felt to be another care issue as neuroleptic agents are often used for behavioral symptom management in delirium (Inouye, 2006). Information on any additional diagnoses made after the third day of admission was collected. In addition, during the follow-up interview (see below) data was collected on the occurrence of new falls, hospitalizations or visits to the emergency department since discharge from the index hospitalization. The primary outcome was functional recovery status after delirium. Poor functional recovery was defined by any one of death, new long-term (permanent) institutionalization in a nursing home or functional decline (as defined below) either at discharge or at three months after discharge. If individuals were discharged to a long-term permanent institutional residence, or deceased during hospitalization, the primary outcome was collected directly from the chart. In London (Ontario), individuals can be discharged directly to a permanent residential institution (with twentyfour hour nursing care available; this occurs as a consequence of needing additional help that is unable to be provided through family and community supports), discharged to a noninstitutional home (their own or residing with someone else), discharged to a retirement home (still considered community living as twenty four hour nursing care is not necessarily available), or discharged to a temporary facility (such as a rehabilitation institute or a respite institute, with the anticipation that the individual will eventually return to non-institutional community living). If individuals were discharged home, to a retirement home, or to a temporary institution (such as a rehabilitation or respite facility), a telephone interview was conducted three months after discharge, to collect information on current
3
functional status and whether there were any repeat hospitalizations, falls or visits to the emergency department since discharge (this was also supplemented by hospital records). Telephone interviews were not done, if patients were readmitted after the index hospitalization and subsequently deceased or discharged to a long-term permanent institution. Functional status was measured during the follow-up interview, using the OARS questionnaire (Fillenbaum, 1978) on ADLs (eating, dressing, grooming, walking, transferring, bathing, toileting, and incontinence). ADLs are graded on a scale from 0–2, with 0 being most dependent. Functional decline was defined as an individual experiencing either a full decline in the ability to perform an ADL (score decreasing from 2 to 0) or a partial decline in at least two ADLs (score decreasing by 1 point in at least 2 ADLs), compared to the individual’s ability to perform ADLs prior to hospital admission (collected at the time of patient enrollment), as has been done in other studies (Marcantonio et al., 2002). Statistical analysis SAS version 9.3 was used for statistical analyses. Selected baseline characteristics of people who had a poor recovery were compared to those without a poor recovery using t-tests, or χ2 tests, or Wilcoxon rank test (for length of stay). Full details of other baseline characteristics are presented in the original study (Dasgupta and Brymer, 2014). The independent variables were the four geriatric syndromes (falls, pressure ulcers, poor oral intake, or suspected aspiration), the five care issues (refusing treatments, need for restraints, use of sitter services, use of security services or new neuroleptic use) and whether any additional diagnoses were made after the first three days of admission. Univariable and multivariable analyses (controlled for five baseline variables) were performed between the independent variables and functional recovery status (dependent variable). The five baseline variables used in the multivariable analyses are those that were found to be associated with poor functional recovery in the original study (Dasgupta and Brymer, 2014): increased age, lower baseline ADL score (higher scores indicating greater independence in performing ADLs), initial high MDAS scores (defined as the average of the first two MDAS scores or the first MDAS score if only one score was available), and the presence of either hypoxia or acute renal failure as an admitting diagnosis. Although other baseline variables were collected (including gender, presence of a neurodegenerative disorder, baseline cognitive
4
M. Dasgupta and C. Brymer
2719 paents at least 70 years of age admied during study period 825 ineligible by exclusion criteria, including transfers to ICU (9), surgery (20), and palliave care (2) 451 refused 176 discharged before being seen (Length of stay, LOS < 3 days) Deceased before caregiver could be reached (n = 2)
16 unable to be seen within 3 days of admission Excluded as re-admied later with LOS > 72 hours or CAM posive subsequently (n = 12) Previously enrolled (n = 2) Total enrolled: 1235 Not Delirious by screening (n = 880) Delirious by screening (n = 355) Unknown funconal status at ADL decline (n = 46)
Funconal recovery
follow-up me (n = 12)
Newly instuonalized (n = 136)
(n= 106)
Deceased (n = 55)
Figure 1. (Colour online) Enrolment of patientsa . a Dasgupta, M. and Brymer, C. (2014). Prognosis of delirium in hospitalized elderly: worse than we thought. Int J Geriatr Psychiatry, 29, 497–505.
