Delirium is associated with low levels of upright activity in geriatric inpatients-results from a prospective observational study.

BACKGROUND: Delirium is common in geriatric inpatients and associated with poor outcomes. Hospitalization is associated with low levels of physical activity. Motor symptoms are common in delirium, but how delirium affects physical activity remains unknown. AIMS: To investigate differences in physical activity between geriatric inpatients with and without delirium. METHODS: We included acutely admitted patients ≥ 75 years in a prospective observational study at a medical geriatric ward at a Norwegian University Hospital. Delirium was diagnosed according to the DSM-5 criteria. Physical activity was measured by an accelerometer-based device worn on the right thigh. The main outcome was time in upright position (upright time) per 24 h (00.00 to 23.59) on the first day of hospitalization with verified delirium status. Group differences were analysed using t test. RESULTS: We included 237 patients, mean age 86.1 years (Standard Deviation (SD) 5.1), and 73 patients (30.8%) had delirium. Mean upright time day 1 for the entire group was 92.2 min (SD 84.3), with 50.9 min (SD 50.7) in the delirium group and 110.6 min (SD 89.7) in the no-delirium group, mean difference 59.7 minutes, 95% Confidence Interval 41.6 to 77.8, p value < 0.001. DISCUSSION: Low levels of physical activity in patients with delirium raise the question if immobilization may contribute to poor outcomes in delirium. Future studies should investigate if mobilization interventions could improve outcomes of delirium. CONCLUSIONS: In this sample of geriatric inpatients, the group with delirium had lower levels of physical activity than the group without delirium.

The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity.

PURPOSE: Delirium is common and associated with poor outcomes, partly due to underdetection. We investigated if the delirium screening tool 4 A's test (4AT) score predicts 1 year mortality and explored the sensitivity and specificity of the 4AT when applied as part of a clinical routine. METHODS: Secondary analyses of a prospective study of 228 patients acutely admitted to a Medical Geriatric Ward. Physicians without formal training conducted the index test (the 4AT); a predefined cut-off ≥ 4 suggested delirium. Reference standard was delirium diagnosed by two geriatricians using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). We calculated hazard ratios (HR) using Cox regression based on the groups 4AT = 0, 1-3, 4-7 and ≥ 8, first unadjusted, then adjusted for the covariates age, comorbidity, and personal activities of daily living. We calculated sensitivity, specificity, and the area under the receiver operating curve (AUC). RESULTS: Mean age of patients was 86.6 years, 139 (61.0%) were female, 78 (34.2%) had DSM-5 delirium; of these, 56 had 4AT-delirium. 1 year mortality was 27.6% (63 patients). Compared to 4AT score 0, the group 4AT ≥ 8 had increased 1 year mortality (HR 2.86, 95% confidence interval 1.28-6.37, p = 0.010). The effect was reduced in multiadjusted analyses (HR 1.69, 95% confidence interval 0.70-4.07, p = 0.24). Sensitivity, specificity, and AUC were 0.72, 0.84, and 0.88, respectively. CONCLUSIONS: 4AT ≥ 8 indicates increased mortality, but the effect was reduced in multiadjusted analyses. 4AT had acceptable sensitivity and specificity when applied as a clinical routine.

Delirium motor subtypes and prognosis in hospitalized geriatric patients - A prospective observational study.

OBJECTIVE: Delirium is common and associated with poor outcomes. Hypoactive motor subtype may predict worse outcome than no-subtype, hyperactive and mixed delirium, but uncertainty remains due to heterogeneity of results and subtyping tools. Other prognostic aspects across delirium motor subtypes are understudied. We investigated differences in one-year mortality, length of stay and institutionalization at discharge and after one year, across delirium motor subtypes in geriatric patients. METHODS: We conducted a prospective observational study, included 311 patients ≥75 years acutely admitted to a geriatric ward, diagnosed delirium using Diagnostic and Statistical Manual of Mental Disorder (5th ed.) criteria and used the Delirium Motor Subtype Scale for subtyping. Differences in mortality across subtypes were investigated using Cox proportional-hazard regression analyses, unadjusted and adjusted for age, comorbidity and delirium severity. We investigated differences in length of stay and institutionalization using the Kruskal-Wallis test and Pearson's chi-squared test with subsequent Hommel-adjusted pairwise comparisons. RESULTS: Ninety-three patients (30%) had delirium; 12 (13%) had no-subtype, 27 (29%) hyperactive, 30 (32%) hypoactive and 24 (26%) mixed delirium. There were no group differences regarding mortality (p = .61) or length of stay (p = .32). Analyses indicated group differences regarding discharge to an institution (p = .028), but pairwise comparisons showed no differences (smallest p = .071, no-subtype 45% vs hypoactive 85%). There were no group differences in institutionalization after one year (p = .26). CONCLUSION: There were no significant differences in one-year mortality, length of stay or institutionalization across delirium motor subtypes in geriatric patients, although the study may indicate better prognosis in the no-subtype group.

