Hostname: page-component-7479d7b7d-rvbq7 Total loading time: 0 Render date: 2024-07-14T17:50:06.811Z Has data issue: false hasContentIssue false

Identification of sub-groups in acutely ill elderly patients with delirium: a cluster analysis

Published online by Cambridge University Press:  14 March 2016

Luísa Lagarto*
Affiliation:
Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-375, Coimbra, Portugal Faculty of Medicine, University of Coimbra, Coimbra, Portugal
Joaquim Cerejeira
Affiliation:
Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3000-375, Coimbra, Portugal Faculty of Medicine, University of Coimbra, Coimbra, Portugal
*
Correspondence should be addressed to: Luísa Nunes Dias Lagarto dos Santos, Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto 3000-375, Portugal. Phone: +00351 912205624. Email: luisalagarto123@gmail.com.

Abstract

Background:

Delirium is a serious neuropsychiatric syndrome affecting mainly elderly participants with acute medical diseases. The pathophysiology of delirium remains poorly understood as it involves complex dynamic interactions between a diversity of risk factors. Exploring how etiological factors interact with each other can clarify the pathophysiological mechanisms and facilitate the early identification of this syndrome. The aim of this study was to explore how different risk factors co-occur in medically ill elderly patients with delirium with cluster analysis and identify clinically meaningful sub-groups in this population.

Methods:

A cross-sectional study was developed. Ninety-nine elderly inpatients admitted to acute medical wards diagnosed with delirium during hospitalization were selected. For each patient sociodemographic characteristics, acute and chronic medical conditions, laboratory parameters, and current medication were collected.

Results:

The cluster analysis extracted three distinct subgroups of participants with delirium. Patients in cluster 1 (n = 28) had higher rates of medication with anticholinergic proprieties. Cluster 2 (n = 29) included participants with cardiac and pulmonary comorbidities associated with both chronic and acute reduction of blood flow and/or oxygenation to the brain. Cluster 3 (n = 42 patients) comprised patients with simultaneous deregulation of different organs/systems, such as electrolytic disturbances, metabolic disturbances, and acute renal failure. Known predisposing factors of delirium, such as age and pre-existing dementia, were similar between groups.

Conclusions:

The results reveal different patterns of clinical characteristics in elderly patients with delirium. This is relevant to clinical care of acute medically ill patients and suggests that different pathways are implicated in delirium pathophysiology.

Type
Research Article
Copyright
Copyright © International Psychogeriatric Association 2016 

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.)