ability, co-morbidity scores, duration of confusion, the presence of hypoactive symptoms, and severity of illness) these were not incorporated into the multivariable models, for this study, as they were not associated with poor functional recovery in the original study. A sensitivity analysis was done excluding individuals who had deceased to see if this changed the associations. It was postulated that deceased individuals may have a shorter length of stay and therefore be less likely to exhibit some of the independent variables assessed. Combining new functional decline with permanent institutionalization was considered reasonable as both indicate greater functional impairment (permanent institutionalization being indicated when functional needs can no longer be supported by existing community services). To assess if one or more of the independent variables were independently associated with recovery status, another multivariable analysis was conducted with forced inclusion of the five baseline variables and all the significantly associated (at the univariable level, at p < 0.05 level) independent variables, with sequential removal of variables if p > 0.05. However, the possibility of collinearity
between many of these independent variables (e.g. between poor oral intake and pressure ulcers or suspected aspiration) was considered potentially problematic. Variance inflation factors (VIF’s) were calculated to assess for degree of collinearity.
Results Of the 355 delirious patients enrolled, recovery status was known on 343 (96%) (see Figure 1 for further details of patient enrolment). At discharge, 54 (15%) had deceased and 86 (24%) were discharged to a permanent residential nursing home. Of the remaining 215 discharged to the community or a temporary rehabilitation or respite bed, recovery status at follow-up, was known in 202 (94%), at a median/mean (SD) of 103/121.4 (SD 81.7) days after discharge. At follow-up, ninety seven (48%) people had poor recovery: one deceased, 50 newly permanently institutionalized and 46 with ADL decline of at least two points. Therefore, the overall rate of poor recovery after delirium was 69% (or 237 out of 342 delirious patients with known follow-up status). The mean
Functional recovery after delirium
5
Table 1. Characteristics of included patients (delirious with follow-up recovery status known) ENTIRE SAMPLE
POOR RECOVERY
FUNCTIONAL
(N = 343)
(N = 237)
RECOVERY
(N = 106)
P-V A L U E a
.........................................................................................................................................................................................................................................................................................................................
Mean age (years) Number female Average co-morbidity score (CIRS)b Average number of admission medications History of neurodegenerative disorderc IQCODE score (SD)d ADL scoree Admission presence of hypoxia Mean initial MDAS scoresf ARF (acute renal failure as admission diagnosis) Median length of hospital stay (days)
84.5 199 (58.0%) 9.80 7.35
86.0 142 (59.9%) 9.72 7.27
81.1 57 (53.8%) 9.99 7.52
< 0.001 0.29 0.53 0.56
138
94
44
0.812
3.71 (0.51) 12.8 120 (35.1%)
3.76 (0.52) 12.6 90 (38.1%)
3.61 (0.47) 13.4 30 (28.3%)
0.006 0.015 0.078
12.7 63 (18.4%)
13.1 50 (21.1%)
11.8 13 (12.3%)
0.008 0.051
16.0
21.0
8.0
< 0.001
a P-values
calculated using t-test, Wilcoxon two-sample test (for length of stay), or χ 2 test, comparing poor recovery to functional recovery groups. b Cumulative illness rating scale (CIRS) used to calculate co-morbidity. c History of neurodegenerative disorder was classified as being present, if there was chart documentation of a past medical history of dementia (of any type), Parkinsons’ disease, normal pressure hydrocephalus, or presently being treated with a cholinesterase inhibitor. d The informant questionnaire of cognitive decline in the elderly (IQCODE) was obtained on all delirious individuals as another measure of cognition. The IQCODE score correlated with other variables, including age, having a history of a neurodegenerative disorder and baseline function or ADL score. It was dropped from the multivariable model as it did not qualify for inclusion in the original study (the P-value for IQCODE in the multivariable model exceeded 0.3). e ADL score was calculated using the OARS questionnaire (eating, dressing, grooming, walking, transferring, bathing, toileting and incontinence). ADLs are graded on a scale from 0–2, with 0 being most dependent. f Mean initial memorial delirium assessment scale (MDAS) scores, a measure of delirium severity, was calculated as the average of the first two MDAS readings after admission (as described in the original study, Dasgupta and Brymer, 2014).
