Prevalencia de primer episodio de delirio, factores relacionados y su impacto sobre mortalidad, en pacientes ingresados en convalecencia / Prevalence of the first episode of delirium, related factors and their impact on mortality, in patients admitted in a convalescence unit

Objetivos: Determinar la prevalencia de aparición de primer episodio de delirium en mayores de 65 años, su impacto sobre mortalidad y factores relacionados. Métodos: Estudio cross-sectional, prospectivo. Durante 4 meses se incluyeron pacientes ≥ 65 años ingresados en una unidad de convalecencia, excluyéndose sujetos con demencia avanzada, diagnóstico de encefalopatía orgánica o evidencia de delirium al momento del ingreso. Se estudiaron variables específicas de la valoración geriátrica y mediante un cuestionario se observaron probables factores predisponentes (deterioro visual/auditivo, uso de medicamentos psicoactivos) y factores precipitantes (uso de catéter urinario, fiebre, mal control del dolor o alteraciones en el sueño). El delirium se diagnosticó mediante la escala CAM. Se realizó análisis multivariable utilizando métodos de regresión logística para descripción de factores relacionados con delirium; y método proporcional de Cox para descripción de los predictores de mortalidad. Resultados: Se incluyeron 195 pacientes. El 39% (76/195) fueron hombres, con edad media de 81.9 años (8.5). El índice de Barthel al ingreso fue 45 (IQR 25-60) y el índice de Charlson 2 (IQR 1-4). El 21% (41/195) presentó delirium previo. La prevalencia de primer episodio de delirium fue de 23.1% (95% CI: 17.7-29.5). Los principales factores relacionados con el riesgo de desarrollo de delirium fueron: la edad OR:1.6 (95%CI 1.01-1.11), el número de errores según Test de Pfeiffer OR:1.4 (95%CI 1.2-1.64) y el Indice de Charlson al ingreso OR:1.25 (95%CI 1.02-1.53). La estancia media fue de 37.1 (21.2) días y e tiempo para desarollo de delirium fue de 15 días. Fueron éxitus 11 sujetos (5.7%). Los principales predictores de mortalidad global, ajustados por edad e índice de Charlson, fueron: Delirium HR:5.26 (95%CI 1.30-21.29) y derivación desde Urgencias (Subagudos) HR:5.34 (95%CI 1.6217.56). Conclusión: Las variables relacionadas con deterioro cognitivo fueron las más importantes relacionadas con el desarrollo de delirium en una unidad de convalescencia. El delirium es un factor independiente de mortalidad en estas unidades

Objectives: To determine the prevalence of the first episode of delirium in patients older than 65 years, its impact on mortality and related factors. Methods: Prospective and cross-sectional study. During 4 months of follow-up, patients older than 65 years admitted in a post-acute convalescence unit were included. Using a questionnaire, we studied probable predisposing factors (visual and hearing impairment, psychoactive drugs) and precipitating factors (bladder catheter, fever, poor control of pain and sleep disturbances). Additionally, demographic data, comorbidity, pre-existing cognitive impairment and physical function were recorded. Subjects with advanced dementia, diagnosis of any organic encephaloencephalopathy or evidence of delirium at the time of the admission were excluded. Delirium was defined according the Confusion Assessment Method. The factors associated with delirium were studied by a multivariate analysis performed by logistic regression. A multivariate Cox proportional hazards regression analysis was used to examine predictors of mortality with competing endpoints (death and discharge alive) and estimated both the daily hazard and cumulative risk of death. Results: A total of 195 patients received follow-up during the observation period. A 39% (76/195) were men (mean 82.1 years). Admission Barthel index score was 45 (IQR 25-60) and Charlson comorbidity score was 2 (IQR 1-4). A 21% (41/195) had presented history of delirium prior. Prevalence of first episode of delirium was 23.1% (95% CI: 17.7-29.5). Principal related factors to delirium were: Age OR:1.6 (95%CI 1.01-1.11), total errors according Pfeiffer's Test OR:1.4 (95%CI 1.2-1.64) and Charlson comorbidity score OR:1.25 (95%CI 1.02-1.53). Mean time for development of delirium was 15 days and average time for hospital discharge was 37.1 days. 11 subjects (5.7%) died during followup. Adjusted by age and Charlson score, main predictors for mortality were: Delirium HR:5.26 (95%CI 1.30-21.29) and derivation from emergency room HR:5.34 (95%CI 1.6217.56). Conclusions: Associated variables with cognitive impairment were the most important with development of first episode of delirium in a convalescence unit. Delirium is an independent factor of mortality in these units

