Delirium and Clusters of Older Patients Affected by Multimorbidity in Acute Hospitals

Published:November 16, 2021DOI:



      Delirium is commonly seen in older adults with multimorbidity, during a hospitalization, resulting from the interplay between predisposing factors such as advanced age, frailty, and dementia, and a series of precipitating factors. The association between delirium and specific multimorbidity is largely unexplored so far although of potential key relevance for targeted interventions. The aim of the study was to check for a potential association of multimorbidity with delirium in a large cohort of older patients hospitalized for an acute medical or surgical condition.


      This is a cross-sectional study nested in the 2017 Delirium Day project.

      Setting and Participants

      The study includes 1829 hospitalized patients (age: 81.8, SD: 5.5). Of them, 419 (22.9%) had delirium.


      Sociodemographic and medical history were collected. The 4AT was used to assess the presence of delirium. The Charlson Comorbidity index was used to assess multimorbidity.


      The results identified neurosensorial multimorbidity as the most prevalent, including patients with dementia, cerebrovascular diseases, and sensory impairments. In light of the highest co-occurrence of 3 neurosensorial chronic conditions, we could hypothesize that a baseline altered brain functional and neural connectivity might determine the vulnerability signature for incipient overall system disruption in presence of acute insults.

      Conclusions and Implications

      Eventually, our findings moved a step forward in supporting the key importance of routine screening for sensory impairments and cognitive status of older patients for the highest risk of in-hospital delirium. In fact, preventive interventions could be particularly relevant and effective in preventing delirium in such vulnerable populations and might help refining this early diagnosis.


