Hostname: page-component-7d684dbfc8-8ckrc Total loading time: 0 Render date: 2023-09-25T01:26:03.070Z Has data issue: false Feature Flags: { "corePageComponentGetUserInfoFromSharedSession": true, "coreDisableEcommerce": false, "coreDisableSocialShare": false, "coreDisableEcommerceForArticlePurchase": false, "coreDisableEcommerceForBookPurchase": false, "coreDisableEcommerceForElementPurchase": false, "coreUseNewShare": true, "useRatesEcommerce": true } hasContentIssue false
  • English
  • Français

Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients

Published online by Cambridge University Press:  19 July 2018

Jamie Cirbus ,
Alasdair M. J. MacLullich ,
Christopher Noel ,
E. Wesley Ely ,
Rameela Chandrasekhar  and
Jin H. Han
Jamie Cirbus
Affiliation:
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Alasdair M. J. MacLullich
Affiliation:
Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Edinburgh, UK Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
Christopher Noel
Affiliation:
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
E. Wesley Ely
Affiliation:
Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee, USA Center for Quality Aging, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Rameela Chandrasekhar
Affiliation:
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Jin H. Han*
Affiliation:
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee, USA Center for Quality Aging, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
*
Correspondence should be addressed to: Jin H. Han, MD, Vanderbilt University Medical Center, Department of Emergency Medicine, 703 Oxford House, Nashville, Tennessee 37232-4700, USA. Phone: +615-936-0087; Fax: +615-936-1316. Email: Jin.h.han@vanderbilt.edu.
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

Delirium is heterogeneous and can vary by etiology.

Objectives:

We sought to determine how delirium subtyped by etiology affected six-month function and cognition.

Design:

Prospective cohort study.

Setting:

Tertiary care, academic medical center.

Participants:

A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED).

Measurements:

The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition.

Results:

In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = −2.9 points, 95%CI: −0.3 to −5.6) and organ dysfunction (β coefficient = −4.3 points, 95%CI: −7.2 to −1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20).

Conclusions:

Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.

Keywords

deliriumetiologysubtypeslong-term functionlong-term cognition
Type
Original Research Article
Information
International Psychogeriatrics , Volume 31 , Issue 2: Issue Theme: Positive Psychiatry II , February 2019 , pp. 267 - 276
Copyright
Copyright © International Psychogeriatric Association 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

This abstract was presented at the Society of Academic Emergency Medicine 2017 Annual Meeting at Orlando, FL.