References

American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults (2015). American geriatrics society abstracted clinical practice guideline for postoperative delirium in older adults. Journal of American Geriatric Society, 63, 142150.Google Scholar
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text rev. Washington, DC: American Psychiatric Association.Google Scholar
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association.Google Scholar
Boustani, M., Campbell, N., Munger, S., Maidment, I. and Fox, C. (2008). Impact of anticholinergics on the aging brain: a review and practical application. Aging Health, 4, 311320.Google Scholar
Brown, T. M. (2005). Basic mechanisms in the pathogenesis of delirium, and a proposed model for clinical assessment. In Stoudemire, A., Fogel, B. and Greenberg, D. (eds.), Psychiatric Care of the Medical Patient, 3rd edn. (pp. 571580). Oxford: Oxford University Press.Google Scholar
Cerejeira, J., Firmino, H., Vaz-Serra, A. and Mukaetova-Ladinska, E. B. (2010). The neuroinflammatory hypothesis of delirium. Acta Neuropathologica, 119, 737754.Google Scholar
Cerejeira, J. and Mukaetova-Ladinska, E. B. (2011). A clinical update on delirium: from early recognition to effective management. Nursing Research and Practice, 2011, 875196.Google Scholar
Charlson, M. E., Pompei, P., Ales, K. L. and MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases, 40, 373383.Google Scholar
Eeles, E. M., White, S. V., O'Mahony, S. M., Bayer, A. J. and Hubbard, R. E. (2012). The impact of frailtyand delirium on mortality in older inpatients. Age Ageing, 41, 412416.Google Scholar
Fong, T. G., Tulebaev, S. R. and Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology, 5, 210220.CrossRefGoogle ScholarPubMed
Foy, A., O'Connell, D., Henry, D., Kelly, J., Cocking, S. and Halliday, J. (1995). Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients. The journals of gerontology. Series A, Biological Sciences and Medical Sciences, 50, M99M106.Google Scholar
Grover, S., Kumar, V. and Chakrabarti, S. (2011). Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium. Journal of Psychosomatic Research, 71, 277281.Google Scholar
Guy, W. (ed.) (1976). Clinical global impressions. In ECDEU Assessment Manual for Psychopharmacology. Revised DHEW Pub. (ADM). (pp. 218222). Rockville, MD: National Institute for Mental Health.Google Scholar
Hshieh, T. T., Fong, T. G., Marcantonio, E. R. and Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. Journal Gerontology: A Biological Science Medical Sciences, 63, 764772.Google Scholar
Inouye, S. K. and Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. Journal of the American Medical Association, 275, 852857.Google Scholar
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P. and Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941948.Google Scholar
Inouye, S. K., Westendorp, R. G. and Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383, 911922.Google Scholar
Jorm, A. (1994). A short form of the informant questionnaire on cognitive decline in the elderly (IQCODE): development and cross-validation. Psychological Medicine, 24, 145153.Google Scholar
Katz, S. (1983). Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. Journal of American Geriatric Society, 31, 721727. Review.Google Scholar
Kenna, H. A., Poon, A. W., de los Angeles, C. P. and Koran, L. M. (2011). Psychiatric complications of treatment with corticosteroids: review with case report. Psychiatry and Clinical Neurosciences, 65, 549560.Google Scholar
Margiotta, A., Bianchetti, A., Ranieri, P. and Trabucchi, M. (2006). Clinical characteristics and risk factors of delirium in demented and not demented elderly medical inpatients. Journal of Nutrition Health and Aging, 10, 535539.Google Scholar
Martinez, F., Tobar, C. and Hill, N. (2015). Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing, 44, 196204.Google Scholar
Peters, R., Burch, L., Warner, J., Beckett, N., Poulter, R. and Bulpitt, C. (2008). Haemoglobin, anaemia, dementia and cognitive decline in the elderly, a systematic review. BMC Geriatrics, 8, 18.Google Scholar
Pieralli, F., Vannucchi, V., Mancini, A., Grazzini, M., Paolacci, G. and Morettini, A. (2014). Delirium is a predictor of in-hospital mortality in elderly patients with community acquired pneumonia. Internal and Emergency Medicine, 9, 195200.CrossRefGoogle ScholarPubMed
Pires, P. W., Dams Ramos, C. M., Matin, N. and Dorrance, A. M. (2013). The effects of hypertension on the cerebral circulation. American Journal of Physiology: Heart and Circulatory Physiology, 304, H1598H1614.Google Scholar
Pisani, M. A., Murphy, T. E., Van Ness, P. H., Araujo, K. L. and Inouye, S. K. (2007). Characteristics associated with delirium in older patients in a medical intensive care unit. Archives of Internal Medicine, 167, 16291634.Google Scholar
Plaschke, K., Kopitz, J., Mattern, J., Martin, E. and Teschendorf, P. (2010). Increased cortisol levels and anticholinergic activity in cognitively unimpaired patients. Journal of Neuropsychiatry Clinical Neuroscience, 22, 433441.CrossRefGoogle ScholarPubMed
Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B. and McDowell, I. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Ascociation Journal, 173, 489495.Google Scholar
Román, G. C. and Kalaria, R. N. (2006). Vascular determinants of cholinergic deficits in Alzheimer disease and vascular dementia. Neurobiology of Aging, 27, 17691785.Google Scholar
Siddiqi, N., Stockdale, R., Britton, A. M. and Holmes, J. (2007). Interventions for preventing delirium in hospitalised patients. Cochrane Database Systematic Reviews, 18, CD005563.Google Scholar
Smith, P. J., Rivelli, S. K., Waters, A. M., Hoyle, A., Durheim, M. T. and Reynolds, J. M. (2015). Delirium affects length of hospital stay after lung transplantation. Journal of Critical Care, 30, 126129.Google Scholar
Teale, E. and Young, J. (2015). Multicomponent delirium prevention: not as effective as NICE suggest? Age Ageing, 44, 915917.Google Scholar
Trzepacz, P. T. (2000). Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Seminars Clinical Neuropsychiatry, 5, 132148.Google Scholar
Udompanich, S., Lip, G. Y., Apostolakis, S. and Lane, D. A. (2013). Atrial fibrillation as a risk factor for cognitive impairment: a semi-systematic review. Quarterly Journal of Medicine, 106, 795802.Google Scholar
Verbalis, J. and Goldsmith, S. (2013). Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. American Journal of Medicine, 126 (10 Suppl. 1), S1S42.CrossRefGoogle ScholarPubMed
Vrolijk, M. F., Opperhuizen, A., Jansen, E. H., Bast, A. and Haenen, G. R. (2015). Anticholinergic accumulation: a slumbering interaction between drugs and food supplements. Basic & Clinical Pharmacology & Toxicology, 117, 427432.CrossRefGoogle ScholarPubMed
Ward, J. H. Jr. (1963). Hierarchical grouping to optimize an objective function. Journal of the American Statistical Association, 58, 236244.Google Scholar
Wood, S. M., Meyers, C. A., Faderl, S., Kantarjian, H. M., Pierce, S. A. and Garcia-Manero, G. (2011). Association of anemia and cognitive dysfunction in patients with acute myelogenous leukemia and myelodysplastic syndrome. American Journal of Hematology, 86, 950952.Google Scholar
World Medical Association (2002). World medical association declaration of helsinki: ethical principles for medical research involving human subjects. Journal Postgraduate Medicine, 48, 206208.Google Scholar