Delirium in patients with dementia and in children: Overlap of symptoms profile and possible role for future diagnosis.

BACKGROUND: Delirium in the extremes of the age spectrum may show similarities in presentations, and these similarities may provide information to develop tools for the diagnosis of delirium superimposed on dementia (DSD). We sought to investigate the symptom profile and subtypes of delirium in patients with dementia, and in infants and preschool children. METHODS: This was an exploratory analysis of previous prospective cohort studies that evaluated delirium with the DSM-IV criteria in patients with dementia, and in critically ill infants (< 2 years of age) and preschool children (2-5 years of age), respectively. Delirium subtypes were defined based on the Richmond Agitation-Sedation Scale. RESULTS: We included 147 patients, 35 adult patients with delirium DSD, 80 infants, and 32 preschool children with delirium. Hypokinesia and apathy were common among both DSD (72%), infants (74%) and preschool children (75%) with delirium, whereas hallucinations and anxiety were less common in both adults with DSD (26%) and infants (10%) and preschool children (14%). Hypoactive delirium was most common delirium subtype among infants (68%) and preschoolers (76%), whereas RASS = 0 (alert) delirium was the most common among adult patients with DSD (55%). CONCLUSIONS: The study reports similarities in the symptoms profile of delirium in a cohort of patients with dementia and delirium, and in infants and preschool-aged children with delirium. These preliminary findings might be informative to design future studies adapting delirium assessments used in in infants and preschool-aged children to patients with dementia, especially in the moderate to severe stages.

Delirium superimposed on dementia: A quantitative and qualitative evaluation of informal caregivers and health care staff experience.

OBJECTIVE: Delirium superimposed on dementia is common and potentially distressing for patients, caregivers, and health care staff. We quantitatively and qualitatively assessed the experience of informal caregiver and staff (staff nurses, nurse aides, physical therapists) caring for patients with delirium superimposed on dementia. METHODS: Caregivers' and staff experience was evaluated three days after delirium superimposed on dementia resolution (T0) with a standardized questionnaire (quantitative interview) and open-ended questions (qualitative interview); caregivers were also evaluated at 1-month follow-up (T1). RESULTS: A total of 74 subjects were included; 33 caregivers and 41 health care staff (8 staff nurses, 20 physical therapists, 13 staff nurse aides/health care assistants). Overall, at both T0 and T1, the distress level was moderate among caregivers and mild among health care staff. Caregivers reported, at both T0 and T1, higher distress related to deficits of sustained attention and orientation, hypokinesia/psychomotor retardation, incoherence and delusions. The distress of health care staff related to each specific item of the Delirium-O-Meter was relatively low except for the physical therapists who reported higher level of distress on deficits of sustained/shifting attention and orientation, apathy, hypokinesia/psychomotor retardation, incoherence, delusion, hallucinations, and anxiety/fear. The qualitative evaluation identified important categories of caregivers' and staff feelings related to the delirium experience. CONCLUSIONS: This study provides information on the implication of the experience of delirium on caregivers and staff. The distress related to delirium superimposed on dementia underlines the importance of providing continuous training, support and experience for both the caregivers and health care staff to improve the care of patients with delirium superimposed on dementia.

Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience.

