Delirium en el adulto mayor hospitalizado / Delirium in elderly hospitalized patients

El delirium corresponde a un síndrome clínico frecuente y relevante en el adulto mayor hospitalizado. Su incidencia e impacto han sido reconocidos desde hace más de 30 años y su importancia en la atención del adulto mayor hospitalizado es creciente debido a que abarca diferentes escenarios clínicos (atención de urgencia, en pacientes hospitalizados por patologías médicas o quirúrgicas, en pacientes admitidos a unidades de cuidados intensivos, entre otros), y al envejecimiento poblacional, que ha conducido a que la atención hospitalaria moderna concentre cada vez una mayor cantidad de adultos mayores portadores de diversas condiciones crónicas, con grados diversos de fragilidad y discapacidad que requieren de nuestra mejor atención, de forma de reducir la aparición u optimizar el manejo de esta condición que puede ser devastadora para la evolución del adulto mayor posterior al egreso hospitalario. El presente capítulo pretende resumir el estado del arte de esta condición señalando, cuando corresponda, algunos de los elementos en controversia y donde nos parece necesario que la investigación nos señale innovadoras respuestas que permitan reducir su impacto.

Delirium is a frequent and relevant clinical syndrome in the elderly hospitalized. Incidence and impact has been recognized for more than 30 years, and its importance in the care of hospitalized older adults is increasing because it occurs in different clinical units (patients admitted in units of emergency, medical or surgical rooms, to intensive care units, among others), and the ageing population, which has led to modern hospital care concentrating a greater number of older adults with various chronic conditions, with varying degrees of frailty and disability that require our better attention, in order to reduce the occurrence or optimize the management of this condition, that can be devastating for the evolution of the elderly after hospital discharge. This chapter aims to summarize the state of the art of this condition, pointing out some controversial elements and where it seems necessary that the research shows us innovative answers that reduce its impact

Delirium en el hospital, una revisión narrativa / Delirium in the hospital, a narrative review

El delirium es una complicación frecuente entre pacientes hospitalizados, particularmente entre adultos mayores y aquellos con deterioro cognitivo. Se ha asociado a mayor mortalidad, estadías hospitalarias prolongadas, deterioro cognitivo, mayores tasas de institucionalización al alta y mayores costos para los sistemas de salud. Su fisiopatología es escasamente comprendida, planteándose en los últimos años un origen inflamatorio predominante. Ello explicaría su transversalidad y relación con la gravedad de cuadros subyacentes. Clínicamente se caracteriza por su inicio agudo con curso fluctuante, inatención, pensamiento desorganizado y un nivel de conciencia alterado. El enfrentamiento diagnóstico exige la búsqueda sistemática de desencadenantes en forma adicional a las manifestaciones del síndrome. Su tratamiento sintomático está basado en los neurolépticos como primera línea y el lorazepam en caso de que los primeros no puedan utilizarse o exista un escenario de indicación especial. Existe evidencia de que el cuadro puede prevenirse mediante la instauración de estrategias multicomponentes.

Delirium is a common complication in hospitalized patients, particularly the elderly and those with cognitive impairment. It has been associated with higher mortality, prolonged hospitalization, cognitive impairment, higher rates of institutionalization at discharge and higher costs for healthcare systems. Its pathophysiology is poorly understood, and more recently a predominantly inflammatory origin has been proposed, which could explain its pervasiveness and association with underlying conditions. Clinically, it is characterized by acute onset with fluctuating course, inattention, disorganized thinking and altered level of consciousness. Diagnostic approach is based on the systematic search for triggering factors as well as the manifestations of the syndrome. Symptomatic treatment is based neuroleptics as first line treatment, and lorazepam when the former cannot be used or there are special indications. There is evidence that the condition can be prevented by resorting to multi-component strategies.

Early interdisciplinary hospital intervention for elderly patients with hip fractures : functional outcome and mortality

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.