age of the sample was 84.5 years of age, with a significant amount of co-morbidity (Table 1). During their hospital stay (Table 2), the aforementioned geriatric syndromes occurred in the range of 13% (pressure ulcers) to 49% (poor oral intake) of delirious people. The presence of any one of the four geriatric syndromes evaluated was associated with poor recovery in univariable and multivariable analyses controlling for baseline factors (for pressure ulcers, the multivariable analysis yielded a trend towards significance, p = 0.051). Difficult care issues were also quite prevalent occurring in 9% (use of security services) to 54% (patients refusing care or treatments) of delirious people. Of the care issues measured, refusal of care or treatments by patients was associated with poor recovery, in the univariable analysis but not in the adjusted analysis. Other care issues (including need for security or sitter services, or the use of new neuroleptic medications) were not associated with recovery status. Diagnoses made after the third day of admission were common occurring in 131 (38%) of delirious
in-patients. The three most common diagnoses made, after the third day of admission were pneumonia, congestive heart failure, and colitis (in 22, 17 and 16 individuals respectively) and 68% of these new diagnoses were made within the first 15 days of hospital stay. Individuals with poor recovery had more than a fourfold increase in the odds of having additional diagnoses made after the third day of admission, in analyses controlling for baseline variables. With the exclusion of deceased individuals, the results were not changed, except that refusing care or treatments was no longer significant at the univariable level (Table 3). The presence of any one of four geriatric syndromes, refusing care, and having additional diagnoses made after the third day of admission were entered into a multivariable model with forced inclusion of baseline variables (age, ADL dependence, MDAS scores, admitting diagnosis of acute renal failure, and hypoxia). Only aspiration and the presence of an additional diagnosis remained independently associated with poor
6
M. Dasgupta and C. Brymer
Table 2. Geriatric syndromes, other care issues and additional diagnoses in delirious individuals (with known recovery status) ADJUSTEDa
UNADJUSTED
TOTAL
POOR
FUNCTIONAL
(%) (N = 343)
RECOVERY
RECOVERY
(N = 237)
(N = 106)
NUMBER
OR (95% CI)
PVALUE
OR (95% CI)
PVALUE
.........................................................................................................................................................................................................................................................................................................................
Geriatric syndromes 45 (13.2%) Pressure ulcersb 72 (21.1%) In hospital fallsb Aspiration concernsb 89 (26.0%) Poor oral intake 169 (49.3%) Care issues Refusing care or 186 (54.2%) treatments 106 (31.0%) Physical restraint useb Observational sitter 97 (28.4%) servicesb Security useb 30 (8.8%) New neuroleptic use (in 98 (28.6%) hospital) Diagnoses made after third day of hospital Diagnoses made after 131 (38.2%) admission a Adjusted for age, ADL score, b Missing data in one person.