Delusions in Patients with Alzheimer's Disease: A Multidimensional Approach.

In Alzheimer's disease (AD) patients with delusions, clinical outcomes and mortality result from a combination of psychological, biological, functional, and environmental factors. We determined the effect of delusions on mortality risk, clinical outcomes linked to comprehensive geriatric assessment (CGA), cognitive, depressive, and neuropsychiatric symptoms (NPS) in 380 consecutive AD patients with Mini-Mental State Examination, Clinical Dementia Rating scale, 15-item Geriatric Depression Scale, and Neuropsychiatric Inventory (NPI), assessing one-year mortality risk using the Multidimensional Prognostic Index (MPI). We included 121 AD patients with delusions (AD-D) and 259 AD patients without delusions (AD-noD). AD-D patients were significantly older, with higher age at onset and cognitive impairment, a more severe stage of dementia, and more depressive symptoms than AD-noD patients. Disease duration was slightly higher in AD-D patients than in those without delusions, although this difference was not statistically significant. At CGA, AD-D patients showed a higher grade of disability in basic and instrumental activities of daily living, and an increased risk of malnutrition and bedsores. The two groups of patients significantly differed in MPI score (AD-D: 0.65 versus AD-noD: 0.51, p <  0.0001) and MPI grade. AD-D patients showed also a significant higher score in NPI of the following NPS than AD-noD patients: hallucinations, agitation/aggression, depression mood, apathy, irritability/lability, aberrant motor activity, sleep disturbances, and eating disorders. Therefore, AD-D patients showed higher dementia severity, and higher impairment in cognitive and depressive symptoms, and several neuropsychiatric domains than AD-noD patients, and this appeared to be associated with higher multidimensional impairment and increased risk of mortality.

Associations between symptoms and all-cause mortality in individuals with serious mental illness.

OBJECTIVE: To determine if aggression, hallucinations or delusions, and depression contribute to excess mortality risk observed in individuals with serious mental illness (SMI). METHODS: We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) aged≥15years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of specific symptoms (HoNOS subscales) on all-cause mortality using Cox regression. RESULTS: We identified 6880 SMI cases (242 deaths) occurring 2007-2010. Bipolar disorder was associated with reduced mortality risk compared to schizophrenia (HR 0.7; 95% CI 0.4-0.96; p=0.028). Mortality was not significantly associated with hallucinations and delusions or overactive-aggressive behaviour, but was associated with physical illness/disability. There was a positive association between mortality and subclinical depression among individuals with schizophrenia (HR 1.5; 1.1-2.2; p=0.019) but a negative association with subclinical and more severe depression among those with schizoaffective disorder (HR 0.1; 0.02-0.4; p=0.001 and 0.3; 0.1-0.8; p=0.021, respectively). CONCLUSIONS: The recognised increased risk of mortality in SMI did not appear to be influenced by severity of hallucinations, delusions, or overactive-aggressive behaviour. Physical illness and lifestyle may need to be addressed and the relationship between depression and mortality requires further investigation.

The incidence of first-onset psychotic symptoms and paranoid ideation in a representative population sample followed from age 70-90 years. Relation to mortality and later development of dementia.