Delirium / Delirium

Delirium, também conhecido como estado confusional agudo é uma alteração cognitiva definida por início agudo, curso flutuante, distúrbios da consciência, atenção, orientação, memória, pensamento, percepção e comportamento. É condição cada vez mais comum entre pacientes hospitalizados e acomete, preferencialmente, pacientes idosos e debilitados. Trata-se de emergência médica, já sendo comprovadas maiores taxas de mortalidade, maior tempo de internação e maiores índices de institucionalização quando do episódio de delirium. O mecanismo fisiopatológico ainda não está bem definido, sendo a alteração na neurotransmissão o mecanismo mais provável. A abordagem do paciente deve incluir a identificação de fatores predisponentes e precipitantes, com intervenções adequadas a cada um visando à resolução do quadro. Apresenta-se por alteração do nível de consciência, déficit de atenção e outros distúrbios da cognição, podendo se apresentar na forma hiperativa, hipoativa ou mista. Apesar de já estar bem definido, por diversas vezes passa despercebido aos profissionais de saúde. A principal medida na abordagem de delirium é a prevenção, e são necessárias medidas institucionais e treinamento dos profissionais de saúde. O tratamento não-farmacológico consiste em medidas que evitem os fatores responsáveis pelo desenvolvimento do delirium, sendo a primeira opção na abordagem inicial. O tratamento farmacológico se reserva aos pacientes com agitação importante, com risco de trauma físico, e que não apresentem resposta às medidas não-farmacológicas. Por sua frequência e importância como fator prognóstico, o delirium deve ser abordado de forma sistematizada, com a elaboração de fluxogramas de atendimento e definição de medidas uniformizadas para cada instituição.

Delirium, also known as acute confusional state is a cognitive impairment defined by acute onset and fluctuating course, disturbance of consciousness, attention, orientation, memory, thought, perception and behavior. It is an increasingly common condition among hospitalized patients and more frequent in, elderly and debilitated patients. It is a medical emergency, already proven higher death rates, longer hospitalization and higher rates of institutionalization due the occurrence of delirium. The pathophysiologic mechanism is not yet well established, with the change in neurotransmission most probably involved. Management of patients should include identification of risk factors and precipitants, with appropriate interventions aimed at each resolution. It is presented by altered level of consciousness, attention deficit and other disorders of cognition, which may present as hyperactive, hypoactive, or mixed. Although well defined, several times delirium goes unrecognized by health professionals. The main measure in addressing delirium is prevention, with institutional measures required as well as training of health professionals. Non-pharmacological treatment consists of measures to prevent the factors responsible for the development of delirium, and is the first option in the initial approach. Pharmacological treatment is reserved for patients with major upheaval, with the risk of physical trauma, and presenting no response to non-pharmacological measures. For the frequency and importance as a prognostic factor, delirium should be approached systematically, with flowcharting care and defining standardized measures for each institution.

Sindrome confusional agudo (delirio) en los servicios de medicina del HNERM / Delirium in patients of the department of medicine of the HNERM

Para determinar la incidencia, etiología y epidemiología del delirio, se realizó un estudio prospectivo descriptivo de 102 pacientes portadores del delirio, diagnosticados mediante la aplicación del Mini-Mental State Examination (MMSE), hospitalizados en los servicios de Medicina Interna del HNERM-IPSS durante los meses de Enero a Julio de 1993. Se encontró una incidencia de 25.9 por ciento, el 90 por ciento de pacientes fueron mayores de 60 años, el 17.6 por ciento presentó delirio puro, el 18.6 por ciento presentó delirio sobre cuadro de demencia. La mortalidad fue del 21.6 por ciento (las causas más frecuentes fueron: Infecciones pulmonares y del tracto urinario, seguido de los transtornos metabólicos). Se concluye que el delirio es un cuadro común en ancianos hospitalizados, que es pobremente diagnosticado y su reconocimiento se facilitaría con la aplicación del MMSE y el uso de un protocolo dirigido de diagnóstico.