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        • Marengoni A.
        • Rizzuto D.
        • Wang H.X.
        • et al.
        Patterns of chronic multimorbidity in the elderly population.
        J Am Geriatr Soc. 2009; 57: 225-230
        • Aubert C.E.
        • Schnipper J.L.
        • Fankhauser N.
        • et al.
        Patterns of multimorbidity associated with 30-day readmission: a multinational study.
        BMC Public Health. 2019; 19: 738
        • Marengoni A.
        • Angleman S.
        • Melis R.
        • et al.
        Aging with multimorbidity: A systematic review of the literature.
        Ageing Res Rev. 2011; 10: 430-439
        • Inouye S.K.
        • Westendorp R.G.
        • Saczynski J.S.
        Delirium in elderly people.
        Lancet. 2014; 383: 911-922
        • Prados-Torres A.
        • Calderon-Larranaga A.
        • Hancco-Saavedra J.
        • et al.
        Multimorbidity patterns: A systematic review.
        Clin Epidemiol. 2014; 67: 254-266
        • Morandi A.
        • Di Santo S.G.
        • Zambon A.
        • et al.
        Delirium, dementia and in-hospital mortality: Results from the Italian delirium Day 2016, a national multicenter study.
        J Gerontol A Biol Sci Med Sci. 2019; 74: 910-916
        • Morandi A.
        • Davis D.
        • Fick D.M.
        • et al.
        Delirium susperimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients.
        J Am Med Dir Assoc. 2014; 15: 349-354
        • Davis D.H.
        • Muniz-Terrera G.
        • Keage H.A.
        • et al.
        • Epidemiological Clinicopathological Studies in Europe (EClipSE) Collaborative Members
        Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies.
        JAMA Psychiatry. 2017; 74: 244-251
        • Kalimisetty S.
        • Askar W.
        • Fay B.
        • Khan A.
        Models for predicting incident delirium in hospitalized older adults: A systematic review.
        J Patient Cent Res Rev. 2017; 4: 69-77
        • Savaskan E.
        Delirium and multimorbidity in the elderly.
        Braxis (Bern 1994). 2012; 12: 1633-1636
        • Lagarto L.
        • Cerejeira J.
        Identification of sub-groups in acutely ill elderly patients with delirium: A cluster analysis.
        Int Psychogeriatr. 2016; 28: 1283-1292
        • Bellelli G.
        • Morandi A.
        • Di Santo S.G.
        • et al.
        Delirium day: A nationwide point prevalence study of delirium in hospitalized patients using an easy standardized diagnostic tool.
        BMC Med. 2016; 14: 106
        • Aloisi G.
        • Marengoni A.
        • Morandi A.
        • et al.
        Drug prescription and delirium in older inpatients: results from the nationwide multicenter Italian delirium day 2015–2016.
        J Clin Psychiatry. 2019; 80: 18m12430
        • Bellelli G.
        • Morandi A.
        • Davis D.H.
        • et al.
        Validation of the 4ATR, a new instrument for rapid delirium screening: a study in 234 hospitalized older people.
        Age Ageing. 2014; 43: 496-502
        • Mac Lullich A.M.J.
        • Shenkin S.D.
        • Goodacre S.
        • et al.
        The 4 ‘A’s test for detecting delirium in acute medical patients: A diagnostic accuracy study.
        Health Technol Assess. 2019; 23: 1-194
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Calderon-Larranaga A.
        • Vetrano D.L.
        • Onder G.
        • et al.
        Assessing and measuring chronic multimorbidity in the older population: A proposal for its operationalization.
        J Gerontol A Biol Sci Med Sci. 2017; 72: 1417-1423
        • Lagergren M.
        • Fratiglioni L.
        • Hallberg I.R.
        • et al.
        A longitudinal study integrating population, care and social services data. The Swedish National study on Aging and Care (SNAC).
        Aging Clin Exp Res. 2004; 16: 158-168
        • Wilson J.E.
        • Mart M.F.
        • Cunningham C.
        • et al.
        Nat Rev Dis Primers. 2020; 6: 90
        • David D.H.J.
        • Skelly D.T.
        • Murray C.
        Worsening cognitive impairment and neurodegenerative pathology progressively increase risk for delirium.
        Am J Geriatr Psychiatry. 2015; 23: 403-415
        • Wilson J.E.
        • Mart M.F.
        • Cunningham C.
        • et al.
        Nat Rev Dis Primers. 2020; 6: 90
        • Van den Boogaard M.
        • Kox M.
        • Quinn K.L.
        • et al.
        Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and noninflamed patients.
        Crit Care. 2011; 15: R297
        • Fong T.
        • Davis D.
        • Growdon M.E.
        • et al.
        The interface between delirium and dementia in elderly adults.
        Lancet Neurol. 2015; 14: 823-832
        • Ciacciarelli A.
        • Sette G.
        • Giubilei F.
        • et al.
        Chronic cerebral hypoperfusion: An undefined, relevant entity.
        J Clin Neurosci. 2020; 73: 8-12
        • Wong S.M.
        • Jansen J.F.A.
        • Zhang C.E.
        • et al.
        Blood brain barrier impairment and hypoperfusion are linked in cerebral small vessel disease.
        Neurology. 2019; 92: e1669-e1677
        • Effendi-Tenang I.
        • Tan M.P.
        • Khallidin N.
        • et al.
        Vision impairment and cognitive function among urban-dwelling Malaysians aged 55 years and over from the Malaysian Elders Longitudinal Research (MELoR) study.
        Arch Gerontol Geriatr. 2020; 90: 104165
        • Zheng D.D.
        • Swenor B.K.
        • Christ S.L.
        • et al.
        Longitudinal associations between visual impairment and cognitive functioning: The Salisbury Eye Evaluation Study.
        JAMA Ophthalmol. 2018; 136: 989-995
        • Rosemann S.
        • Smith D.
        • Dewenter M.
        • et al.
        Age-related hearing loss influences functional connectivity of auditory cortex for the mc Gurk illusion.
        Cortex. 2020; 129: 266-280
        • Morandi A.
        • Inzitari M.
        • Udina C.
        • et al.
        Visual and hearing impairment are associated with delirium in hospitalized patients: Results of a multisite prevalence study.
        J Am Med Dir Assoc. 2021; 22: 1162-1167.e3
        • National Clinical Guideline Centre (UK)
        Delirium diagnosis, prevention and management. NICE clinical guidelines, No. 103. Delirium: Diagnosis, Prevention and Management.
        Royal College of Physicians (UK), 2010