Abstract
Objectives
Delirium is known to contribute to increased rates of institutionalization and mortality.
The full extent of adverse outcomes, however, remains understudied. We aimed to systematically
assess the discharge destinations and mortality risk in delirious patients in a large
sample across all hospital services.
Design
Pragmatic prospective cohort study of consecutive admissions to a large health care
system.
Setting and Participants
A total of 27,026 consecutive adults (>18 years old) with length of stay of at least
24 hours in a tertiary care center from January 1 to December 31, 2014.
Methods
Presence of delirium determined by routine delirium screening. Clinical characteristics,
discharge destination, and mortality were collected. Calculation of odds ratios (ORs)
with logistic regression with adjustment for age, sex, and Charlson comorbidity index
(CCI).
Results
Delirium was detected in 19.7% of patients (5313 of 27,026), median age of delirious
patients was 56 years (25–75 interquartile range = 37–70). The electronic health record
(DSM-5-based) delirium algorithm correctly identified 93.3% of delirium diagnoses
made by consultation-liaison psychiatrists. Across services, the odds of delirious
patients returning home was significantly reduced [OR 0.12; confidence interval (CI)
0.10–0.13; P < .001]. Rather, these patients were transferred to acute rehabilitation (OR 4.15;
CI 3.78–4.55; P < .001) or nursing homes (OR 4.12; CI 3.45–4.93; P < .001). Delirious patients had a significantly increased adjusted mortality risk
(OR 30.0; CI 23.2–39.4; P < .001).
Conclusions and Implications
This study advances our understanding of the discharge destination across all services
in adults admitted to a large hospital system. Delirium was associated with reduced
odds of returning home, increased odds of discharge to a setting of higher dependency,
and excess mortality independent of comorbidity, age, and sex. These findings emphasize
the potentially devastating outcomes associated with delirium and highlight the need
for timely diagnosis and hospital-wide management.
Keywords
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References
- Diagnostic and Statistical Manual of Mental Disorders.5th ed. (DSM-5). American Psychiatric Association, 2013
- “Delirium Day”: a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool.BMC Med. 2016; 14: 106
- Characterizing and predicting rates of delirium across general hospital settings.Gen Hosp Psychiatry. 2017; 46: 1-6
- Frequency of delirium and subsyndromal delirium in an adult acute hospital population.Br J Psychiatry. 2014; 205: 478-485
- Delirium in an adult acute hospital population: predictors, prevalence and detection.BMJ Open. 2013; 3: e001772
- Delirium is a risk factor for institutionalization and functional decline in older hip fracture patients.J Psychosom Res. 2014; 76: 68-74
- Outcome of delirium in critically ill patients: systematic review and meta-analysis.BMJ. 2015; 350: h2538
- Delirium concisely: condition is associated with increased morbidity, mortality, and length of hospitalization.Geriatrics. 2006; 61: 18-21
- Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis.JAMA. 2010; 304: 443-451
- Delirium, frailty, and mortality: interactions in a prospective study of hospitalized older people.J Gerontol A Biol Sci Med Sci. 2018; 73: 415-418
- Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies.JAMA Psychiatry. 2017; 74: 244-251
- Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study.BMC Geriatr. 2018; 18: 24
- The interface between delirium and dementia in elderly adults.Lancet Neurol. 2015; 14: 823-832
- Acute brain failure: pathophysiology, diagnosis, management, and sequelae of delirium.Crit Care Clin. 2017; 33: 461-519
- Delirium in elderly people.Lancet. 2014; 383: 911-922
- Economic impact of poststroke delirium and associated risk factors: findings from a prospective cohort study.Stroke. 2021; 53: 3325-3334
- Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair.J Am Geriatr Soc. 2002; 50: 850-857