References

Abraha, I. et al. (2015). Efficacy of non-pharmacological interventions to prevent and treat delirium in older patients: a systematic overview. The senator project ONTOP series. PLoS One, 10, e0123090.10.1371/journal.pone.0123090CrossRefGoogle ScholarPubMed
AGS/NIA Delirium Conference Writing Group, P. C. and Faculty (2015). The American geriatrics society/national institute on aging bedside-to-bench conference: research agenda on delirium in older adults. Journal of the American Geriatrics Society, 63, 843–852.10.1111/jgs.13406CrossRefGoogle Scholar
American Psychiatric Association and American Psychiatric Association. DSM-5 Task Force. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association.Google Scholar
Andrew, M. K., Freter, S. H. and Rockwood, K. (2005). Incomplete functional recovery after delirium in elderly people: a prospective cohort study. BMC Geriatrics, 5, 5.10.1186/1471-2318-5-5CrossRefGoogle ScholarPubMed
Cunningham, C. (2011). Systemic inflammation and delirium: important co-factors in the progression of dementia. Biochemical Society Transactions, 39, 945–953.10.1042/BST0390945CrossRefGoogle Scholar
Davis, D. H. et al. (2017). Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies. JAMA Psychiatry, 74, 244–251.10.1001/jamapsychiatry.2016.3423CrossRefGoogle ScholarPubMed
Ely, E. W. et al. (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA, 286, 2703–2710.10.1001/jama.286.21.2703CrossRefGoogle Scholar
Francis, J., Martin, D. and Kapoor, W. N. (1990). A prospective study of delirium in hospitalized elderly. JAMA, 263, 1097–1101.10.1001/jama.1990.03440080075027CrossRefGoogle ScholarPubMed
Gross, A. L. et al. (2012). Delirium and long-term cognitive trajectory among persons with dementia. Archives of Internal Medicine, 172, 1–8.10.1001/archinternmed.2012.3203CrossRefGoogle ScholarPubMed
Grossmann, F. F., Hasemann, W., Graber, A., Bingisser, R., Kressig, R. W. and Nickel, C. H. (2014). Screening, detection and management of delirium in the emergency department - a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified confusion assessment method for the emergency department (mCAM-ED). Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22, 19.10.1186/1757-7241-22-19CrossRefGoogle Scholar
Han, J. H. et al. (2009). Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Academic Emergency Medicine, 16, 193–200.10.1111/j.1553-2712.2008.00339.xCrossRefGoogle ScholarPubMed
Han, J. H. et al. (2010). Delirium in the emergency department: an independent predictor of death within 6 months. Annals of Emergency Medicine, 56, 244–252.10.1016/j.annemergmed.2010.03.003CrossRefGoogle ScholarPubMed
Han, J. H. et al. (2011). Delirium in older emergency department patients is an independent predictor of hospital length of stay. Academic Emergency Medicine, 18, 451–457.10.1111/j.1553-2712.2011.01065.xCrossRefGoogle ScholarPubMed
Han, J. H. et al. (2013). A quick and easy delirium assessment for non-physician research personnel. Academic Emergency Medicine, 20, S125–126.Google Scholar
Han, J. H. et al. (2014). Validation of the confusion assessment method for the intensive care unit in older emergency department patients. Academic Emergency Medicine, 21, 180–187.10.1111/acem.12309CrossRefGoogle ScholarPubMed
Han, J. H. et al. (2017a). Exploring delirium's heterogeneity: association between arousal subtypes at initial presentation and 6-month mortality in older emergency department patients. The American Journal of Geriatric Psychiatry, 25, 233–242.10.1016/j.jagp.2016.05.016CrossRefGoogle ScholarPubMed
Han, J. H. et al. (2017b). Delirium in the emergency department and its extension into hospitalization (DELINEATE) study: effect on 6-month function and cognition. Journal of the American Geriatrics Society, 65, 1333–1338.10.1111/jgs.14824CrossRefGoogle ScholarPubMed
Han, J. H., Wilson, A., Graves, A. J., Shintani, A., Schnelle, J. F. and Ely, E. W. (2016). A quick and easy delirium assessment for nonphysician research personnel. American Journal of Emergency Medicine, 34, 1031–1036.10.1016/j.ajem.2016.02.069CrossRefGoogle ScholarPubMed
Inouye, S. K. et al. (2014). The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Annals of Internal Medicine, 160, 526–533.10.7326/M13-1927CrossRefGoogle ScholarPubMed
Inouye, S. K. et al. (2016). The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimer's & Dementia, 12, 766–775.10.1016/j.jalz.2016.03.005CrossRefGoogle ScholarPubMed
Jackson, T. A., Wilson, D., Richardson, S. and Lord, J. M. (2016). Predicting outcome in older hospital patients with delirium: a systematic literature review. International Journal of Geriatric Psychiatry, 31, 392–399.10.1002/gps.4344CrossRefGoogle ScholarPubMed