BACKGROUND: Limited data are available on the incidence of psychotic symptoms in the elderly. OBJECTIVE: To elucidate the incidence of first-onset psychotic symptoms in the elderly and their relation to mortality and later development of dementia. METHOD: A population-sample (n = 392) born 1901-1902 was assessed from age 70-90 with psychiatric examinations, medical record reviews and from age 85, also with key-informant interviews. Individuals developing dementia were excluded. RESULT: The cumulative incidence of first-onset psychotic symptoms was 4.8% (8.0% including key-informant reports in the total sample) and 19.8 % in those who survived to age 85. Sixty-four percent of those with first-onset hallucinations later developed dementia, compared to 30% of those with delusions and 25% of those without psychotic symptoms. CONCLUSIONS: One fifth of non-demented elderly who survives up to age 85 develops first-onset psychotic symptoms. Hallucinations predict dementia, but most elderly individuals with first-onset psychotic symptoms do not develop dementia.

Hallucinations and mortality in Alzheimer disease.

OBJECTIVE: The authors tested the relationship of hallucinations and delusions to mortality in Alzheimer disease (AD). METHODS: A group of 407 persons with clinically diagnosed AD completed a uniform clinical evaluation, after which vital status was monitored for a mean of 3.7 years. At the initial evaluation, a previously established, structured, informant interview was used to ascertain the presence of hallucinations and delusional thinking. The evaluation also included a structured medical history, inspection of all medications, and detailed assessment of cognitive functioning and parkinsonian signs. RESULTS: At study onset, hallucinations were present in 41.0% of participants and delusions in 54.4%. During follow-up, 146 deaths occurred. In a proportional-hazards model adjusted for age, sex, race, and education, hallucinations were associated with a 78% increase in risk of death. The association was not substantially altered in subsequent analyses that controlled for level of cognitive impairment, severity of parkinsonism, use of antipsychotic medications, and the presence of chronic medical conditions. Risk of death was more than doubled in those with both auditory and visual hallucinations. By contrast, we did not find evidence of an association of delusions with mortality. CONCLUSION: Hallucinations are associated with an increased risk of death in AD.

The effect of a structured intervention on caregivers of patients with dementia and problem behaviors: a randomized controlled pilot study.

The objective was to assess the effect of a structured intervention on caregiver stress and the institutionalization rate of patients with dementia and problem behaviors. Caregivers contacting the Federazione Alzheimer Italia (AI) to receive help, advice, or information in relation to problem behaviors of outpatients were enrolled. Eligible caregiver-patient dyads were randomized to receive either a structured intervention or the counseling AI usually provides (control group). After basal assessment, families were reassessed at 6 and 12 months. Problem behavior (particularly agitation) was the only variable significantly correlated (P = 0.006) with the baseline caregivers' stress score. Thirty-nine families completed the 12-month follow-up; the mean problem behavior score was significantly lower in the intervention than the control group (p < 0.03); the time needed for care of the patient increased by 0.5 +/- 9.7 hours/day in the control group and decreased by 0.3 +/- 4.1 in the intervention group (p = 0.4, Wilcoxon test). The main determinant of institutionalization seemed to be the level of caregiver stress (p = 0.03). In patients of the intervention group, there was a significant reduction in the frequency of delusions. This pilot study suggests that caregiver stress is relieved by a structured intervention. The number of families lost to follow-up, the relatively short duration of the study, and the ceiling effect due to the severity of the clinical characteristics of patients probably all partly dilute the observed findings.

Risk of mortality and institutionalization in demented patients with delusions.

Delusions are a common symptom during the course of dementia. Despite their clinical relevance, however, it is still unclear whether they are of prognostic value. This longitudinal study involving, at baseline, 99 demented Alzheimer disease (AD) and multi-infarct dementia (MID) patients, investigates the risk of mortality and institutionalization at 2 years after discharge from a dementia unit in patients with and without delusions at baseline. Results indicate that the presence of delusions is a significant predictor of future institutionalization (odds ratio 3.6, confidence interval 1.3-9.6), even when confounding factors such as age, educational level, and severity of cognitive and functional impairment are statistically controlled. No significant impact on survival was found.