OBJECTIVE: Delirium superimposed on dementia is common and is associated with adverse outcomes. Yet little is known about the patients' personal delirium experiences. We used quantitative and qualitative methods to assess the delirium superimposed on dementia experience among older patients. METHODS: We conducted a prospective cohort study among patients with delirium superimposed on dementia who were admitted to a rehabilitation ward. Delirium was diagnosed using DSM-IV-TR criteria. Delirium severity and symptoms were evaluated with the Delirium-O-Meter (D-O-M). The experience of delirium was assessed after delirium resolution (T0) and one month later (T1) with a standardized questionnaire and a qualitative interview. Level of distress was measured with the Delirium Experience Questionnaire. RESULTS: Of the 30 patients included in the study, 50% had mild dementia; 33% and 17% had moderate and severe dementia. Half of the patients had evidence of the full range of D-O-M delirium symptoms. We evaluated 30 patients at T0 and 20 at T1. At T0, half of the patients remembered being confused as part of the delirium episode, and reported an overall moderate level of related distress. Patients reported high distress related to memories of anxiety/fear, delusions, restlessness, hypokinesia, and impaired orientation. Qualitative interviews revealed six main aspects of patient delirium experiences: Emotions; Cognitive Impairment; Psychosis; Memories; Awareness of Change; and Physical Symptoms. CONCLUSIONS: The study provides novel information on the delirium experience in patients with dementia. These findings are the key for health care providers to improve the everyday care of this important group of frail older patients.

Association between statin use at admission to inpatient rehabilitation and functional status at discharge among older patients.

The effect of statins on functional status in older patients is unclear. Statins might carry a deleterious effect on muscle function leading to myopathy and therefore affecting functional recovery. We evaluated the relationship between statin exposure at in-hospital rehabilitation admission and functional outcome at discharge. This was a retrospective cohort study of older patients 70 years and older consecutively admitted to an in-hospital rehabilitation after an acute hospitalization. Statin exposure was measured at the time of rehabilitation admission. Functional status was defined with the Barthel Index (BI) score at the time of discharge. A multi-variable linear regression model was used to evaluate the association between statin exposure and functional status at discharge adjusting for potential confounders through a propensity score for statin exposure. A total of 2435 patients were included. The cohort had a mean age of 81.1 years. Of these 9% (n=220) were on statins at the time of admission. In the multi-variable analysis, the use of statins at the time of admission was independently associated with an improved functional status at discharge (point estimate 5.2; 95% confidence interval 1.5-8.9; p<0.01) after adjusting for relevant confounders. Patients who were receiving statins at the time of admission had a BI score 5 points higher compared to those who were not receiving statins. The use of statins was overall safe in a group of co-morbid older patients undergoing rehabilitation training after an acute hospitalization. Additionally, a possible benefit was found given the positive association between statin use and higher functional status at discharge.

Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people.

OBJECTIVE: to evaluate the performance of the 4 'A's Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice. DESIGN: : prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments. SETTING: : an acute geriatrics ward and a department of rehabilitation. PARTICIPANTS: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months. MEASUREMENTS: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium. RESULTS: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia. CONCLUSIONS: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.

Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients.

OBJECTIVE: Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation. DESIGN: Prospective cohort study. SETTING: Hospital rehabilitation unit. PARTICIPANTS: A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006. MEASUREMENTS: Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations. RESULTS: The median age was 77 years (interquartile range: 71-83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6-42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8-8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1-2.8; P = .01). CONCLUSIONS: DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.

Predictors of rehospitalization among elderly patients admitted to a rehabilitation hospital: the role of polypharmacy, functional status, and length of stay.

OBJECTIVES: Rehospitalizations for elderly patients are an increasing health care burden. Nonetheless, we have limited information on unplanned rehospitalizations and the related risk factors in elderly patients admitted to in-hospital rehabilitation facilities after an acute hospitalization. SETTING: In-hospital rehabilitation and aged care unit. DESIGN: Retrospective cohort study. PARTICIPANTS: Elderly patients 65 years or older admitted to an in-hospital rehabilitation hospital after an acute hospitalization between January 2004 and June 2011. MEASUREMENTS: The rate of 30-day unplanned rehospitalization to hospitals was recorded. Risk factors for unplanned rehospitalization were evaluated at rehabilitation admission: age, comorbidity, serum albumin, number of drugs, decline in functional status, delirium, Mini Mental State Examination score, and length of stay in the acute hospital. A multivariable Cox proportional regression model was used to identify the effect of these risk factors for time to event within the 30-day follow-up. RESULTS: Among 2735 patients, with a median age of 80 years (interquartile range 74-85), 98 (4%) were rehospitalized within 30 days. Independent predictors of 30-day unplanned rehospitalization were the use of 7 or more drugs (hazard ratio [HR], 3.94; 95% confidence interval, 1.62-9.54; P = .002) and a significant decline in functional status (56 points or more at the Barthel Index) compared with the month before hospital admission (HR 2.67, 95% CI: 1.35-5.27; P = .005). Additionally, a length of stay in the acute hospital of 13 days or more carried a twofold higher risk of rehospitalization (HR 2.67, 95% CI: 1.39-5.10); P = .003). CONCLUSIONS: The rate of unplanned rehospitalization was low in this study. Polypharmacy, a significant worsening of functional status compared with the month before acute hospital admission, and hospital length of stay are important risk factors.