Jorm, A. F. (1994). A short form of the informant questionnaire on cognitive decline in the elderly (IQCODE): development and cross-validation. Psychological Medicine, 24, 145–153.10.1017/S003329170002691XCrossRefGoogle Scholar
Kelly, K. G., Zisselman, M., Cutillo-Schmitter, T., Reichard, R., Payne, D. and Denman, S. J. (2001). Severity and course of delirium in medically hospitalized nursing facility residents. The American Journal of Geriatric Psychiatry, 9, 72–77.10.1097/00019442-200102000-00011CrossRefGoogle ScholarPubMed
Kiely, D. K., Jones, R. N., Bergmann, M. A. and Marcantonio, E. R. (2007). Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients. The Journals of Gerontology. Series A, Biological Sciences and Medical Science, 62, 174–179.10.1093/gerona/62.2.174CrossRefGoogle ScholarPubMed
Kim, S. Y. et al. (2015). Differential associations between delirium and mortality according to delirium subtype and age: a prospective cohort study. Psychosomatic Medicine, 77, 903–910.10.1097/PSY.0000000000000239CrossRefGoogle ScholarPubMed
Knaus, W. A., Draper, E. A., Wagner, D. P. and Zimmerman, J. E. (1985). APACHE II: a severity of disease classification system. Critical Care Medicine, 13, 818–829.10.1097/00003246-198510000-00009CrossRefGoogle ScholarPubMed
Laurila, J. V., Laakkonen, M. L., Tilvis, R. S. and Pitkala, K. H. (2008). Predisposing and precipitating factors for delirium in a frail geriatric population. Journal of Psychosomatic Research, 65, 249–254.10.1016/j.jpsychores.2008.05.026CrossRefGoogle Scholar
McCusker, J., Bellavance, F., Cardin, S. and Belzile, E. (1999). Validity of an activities of daily living questionnaire among older patients in the emergency department. Journal of Clinical Epidemiology, 52, 1023–1030.10.1016/S0895-4356(99)00084-0CrossRefGoogle ScholarPubMed
Meagher, D. J. et al. (2008). Motor symptoms in 100 patients with delirium versus control subjects: comparison of subtyping methods. Psychosomatics, 49, 300–308.10.1176/appi.psy.49.4.300CrossRefGoogle ScholarPubMed
Meagher, D. J., Leonard, M., Donnelly, S., Conroy, M., Adamis, D. and Trzepacz, P. T. (2011). A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis. Journal of Psychosomatic Research, 71, 395–403.10.1016/j.jpsychores.2011.06.001CrossRefGoogle ScholarPubMed
Murray, S. B., Bates, D. W., Ngo, L., Ufberg, J. W. and Shapiro, N. I. (2006). Charlson Index is associated with one-year mortality in emergency department patients with suspected infection. Academic Emergency Medicine, 13, 530–536.10.1197/j.aem.2005.11.084CrossRefGoogle ScholarPubMed
Pitkala, K. H., Laurila, J. V., Strandberg, T. E. and Tilvis, R. S. (2005). Prognostic significance of delirium in frail older people. Dementia and Geriatric Cognitive Disorders, 19, 158–163.10.1159/000082888CrossRefGoogle ScholarPubMed
Serrano, S., Domingo, J., Rodriguez-Garcia, E., Castro, M. D. and Ser, del T. (2007). Frequency of cognitive impairment without dementia in patients with stroke: a two-year follow-up study. Stroke, 38, 105–110.10.1161/01.STR.0000251804.13102.c0CrossRefGoogle ScholarPubMed
Trzepacz, P. T., Maldonado, J. R., Kean, J. et al. (2009). The Delirium Rating Scale Revised-98 (DRS-R98) Administration Manual. A Guide to Increase Understanding of How to Solicit Delirium Symptoms to Administer the DRS-R98. Indianapolis, IN: Trzepacz.Google Scholar
Vasunilashorn, S. M. et al. (2016a). Derivation and validation of a severity scoring method for the 3-minute diagnostic interview for confusion assessment method–defined delirium. Journal of the American Geriatrics Society, 64, 1684–1689.10.1111/jgs.14234CrossRefGoogle ScholarPubMed
Vasunilashorn, S. M. et al. (2016b). Quantifying the severity of a delirium episode throughout hospitalization: the combined importance of intensity and duration. Journal of General Internal Medicine, 31, 1164–1171.10.1007/s11606-016-3671-9CrossRefGoogle ScholarPubMed
Vasunilashorn, S. M. et al. (2017). High C-Reactive protein predicts delirium incidence, duration, and feature severity after major noncardiac surgery. Journal of the American Geriatrics Society, 65, e109–e116.10.1111/jgs.14913CrossRefGoogle ScholarPubMed
Vida, S., Galbaud du Fort, G., Kakuma, R., Arsenault, L., Platt, R. W. and Wolfson, C. M. (2006). An 18-month prospective cohort study of functional outcome of delirium in elderly patients: activities of daily living. International Psychogeriatrics, 18, 681–700.10.1017/S1041610206003310CrossRefGoogle ScholarPubMed
Witlox, J., Eurelings, L. S., de Jonghe, J. F., Kalisvaart, K. J., Eikelenboom, P. and van Gool, W. A. (2010). Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA, 304, 443–451.10.1001/jama.2010.1013CrossRefGoogle ScholarPubMed
Supplementary material: PDF

Cirbus et al. supplementary material

Cirbus et al. supplementary material 1

Download Cirbus et al. supplementary material(PDF)
PDF 270 KB