Delirium and cognitive impairment among older patients in Norwegian emergency departments. / Delirium og kognitiv svikt blant eldre i norske akuttmottak.

BACKGROUND: Delirium is common and underdiagnosed among patients in hospitals, and is associated with complications, increased mortality, onset of dementia and need for nursing home care. Cognitive impairment from other causes is also common among hospitalised elderly people and is a key risk factor for delirium. Since no relevant prevalence studies have been undertaken in Norwegian hospitals, we investigated the prevalence of delirium among elderly patients in Norwegian emergency departments on World Delirium Awareness Day, 14 March 2018. MATERIAL AND METHOD: We included patients ≥ 75 years who arrived in ten Norwegian emergency departments between 08:00 and 22:00 on that day. We identified delirium and cognitive impairment using the '4AT' screening tool and registered the patients' age and gender and the hospital and department to which they were admitted (internal medicine, surgery, orthopaedics, 'other'). RESULTS: Of 118 included patients, 20 (17 per cent) showed signs of delirium and 36 (30 per cent) showed signs of other forms of cognitive impairment. All hospitals and all categories of departments received patients with signs of delirium and cognitive impairment. INTERPRETATION: Delirium and other forms of cognitive impairment are both common among elderly patients in Norwegian emergency departments. Our results indicate that all hospital departments who treat elderly patients frequently observe these issues. All departments should therefore have routines to identify and deal with patients who suffer from delirium and cognitive impairment.

Motor activity across delirium motor subtypes in geriatric patients assessed using body-worn sensors: a Norwegian cross-sectional study.

OBJECTIVES: It remains unclear if geriatric patients with different delirium motor subtypes express different levels of motor activity. Thus, we used two accelerometer-based devices to simultaneously measure upright activity and wrist activity across delirium motor subtypes in geriatric patients. DESIGN: Cross-sectional study. SETTINGS: Geriatric ward in a university hospital in Norway. PARTICIPANTS: Sixty acutely admitted patients, ≥75 years, with DSM-5-delirium. OUTCOME MEASURES: Upright activity measured as upright time (minutes) and sit-to-stand transitions (numbers), total wrist activity (counts) and wrist activity in a sedentary position (WAS, per cent of the sedentary time) during 24 hours ongoing Delirium Motor Subtype Scalesubtyped delirium. RESULTS: Mean age was 86.7 years. 15 had hyperactive, 20 hypoactive, 17 mixed and 8 had no-subtype delirium. We found more upright time in the no-subtype group than in the hypoactive group (119.3 vs 37.8 min, p=0.042), but no differences between the hyperactive, the hypoactive and the mixed groups (79.1 vs 37.8 vs 50.1 min, all p>0.28). The no-subtype group had a higher number of transitions than the hypoactive (54.3 vs 17.4, p=0.005) and the mixed groups (54.3 vs 17.5, p=0.013). The hyperactive group had more total wrist activity than the hypoactive group (1.238×104 vs 586×104 counts, p=0.009). The hyperactive and the mixed groups had more WAS than the hypoactive group (20% vs 11%, p=0.032 and 19% vs 11%, p=0.049). CONCLUSIONS: Geriatric patients with delirium demonstrated a low level of upright activity, with no differences between the hyperactive, hypoactive and mixed groups, possibly due to poor gait function. The hyperactive and mixed groups had more WAS than the hypoactive group, indicating true differences in motor activity across delirium motor subtypes, also in geriatric patients. Wrist activity appears more suitable than an upright activity for both diagnostic purposes and activity monitoring in geriatric delirium.

Environmental factors and risk of delirium in geriatric patients: an observational study.