38 (16.0%) 58 (24.5%) 76 (32.1%) 136 (57.4%)
7 (6.7%)b 14 (13.3%) 13 (12.4%) 33 (31.1%)
2.67 (1.15, 6.20) 2.11 (1.12, 3.98) 3.34 (1.76, 6.35) 2.98 (1.83, 4.84)
0.018 0.020
Poor functional recovery after delirium is associated with other geriatric syndromes and additional illnesses ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Monidipa Dasgupta1,2 and Chris Brymer1 1
Division of Geriatric Medicine, Department of Medicine, Shulich School of Medicine, University of Western Ontario, University Hospital, 339 Windermere Road, London, On, Canada, N6A 5A5 2 Lawson Health Research Institute, London, Ontario, Canada
ABSTRACT
Background: Delirious individuals are at increased risk for functional decline, institutionalization and death. Delirium is also associated with other geriatric syndromes, behavioral care issues, and new illnesses. The objectives of this study were to determine how often certain geriatric syndromes, care issues, and additional diagnoses occur in delirious individuals, and to see whether they correlate with worse functional recovery. Methods: Consecutive delirious older medical in-patients (n = 343) were followed for the occurrence of geriatric syndromes (falls, pressure ulcers, poor oral intake, and aspiration), care issues (refusing treatments or care, need for sitters, security services, physical restraints, and new neuroleptic medications) and additional diagnoses occurring after the third day of admission. Poor functional recovery was defined by any one of death, permanent institutionalization or increased dependence for activities of daily living (ADLs) at discharge or three months after discharge from hospital, elicited through chart review or a follow-up telephone interview. Results: Poor functional recovery was seen in 237 (69%) delirious patients. Geriatric syndromes and additional illnesses were common and associated with poor functional recovery (falls in 21%, adjusted OR 2.27; possible aspiration in 26%, adjusted OR 3.06; poor oral intake in 49%, adjusted OR = 2.31; additional illnesses in 38%, adjusted OR 3.54). Care issues were also common (range 9%–54%) but not associated with poor recovery. Conclusions: Geriatric syndromes, behavioral care issues and additional illnesses are common in delirium. Future studies should assess whether monitoring for and intervening against geriatric syndromes and additional illnesses may improve functional outcomes after delirium. Key words: delirium, activities of daily living, aged care, adverse events
Introduction Delirium is a cognitive-behavioral syndrome seen in 11%–42% (Siddiqi et al., 2006) of medically hospitalized, acutely ill individuals. It is associated with increased length of stay, cost, functional decline, institutionalization and death, even with treatment of the underlying associated illness(es) (Inouye, 2006; Siddiqi et al., 2006) Although some delirious individuals recover, many have persistent delirium symptoms which are associated with poorer functional outcomes and death (Levkoff et al., 1992; McCusker et al., 2003; Kiely et al., Correspondence should be addressed to: Monidipa Dasgupta, Associate Professor, Geriatric medicine-B9-103, University Hospital, 339 Windermere Road, London, ON, Canada N6A 5A5. Phone: 519-685-8500, ext. 33922#; Fax: 519-663-3472. Email: [email protected]. Received 6 Sep 2014; revision requested 5 Oct 2014; revised version received 23 Oct 2014; accepted 13 Nov 2014.
2006; Speciale et al., 2007; Kiely et al., 2009). Some delirium may be preventable, but once delirium develops, little is known about how to improve patient outcomes (Young and George, 2003). Delirious patients are also at increased risk for having geriatric syndromes, new acute illnesses and needing repeat hospitalizations (George et al., 1997; Marcantonio et al., 2005). These geriatric syndromes can include falls, pressure sores, immobility, incontinence, malnutrition or weight loss, and dehydration (Fick and Forman, 2000; Marcantonio et al., 2005; Speciale et al., 2007; Lakatsos et al., 2009). Behavioral symptoms, possibly resulting in restraint use or pulling out intravenous lines, can also accompany delirium and may be associated with increased length of hospital stay (Fick and Forman, 2000; Saravay et al., 2004). However, there is sparse data on how often these complicating factors occur in delirium,
2
M. Dasgupta and C. Brymer
and how they may impact ultimately on functional recovery. We recently completed a prospective study on older medical in-patients with delirium. Consecutive medical admissions were actively screened for delirium. Delirious patients were followed throughout their hospitalization and information was collected on the occurrence of certain geriatric syndromes (e.g. falls, pressure ulcers, poor oral intake), other care issues (e.g. refusal of treatments or care, need for physical restraints or hospital security services), new neuroleptic medication use, and any additional diagnoses made after admission. A three month follow-up telephone interview was conducted on delirious patients who were discharged to the community from hospital, and information was collected on functional recovery as well as the need for re-hospitalizations or emergency room visits. The objectives of the present study were to determine how often delirious individuals have certain geriatric syndromes, care issues or additional diagnoses made (after admission), and whether these are associated with poor functional recovery (defined by functional decline, need for new permanent institutionalization or death). It was hypothesized that the occurrence of geriatric syndromes, care issues or additional diagnoses would be associated with adverse functional recovery in delirious individuals.