The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation.

OBJECTIVES: Delirium is a common poststroke complication, but its prevalence and effect in rehabilitation settings is unknown. We retrospectively assessed the prevalence of delirium in elderly patients undergoing poststroke rehabilitation and its association with short-term outcomes. METHODS: All patients (aged ≥65 years) admitted to the Department of Rehabilitation between November 2007 and October 2011 after a recent stroke were screened for delirium. Delirium was diagnosed using the confusion assessment method. Multiple logistic regressions were used to evaluate the association between delirium, institutionalization, and inhospital death, while multiple linear regressions were used for the association between delirium and functional recovery, defined in 3 different ways which include (1) measuring the relative functional gain of the Barthel index (BI-RFG); (2) the change in Barthel index (BI) walking subscore from admission to discharge; and (3) the change in Tinetti score from admission to discharge. RESULTS: In all, 58 (33%) patients of the total 176 patients were consecutively admitted to our department with delirium. After adjustment for potential confounders, poststroke delirium (PSD) was an independent predictor of institutionalization (odds ratio [OR] = 7.23; 95% confidence interval [CI] = 4.79 to 10.91; P ≤ .0003) and inhospital death (OR = 4.26; 95% CI = 1.15 to 15.81; P = .03); PSD was not a predictor of functional recovery at discharge, neither using the BI-RFG (P = .96) nor using the change from admission to discharge of both the BI walking subscore (P = .57) and the Tinetti score (P = .61) as outcome measures. CONCLUSIONS: In elderly patients undergoing poststroke rehabilitation, delirium is an independent predictor of institutionalization and inhospital death, but it does not affect functional recovery.

Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery.

OBJECTIVE: Hip fractures (HF) are a growing cause of death and disability among older people, especially in the very old. Although the incidence of these events increases with age and nonagenarians represent a population at high risk, few studies selectively focused on these patients and on their potential to recover gait ability after HF. The aim of this study was to describe the clinical, biological, cognitive, and functional characteristics of a population of HF patients aged 90 years or older, to examine their functional recovery in gait (with or without aids), in-hospital mortality and destination at discharge, and, finally, to assess their 1-year survival according to the functional status achieved at discharge. DESIGN: Retrospective study. SETTING: Department of Rehabilitation and Aged Care. PARTICIPANTS: Seventy-six nonagenarians admitted to a department of rehabilitation after HF surgery. MEASUREMENT: Patients underwent a multidimensional assessment on admission and at discharge. Outcome measures at discharge were the global scores of Tinetti and the Barthel Index, the score at the transferring and walking subitems of the Barthel Index, and the independence to walk with or without aids. Furthermore, we assessed the rate of discharge to home after rehabilitation and the rate of in-hospital death. Logistic regressions were used to assess clinical variables associated with the inability to walk at discharge. Postdischarge 12-month survival was assessed with Kaplan Meyer analysis and compared with Cox proportional hazard regression models, adjusted for confounders. INTERVENTION: A standardized rehabilitation treatment of 2 sessions (40 minutes per session) daily from Monday to Friday and of 1 session on Saturday that included exercises of strengthening, transfers, postural and gait training, and adaptive equipment training. RESULTS: Five patients died during their admission to the department. Among the 71 survivors, 84.5% were able to walk at discharge with an assistive device, either a cane or a walker. Comorbidity and prefracture Barthel Index global score were the only 2 variables associated with the failure to be independent in walking at discharge. At 1 year, mortality was significantly higher for those patients who did not recover walking ability after rehabilitation. CONCLUSION: A large proportion of nonagenarians are able to achieve independence in walking ability (with assistive device) after rehabilitation following HF surgery. The achievement of this ability after rehabilitation is also an important prognostic factor for 1-year survival.

