ContextIn the intensive care unit (ICU), delirium is a common yet underdiagnosed
form of organ dysfunction, and its contribution to patient outcomes is unclear.ObjectiveTo determine if delirium is an independent predictor of clinical outcomes,
including 6-month mortality and length of stay among ICU patients receiving
mechanical ventilation.Design, Setting, and ParticipantsProspective cohort study enrolling 275 consecutive mechanically ventilated
patients admitted to adult medical and coronary ICUs of a US university-based
medical center between February 2000 and May 2001. Patients were followed
up for development of delirium over 2158 ICU days using the Confusion Assessment
Method for the ICU and the Richmond Agitation-Sedation Scale.Main Outcome MeasuresPrimary outcomes included 6-month mortality, overall hospital length
of stay, and length of stay in the post-ICU period. Secondary outcomes were
ventilator-free days and cognitive impairment at hospital discharge.ResultsOf 275 patients, 51 (18.5%) had persistent coma and died in the hospital.
Among the remaining 224 patients, 183 (81.7%) developed delirium at some point
during the ICU stay. Baseline demographics including age, comorbidity scores,
dementia scores, activities of daily living, severity of illness, and admission
diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month
mortality rates (34% vs 15%, P = .03) and spent 10
days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age,
severity of illness, comorbid conditions, coma, and use of sedatives or analgesic
medications), delirium was independently associated with higher 6-month mortality
(adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P = .008), and longer hospital stay (adjusted HR, 2.0;
95% CI, 1.4-3.0; P<.001). Delirium in the ICU
was also independently associated with a longer post-ICU stay (adjusted HR,
1.6; 95% CI, 1.2-2.3; P = .009), fewer median days
alive and without mechanical ventilation (19 [interquartile range, 4-23] vs
24 [19-26]; adjusted P = .03), and a higher incidence
of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P = .002).ConclusionDelirium was an independent predictor of higher 6-month mortality and
longer hospital stay even after adjusting for relevant covariates including
coma, sedatives, and analgesics in patients receiving mechanical ventilation.

https://jamanetwork.com/journals/jama/articlepdf/198503/JCE30038.pdf

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

Background Nurses play a key role in recognition of delirium, yet delirium is often unrecognized by nurses. Our goals were to compare nurse ratings for delirium using the Confusion Assessment Method based on routine clinical observations with researcher ratings based on cognitive testing and to identify factors associated with underrecognition by nurses. Methods In a prospective study, 797 patients 70 years and older underwent 2721 paired delirium ratings by nurses and researchers. Patient-related factors associated with underrecognition of delirium by nurses were examined. Results Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in only 19% of observations and 31% of patients compared with researchers. Sensitivities of nurses' ratings for delirium and its key features were generally low (15%-31%); however, specificities were high (91%-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: hypoactive delirium (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses increased with the number of risk factors present from 2% (0 risk factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P trend Conclusions Nurses often missed delirium when present, but rarely identified delirium when absent. Recognition of delirium can be enhanced with education of nurses in delirium features, cognitive assessment, and factors associated with poor recognition.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/649403/ioi00931.pdf

Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings.

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

Delirium Superimposed on Dementia: A Systematic Review

https://www.amjmed.com/article/0002-9343(94)90011-6/pdf

The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients

OBJECTIVE: Delirium is frequent in elderly hospitalized patients. Many studies have examined its risk factors, but results have been quite variable. Thus, the goal of this study is to identify through systematic literature review the risk factors associated with the development of delirium in hospitalized geriatric patients.

/pdf/delirium-risk-factors-in-elderly-hospitalized-patients-4bn1aspv1u.pdf

Delirium risk factors in elderly hospitalized patients

tudy Objective
To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture.

Design
The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies.

Setting
Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital.

Subjects
Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively).

Measurements and Main Results
All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients.

Conclusions
ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.

Gustav Bucht

Papers

Underdiagnosis and Poor Documentation of Acute Confusional States in Elderly Hip Fracture Patients