Methods One thousand two hundred and thirty five consecutive medical in-patients admitted to the London Health Sciences Centre (a tertiary care academic teaching hospital), in London, Ontario, Canada, who were 70 years of age or older, were screened for delirium, using a structured interview as previously described (Dasgupta and Brymer, 2014). Eligible and consenting patients were screened every two days after enrollment, three times in total or until discharge (whichever occurred first), and classified as delirious if they met confusion assessment method criteria (Inouye et al., 1990) for delirium. Exclusion criteria included lack of a willing caregiver or substitute decision maker, transfer to a non-medical unit within seven days of admission, admission solely for palliation or institutionalization, inability to communicate in English, pre-hospitalization long-term residence in a nursing home, complete dependence for ADLs (Fillenbaum, 1978), transfers from other inpatient units, or enrollment in other intervention studies. For cognitively impaired participants (and all delirious participants), consent was required
from both the participant and a substitute-decision maker. The study was approved by the Health Sciences Research Ethics Board of the University of Western Ontario. As the primary purpose of this study was to assess indicators of poor recovery in delirious patients, participants could be approached more than once for the study if both of the following occurred: (i) a participant was admitted to hospital and discharged within 72 h and (ii) if the participant was not delirious during the initial admission. If this occurred, data from only one of the admissions was included in the dataset (the admission during which the participant was delirious, or the longer admission). Three hundred and fifty five individuals were classified as being delirious and followed during their hospitalization. Delirious individuals were followed by the research assistant (RA) in hospital, every two days for the first week, bi-weekly for the subsequent two weeks, weekly thereafter for two months and monthly thereafter until study participants were discharged from hospital. Data were collected on demographics, baseline function using the OARS questionnaire (Fillenbaum, 1978) on ADLs (eating, dressing, grooming, walking, transferring, bathing, toileting, and incontinence), whether there was history of a known neurodegenerative disorder (any one of dementia, Parkinson’s disease, being on a cholinesterase inhibitor, possible mild cognitive impairment, traumatic brain injury or normal pressure hydrocephalus), baseline cognitive function, measured with the informant questionnaire of cognitive decline in the elderly, IQCODE (Jorm, 2004), co-morbidity using the cumulative illness rating scale (Parmalee et al., 1995), and admitting diagnoses. Delirium severity was also measured using the memorial delirium assessment scale (MDAS) (Breitbart et al., 1997). Delirious individuals were interviewed to assess for delirium at each visit by the RA, using a structured interview, and their charts were also monitored for any new medications that were started, the occurrence of certain geriatric syndromes, behavioral issues affecting the provision of care (hereafter referred to as care issues) and any additional diagnoses made after the third day of admission. The RA also noted if any lap or limb restraints were applied, and if security or sitter services were present. If patients were readmitted within one week of discharge for the same diagnosis, because of inability to manage at home, data from the second admission was also collected (as a continuation of the first hospitalization) and included as part of the participant’s hospital data. The presence of certain geriatric syndromes was based upon whether they were noted to have been
Functional recovery after delirium
present in the hospital chart. All parts of the hospital chart were assessed including the orders section, the medication administration records, and clinical progress notes by all care providers. Data on the following syndromes was collected: (1) pressure sores (documentation of ulcers, skin breakdown or need for wound care consult); (2) decreased oral intake; (3) concerns about trouble swallowing and (4) in-hospital falls. The following care issues were assessed (chart documentation or if present when seen by the RA): (1) notes of patients refusing vital signs, investigations, treatments or other care; (2) use of physical limb or waist restraints (excluding bedrails, geri chairs or other tethering devices such as intravenous lines or foley catheters); (3) use of observational sitter services (sitters are ordered for safety concerns); (4) use of hospital security services (for safety concerns) and (5) use of new neuroleptic medications. The latter was felt to be another care issue as neuroleptic agents are often used for behavioral symptom management in delirium (Inouye, 2006). Information on any additional diagnoses made after the third day of admission was collected. In addition, during