Are fluctuations in motor performance a diagnostic sign of delirium?

BACKGROUND: Although delirium is known as a mental disorder, recent evidence suggests that it is associated with short- and long-term impairment of functional status. OBJECTIVE: To evaluate whether a pattern of fluctuations in motor performance are a diagnostic sign of delirium. DESIGN: Case-controlled study with prospective evaluations of 4 groups of patients. SETTING: Department of Rehabilitation and Aged Care. METHODS: Fifteen patients with incident delirium alone (Del group) and 15 patients with incident delirium superimposed on dementia (DSD group) were compared with 15 patients with neither delirium nor dementia (No Del-No Dem group) and 15 patients with dementia but no delirium (Dem group), respectively. Eligibility criteria were age 65 years or older, ability on admission to maintain sitting position for at least 10 minutes, and absence of visual/hearing impairment or delirium on admission. All patients underwent a multidimensional assessment on admission and serial evaluations of motor performance using Trunk Control Test (TCT) and Tinetti scale. These assessments were fixed at 5 different times, coincident with admission (T(0)), predelirium (T(1)), onset of delirium (T(2)), resolution of delirium (T(3)), and discharge (T(4)). RESULTS: Patients in the Dem, DSD, and Del groups were significantly more impaired at T(0) in cognitive and functional status and motor performance compared with No Del-No Dem patients. At T(1) all groups improved, although in different ways. At T(2) only in the Del and DSD groups, but not in the others, there was a pattern of decline in TCT and Tinetti scores (P < .0005 at t test for pair comparison for both tests) and a specular pattern of improvement at T(3) (P < .0005 at t test for pair comparison for both tests). Patients in the Del and DSD groups had the poorest attentive and executive performances at T(2), which significantly improved at T(3). In No Del-No Dem and Dem groups, attentive and executive functions did not change from T(2) to T(3.) CONCLUSION: Patients with delirium exhibit a pattern of fluctuating motor performance that is chronologically related with the onset and the end of delirium, ie, they decline when delirium develops and improve when delirium ends. This pattern seems to be typical of delirium, as it is appreciable in subjects with dementia developing delirium but not in patients with dementia alone. A fluctuation of motor performance should be considered a diagnostic sign of delirium.

Clinical complexity and Occam's razor: navigating between Scylla and Charibdy of the geriatric practice. A case of secondary hypertension in a very old patient.

The clinical approach toward elderly patients is often very complex and associated with an increased risk of medical errors. This case report is an example of how various objective (related to patient) and subjective (related to physicians) factors may influence the optimal diagnostic approach in elderly frail patients. We also discuss geriatric practice, which must be characterized by the intellectual honesty to refuse any sort of prejudices (such as ageism) and by the skill to navigate between the Scylla (ie, viewing clinical problems as unrelated to each other) and the Charibdy (ie, applying the Occam's razor principle) of the patient's complexity.

Subcortical vascular lesions predict falls at 12 months in elderly patients discharged from a rehabilitation ward.