BACKGROUND: Patients with delirium have increased risk of death, dementia and institutionalization, and prognosis differs between delirium motor subtypes. A few studies have identified associations between environmental factors like room-transfers and time spent in the emergency department (ED) and delirium, but no studies have investigated if environmental factors may influence delirium motor subtypes. We wanted to explore if potentially stressful events like ward-transfers, arriving ED at nighttime, time spent in ED and nigthttime investigations were associated with development of delirium (incident delirium) and delirium motor subtypes. METHODS: We used the DSM-5 criteria to diagnose delirium and the Delirium Motor Subtype Scale for motor subtyping. We defined hyperactive and mixed delirium as delirium with hyperactive symptoms, and hypoactive and no-subtype delirium as delirium without hyperactive symptoms. We registered ward-transfers, time of arrival in ED, time spent in ED and nighttime investigations (8 p.m. to 8 a.m.), and calculated Global Deterioration Scale (GDS) and Cumulative Illness Rating Scale (CIRS) to adjust for cognitive impairment and comorbidity. We used logistic regression analyses with incident delirium and delirium with hyperactive symptoms as outcome variables, and ward-transfers, arriving ED at nighttime, time spent in ED and nighttime investigations as exposure variables, adjusting for age, GDS and CIRS in the analyses for incident delirium. RESULTS: We included 254 patients, mean age 86.1 years (SD 5.2), 49 (19.3%) had incident delirium, 22 with and 27 without hyperactive symptoms. There was a significant association between nighttime investigations and incident delirium in both the unadjusted (odds ratio (OR) 2.22, 95% confidence interval (CI) 1.17 to 4.22, p = 0.015) and the multiadjusted model (OR 2.61, CI 1.26 to 5.40, p = 0.010). There were no associations between any other exposure variables and incident delirium. No exposure variables were associated with delirium motor subtypes. CONCLUSIONS: Nighttime investigations were associated with incident delirium, even after adjusting for age, cognitive impairment and comorbidity. We cannot out rule that the medical condition leading to nighttime investigations is the true delirium-trigger, so geriatric patients must still receive emergency investigations at nighttime. Hospital environment in broad sense may be a target for delirium prevention.

Physical activity among hospitalized older adults - an observational study.

BACKGROUND: Low level of physical activity is common among hospitalized older adults and is associated with worse prognosis. The aim of this paper is to describe the pattern and level of physical activity in a group of hospitalized older adults and to identify factors associated with physical activity. METHODS: We measured physical activity on day three after admission using accelerometer based activity monitors and time in upright position as outcome measure. We collected data of physical function (Short Physical Performance Battery, SPPB. 0-12), cognitive function (Mini Mental Status Examination, MMSE, 0-30 and diagnosis of cognitive impairment at discharge, yes/no), personal Activities of Daily Living (p-ADL, Barthel Index, BI, 0-20) and burden of disease (Cumulative Illness Rating Scale, CIRS, 0-56). We analyzed data using univariable and multivariable linear regression models, with time in upright position as dependent variable. RESULTS: We recorded physical activity in a consecutive sample of thirty-eight geriatric patients. Their (mean age 82.9 years, SD 6.3) mean time in upright position one day early after admission was 117.1 min (SD 90.1, n = 38). Mean SPPB score was 4.3 (SD 3.3, n = 34). Mean MMSE score was 19.3 (SD 5.3, n = 30), 73% had a diagnosis of cognitive impairment (n = 38). Mean BI score was 16.4 (SD 4.4, n = 36). Mean CIRS score was 17.0 (SD 4.2, n = 38). There was a significant association between SPPB score and time in upright position (p = 0.048): For each one unit increase in SPPB, the expected increase in upright time was 11.7 min. There was no significant association between age (p = 0.608), diagnosis of cognitive impairment (p = 0.794), p-ADL status (p = 0.127), CIRS score (p = 0.218) and time in upright position. The overall model fit was R2 0.431. CONCLUSION: Participants' mean time in upright position one day early after admission was almost two hours, indicating a high level of physical activity compared to results from similar studies. Physical function was the only variable significantly associated with physical activity indicating that SPPB could be a useful screening tool and that mobilization regimes should be delivered routinely for patients with reduced physical function.

[COX-2 inhibitors--one step forward and two steps back]. / COX-2-hemmere--ett skritt frem og to tilbake.

BACKGROUND: Selective cyclooxygenase-2 (COX-2) inhibitors are widely used. They have no advantages in terms of efficacy, and it is not documented that they cause fewer adverse effects than conventional NSAIDs. MATERIAL AND METHODS: The adverse effects of rofecoxib, celecoxib and other NSAIDs are reviewed. Relevant literature was identified on Medline and in the reference lists in key articles. RESULTS: Rofecoxib and the novel COX-2 inhibitors etoricoxib and valdecoxib have a higher degree of COX-2 selectivity than traditional NSAIDs. Celecoxib is less COX-2 selective and appears to be similar to diclofenac. Rofecoxib induces thromboembolic adverse effects more frequently than conventional NSAIDs. INTERPRETATION: The cardiovascular problems conferred by rofecoxib are probably a class effect and thus inducible by other selective COX-2 inhibitors. Pending comprehensive safety data, caution is warranted regarding the use of these drugs.