the follow-up interview (see below) data was collected on the occurrence of new falls, hospitalizations or visits to the emergency department since discharge from the index hospitalization. The primary outcome was functional recovery status after delirium. Poor functional recovery was defined by any one of death, new long-term (permanent) institutionalization in a nursing home or functional decline (as defined below) either at discharge or at three months after discharge. If individuals were discharged to a long-term permanent institutional residence, or deceased during hospitalization, the primary outcome was collected directly from the chart. In London (Ontario), individuals can be discharged directly to a permanent residential institution (with twentyfour hour nursing care available; this occurs as a consequence of needing additional help that is unable to be provided through family and community supports), discharged to a noninstitutional home (their own or residing with someone else), discharged to a retirement home (still considered community living as twenty four hour nursing care is not necessarily available), or discharged to a temporary facility (such as a rehabilitation institute or a respite institute, with the anticipation that the individual will eventually return to non-institutional community living). If individuals were discharged home, to a retirement home, or to a temporary institution (such as a rehabilitation or respite facility), a telephone interview was conducted three months after discharge, to collect information on current
3
functional status and whether there were any repeat hospitalizations, falls or visits to the emergency department since discharge (this was also supplemented by hospital records). Telephone interviews were not done, if patients were readmitted after the index hospitalization and subsequently deceased or discharged to a long-term permanent institution. Functional status was measured during the follow-up interview, using the OARS questionnaire (Fillenbaum, 1978) on ADLs (eating, dressing, grooming, walking, transferring, bathing, toileting, and incontinence). ADLs are graded on a scale from 0–2, with 0 being most dependent. Functional decline was defined as an individual experiencing either a full decline in the ability to perform an ADL (score decreasing from 2 to 0) or a partial decline in at least two ADLs (score decreasing by 1 point in at least 2 ADLs), compared to the individual’s ability to perform ADLs prior to hospital admission (collected at the time of patient enrollment), as has been done in other studies (Marcantonio et al., 2002). Statistical analysis SAS version 9.3 was used for statistical analyses. Selected baseline characteristics of people who had a poor recovery were compared to those without a poor recovery using t-tests, or χ2 tests, or Wilcoxon rank test (for length of stay). Full details of other baseline characteristics are presented in the original study (Dasgupta and Brymer, 2014). The independent variables were the four geriatric syndromes (falls, pressure ulcers, poor oral intake, or suspected aspiration), the five care issues (refusing treatments, need for restraints, use of sitter services, use of security services or new neuroleptic use) and whether any additional diagnoses were made after the first three days of admission. Univariable and multivariable analyses (controlled for five baseline variables) were performed between the independent variables and functional recovery status (dependent variable). The five baseline variables used in the multivariable analyses are those that were found to be associated with poor functional recovery in the original study (Dasgupta and Brymer, 2014): increased age, lower baseline ADL score (higher scores indicating greater independence in performing ADLs), initial high MDAS scores (defined as the average of the first two MDAS scores or the first MDAS score if only one score was available), and the presence of either hypoxia or acute renal failure as an admitting diagnosis. Although other baseline variables were collected (including gender, presence of a neurodegenerative disorder, baseline cognitive
4
M. Dasgupta and C. Brymer
2719 paents at least 70 years of age admied during study period 825 ineligible by exclusion criteria, including transfers to ICU (9), surgery (20), and palliave care (2) 451 refused 176 discharged before being seen (Length of stay, LOS < 3 days) Deceased before caregiver could be reached (n = 2)
16 unable to be seen within 3 days of admission Excluded as re-admied later with LOS > 72 hours or CAM posive subsequently (n = 12) Previously enrolled (n = 2) Total enrolled: 1235 Not Delirious by screening (n = 880) Delirious by screening (n = 355) Unknown funconal status at ADL decline (n = 46)
Funconal recovery
follow-up me (n = 12)
Newly instuonalized (n = 136)
(n= 106)
Deceased (n = 55)
Figure 1. (Colour online) Enrolment of patientsa . a Dasgupta, M. and Brymer, C. (2014). Prognosis of delirium in hospitalized elderly: worse than we thought. Int J Geriatr Psychiatry, 29, 497–505.