OBJECTIVE: To test whether subcortical vascular lesions are associated with falls in elderly patients with gait disorder discharged from a rehabilitation ward. DESIGN: Secondary 12-month follow-up analysis of an observational survey focusing on the prevalence of subcortical vascular lesions in a population of elderly patients discharged from rehabilitation hospitals. SETTING: A rehabilitation and aged care unit. PARTICIPANTS: Consecutively admitted elderly patients (N=214) with gait disorder. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: On admission, all patients underwent comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. Subcortical vascular lesions were assessed on computed tomography films with a validated rating scale. All patients received a standardized rehabilitative program. Twelve months after discharge, all patients were interviewed by telephone, mainly focusing on the occurrence of falls during the follow-up period. Potential predictors of falls were assessed in univariate and multivariate analyses. RESULTS: Univariate predictors of falls were age, sex, Mini-Mental State Examination, Barthel Index on admission, and subcortical vascular lesions. In multivariate analyses, subcortical vascular lesions were the only significant predictor of risk of falling; patients with moderate and severe subcortical vascular lesions scores had a greater risk of falling (odds ratio [OR]=3.0; 95% confidence interval [CI], 1.3-7.1; P=.012; OR=3.9; 95% CI, 1.6-9.2; P=.002, respectively) than those with no subcortical vascular lesions. CONCLUSIONS: Subcortical vascular lesions are associated with falls at 12 months in elderly patients with gait disorder discharged from a rehabilitative ward. Future research is needed to confirm our results.

Depressive symptoms combined with dementia affect 12-months survival in elderly patients after rehabilitation post-hip fracture surgery.

OBJECTIVES: To assess whether the association of depression and dementia affects 12-month survival of elderly patients after rehabilitation post-hip fracture (HF) surgery. METHODS: Two hundred eleven inpatients admitted to a Rehabilitation and Aged Care Unit (RACU) following surgery for HF were screened for depression with the 15-item Geriatric Depression Scale (GDS) and stratified into four groups according to dementia (n = 40), depressive symptoms (n = 54, GDS score > 7/15), both (n = 27), and neither conditions (n = 90). The 12-months survival after discharge was assessed among groups with Kaplan Meyer analysis and compared with Cox proportional hazard regression models adjusted for covariates. Subjects with neither depression nor dementia were the reference group. RESULTS: Survival of patients with depression and dementia was significantly lower than the other 3 groups: after adjustment for age, gender, comorbidity (Charlson Index), use of antidepressants, and Barthel Index at discharge, their Hazard Ratio (HR) was 8.7 (95% CI 1.5-48.5; p = 0.01); in the same Cox regression model, the HR of patients with dementia alone was 3.4 (95% CI 0.5-24.0; p = 0.20) while the HR of patients with depressive symptoms but no dementia was 5.0 (95% CI 0.8-28.3; p = 0.07). CONCLUSIONS: The co-occurrence of depression and dementia significantly increases the 12-months risk of dying in elderly patients after rehabilitation post-HF surgery.

Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility.

BACKGROUND: Delirium superimposed on dementia (DSD) is highly prevalent and associated with high mortality among hospitalized elderly patients, yet little is known about the effect of DSD on midterm mortality. The purpose of this study was to assess 12-month survival in patients with DSD and matched groups with dementia alone, delirium alone, or neither delirium nor dementia. METHODS: Among 1278 consecutively admitted elderly participants (aged > or =65 years) to our Rehabilitation Unit between January 2002 and May 2005, four matched samples of 47 participants each (DSD, dementia alone, delirium alone, or neither delirium nor dementia) were selected. Matching was based on age, gender, and reason for admission. Postdischarge 12-month survival was assessed in the four groups with Kaplan-Meyer analysis and compared with Cox proportional hazard regression models adjusted for confounders. RESULTS: Survival was significantly lower for DSD patients than for the other three groups. After adjustment for comorbidity and Barthel Index score before admission, patients with DSD had significantly higher mortality (hazard ratio, 2.3; 95% confidence interval, 1.1-5.5; p =.04) than did patients with neither delirium nor dementia. CONCLUSIONS: Demented patients who experienced delirium during hospitalization had a more than twofold increased risk of mortality in the 12 months following discharge than did patients with dementia alone, with delirium alone, or with neither dementia nor delirium.