- Prevalence and detection of delirium in elderly emergency department patients.CMAJ. 2000; 163: 977-981
- Underdiagnosis of delirium in the elderly in acute care hospital settings: lessons not learned.Psychogeriatrics. 2018; 18: 268-275
- A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients - a cohort study.BMC Health Serv Res. 2018; 18: 550
- Declaration of Helsinki: ethical principles for medical research involving human subjects.JAMA. 2013; 310: 2191-2194
- Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.Ann Intern Med. 2007; 147: W163-W194
- The Delirium Observation Screening Scale: a screening instrument for delirium.Res Theory Nurs Pract. 2003; 17: 31-50
- Intensive Care Delirium Screening Checklist: evaluation of a new screening tool.Intensive Care Med. 2001; 27: 859-864
- ePAAC: ergebnisorientiertes PflegeAssessment AcuteCare (Version 2.0).2012
- The Neecham Confusion Scale and the Delirium Observation Screening Scale: capacity to discriminate and ease of use in clinical practice.BMC Nurs. 2007; 6: 3
- Assessment of instruments for measurement of delirium severity: a systematic review.JAMA Intern Med. 2019; 179: 231-239
- Impact of different diagnostic criteria on prognosis of delirium: a prospective study.Dement Geriatr Cogn Disord. 2004; 18: 240-244
- Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.Med Care. 2005; 43: 1130-1139
- Reality orientation for geriatric patients.Hosp Community Psychiatry. 1966; 17: 133-135
- An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers.Biometrics. 1977; 33: 363-374
- Controlling the false discovery rate: a practical and powerful approach to multiple testing.J R Statist Soc B. 1995; 57: 289-300
- R: A language and environment for statistical computing. R Foundation for Statistical Computing. Version 4.0.3. 2020
- Delirium in trauma patients: a 1-year prospective cohort study of 2026 patients.Eur J Trauma Emerg Surg. 2022; 48: 1017-1024
- Hospital use, institutionalisation and mortality associated with delirium.Age Ageing. 2010; 39: 470-475
- Delirium in the nursing home patients seen in the emergency department.J Am Geriatr Soc. 2009; 57: 889-894
- A point prevalence study of delirium in Italian nursing homes.Dement Geriatr Cogn Disord. 2018; 46: 27-41
- The association between frailty and delirium among hospitalized patients: an updated meta-analysis.J Am Med Dir Assoc. 2021; 22: 527-534
- Delirium, dementia and in-hospital mortality: the results from the Italian Delirium Day. 2016, a national multicenter study.J Gerontol A Biol Sci Med Sci. 2019; 74: 910-916
- The predisposing and precipitating risk factors for delirium in neurosurgery: a prospective cohort study of 949 patients.Acta Neurochir (Wien). 2019; 161: 1307-1315
- Mortality among older adults after a traumatic brain injury: a meta-analysis.Brain Injury. 2013; 27: 31-40
- Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients.J Neurol. 2019; 366: 2065-2075
- Long-term survival and causes of death after stroke.Stroke. 2001; 32: 2131-2136
- Trends in characteristics, mortality, and other outcomes of patients with newly diagnosed cirrhosis.JAMA Netw Open. 2019; 2: e196412
- A call to action for delirium research: meta-analysis and regression of delirium associated mortality.BMC Geriatr. 2020; 20: 325
- Which medications to avoid in people at risk of delirium: a systematic review.Age Ageing. 2011; 40: 23-29
- Does preoperative risk for delirium moderate the effects of postoperative pain and opiate use on postoperative delirium?.Am J Geriatr Psychiatry. 2013; 21: 946-956
Article info
Publication history
Published online: February 13, 2022
Footnotes
C.M.Z., T.R.S., S.K.I., and S.B. contributed equally to this article.
S.K.I.'s time was supported in part by grant no. R33AG071744 from the U.S. National Institutes of Health, United States. T.R.S. was supported by an Early.Postdoc Mobility Fellowship of the Swiss National Science Foundation, Switzerland, grant no. [P2ZHP3_195191].
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© 2022 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