ability, co-morbidity scores, duration of confusion, the presence of hypoactive symptoms, and severity of illness) these were not incorporated into the multivariable models, for this study, as they were not associated with poor functional recovery in the original study. A sensitivity analysis was done excluding individuals who had deceased to see if this changed the associations. It was postulated that deceased individuals may have a shorter length of stay and therefore be less likely to exhibit some of the independent variables assessed. Combining new functional decline with permanent institutionalization was considered reasonable as both indicate greater functional impairment (permanent institutionalization being indicated when functional needs can no longer be supported by existing community services). To assess if one or more of the independent variables were independently associated with recovery status, another multivariable analysis was conducted with forced inclusion of the five baseline variables and all the significantly associated (at the univariable level, at p < 0.05 level) independent variables, with sequential removal of variables if p > 0.05. However, the possibility of collinearity
between many of these independent variables (e.g. between poor oral intake and pressure ulcers or suspected aspiration) was considered potentially problematic. Variance inflation factors (VIF’s) were calculated to assess for degree of collinearity.
Results Of the 355 delirious patients enrolled, recovery status was known on 343 (96%) (see Figure 1 for further details of patient enrolment). At discharge, 54 (15%) had deceased and 86 (24%) were discharged to a permanent residential nursing home. Of the remaining 215 discharged to the community or a temporary rehabilitation or respite bed, recovery status at follow-up, was known in 202 (94%), at a median/mean (SD) of 103/121.4 (SD 81.7) days after discharge. At follow-up, ninety seven (48%) people had poor recovery: one deceased, 50 newly permanently institutionalized and 46 with ADL decline of at least two points. Therefore, the overall rate of poor recovery after delirium was 69% (or 237 out of 342 delirious patients with known follow-up status). The mean
Functional recovery after delirium
5
Table 1. Characteristics of included patients (delirious with follow-up recovery status known) ENTIRE SAMPLE
POOR RECOVERY
FUNCTIONAL
(N = 343)
(N = 237)
RECOVERY
(N = 106)
P-V A L U E a
.........................................................................................................................................................................................................................................................................................................................
Mean age (years) Number female Average co-morbidity score (CIRS)b Average number of admission medications History of neurodegenerative disorderc IQCODE score (SD)d ADL scoree Admission presence of hypoxia Mean initial MDAS scoresf ARF (acute renal failure as admission diagnosis) Median length of hospital stay (days)
84.5 199 (58.0%) 9.80 7.35
86.0 142 (59.9%) 9.72 7.27
81.1 57 (53.8%) 9.99 7.52
< 0.001 0.29 0.53 0.56
138
94
44
0.812
3.71 (0.51) 12.8 120 (35.1%)
3.76 (0.52) 12.6 90 (38.1%)
3.61 (0.47) 13.4 30 (28.3%)
0.006 0.015 0.078
12.7 63 (18.4%)
13.1 50 (21.1%)
11.8 13 (12.3%)
0.008 0.051
16.0
21.0
8.0
< 0.001
a P-values
calculated using t-test, Wilcoxon two-sample test (for length of stay), or χ 2 test, comparing poor recovery to functional recovery groups. b Cumulative illness rating scale (CIRS) used to calculate co-morbidity. c History of neurodegenerative disorder was classified as being present, if there was chart documentation of a past medical history of dementia (of any type), Parkinsons’ disease, normal pressure hydrocephalus, or presently being treated with a cholinesterase inhibitor. d The informant questionnaire of cognitive decline in the elderly (IQCODE) was obtained on all delirious individuals as another measure of cognition. The IQCODE score correlated with other variables, including age, having a history of a neurodegenerative disorder and baseline function or ADL score. It was dropped from the multivariable model as it did not qualify for inclusion in the original study (the P-value for IQCODE in the multivariable model exceeded 0.3). e ADL score was calculated using the OARS questionnaire (eating, dressing, grooming, walking, transferring, bathing, toileting and incontinence). ADLs are graded on a scale from 0–2, with 0 being most dependent. f Mean initial memorial delirium assessment scale (MDAS) scores, a measure of delirium severity, was calculated as the average of the first two MDAS readings after admission (as described in the original study, Dasgupta and Brymer, 2014).
age of the sample was 84.5 years of age, with a significant amount of co-morbidity (Table 1). During their hospital stay (Table 2), the aforementioned geriatric syndromes occurred in the range of 13% (pressure ulcers) to 49% (poor oral intake) of delirious people. The presence of any one of the four geriatric syndromes evaluated was associated with poor recovery in univariable and multivariable analyses controlling for baseline factors (for pressure ulcers, the multivariable analysis yielded a trend towards significance, p = 0.051). Difficult care issues were also quite prevalent occurring in 9% (use of security services) to 54% (patients refusing care or treatments) of delirious people. Of the care issues measured, refusal of care or treatments by patients was associated with poor recovery, in the univariable analysis but not in the adjusted analysis. Other care issues (including need for security or sitter services, or the use of new neuroleptic medications) were not associated with recovery status. Diagnoses made after the third day of admission were common occurring in 131 (38%) of delirious
in-patients. The three most common diagnoses made, after the third day of admission were pneumonia, congestive heart failure, and colitis (in 22, 17 and 16 individuals respectively) and 68% of these new diagnoses were made within the first 15 days of hospital stay. Individuals with poor recovery had more than a fourfold increase in the odds of having additional diagnoses made after the third day of admission, in analyses controlling for baseline variables. With the exclusion of deceased individuals, the results were not changed, except that refusing care or treatments was no longer significant at the univariable level (Table 3). The presence of any one of four geriatric syndromes, refusing care, and having additional diagnoses made after the third day of admission were entered into a multivariable model with forced inclusion of baseline variables (age, ADL dependence, MDAS scores, admitting diagnosis of acute renal failure, and hypoxia). Only aspiration and the presence of an additional diagnosis remained independently associated with poor
6
M. Dasgupta and C. Brymer
Table 2. Geriatric syndromes, other care issues and additional diagnoses in delirious individuals (with known recovery status) ADJUSTEDa
UNADJUSTED
TOTAL
POOR
FUNCTIONAL
(%) (N = 343)
RECOVERY
RECOVERY
(N = 237)
(N = 106)
NUMBER
OR (95% CI)
PVALUE
OR (95% CI)
PVALUE
.........................................................................................................................................................................................................................................................................................................................
Geriatric syndromes 45 (13.2%) Pressure ulcersb 72 (21.1%) In hospital fallsb Aspiration concernsb 89 (26.0%) Poor oral intake 169 (49.3%) Care issues Refusing care or 186 (54.2%) treatments 106 (31.0%) Physical restraint useb Observational sitter 97 (28.4%) servicesb Security useb 30 (8.8%) New neuroleptic use (in 98 (28.6%) hospital) Diagnoses made after third day of hospital Diagnoses made after 131 (38.2%) admission a Adjusted for age, ADL score, b Missing data in one person.
38 (16.0%) 58 (24.5%) 76 (32.1%) 136 (57.4%)
7 (6.7%)b 14 (13.3%) 13 (12.4%) 33 (31.1%)
2.67 (1.15, 6.20) 2.11 (1.12, 3.98) 3.34 (1.76, 6.35) 2.98 (1.83, 4.84)
0.018 0.020
