Fatores relacionados ao delirium e à mortalidade em idosos vítimas de fratura de fêmur em uma enfermaria de ortopedia / Factors related to delirium and mortality in older adults with femur fracture on an orthopedic unit

OBJETIVO: Correlacionar as principais características clínicas do idoso internado por fratura de fêmur com a incidência de delirium e mortalidade durante a internação. MÉTODOS: Estudo transversal em pacientes com idade acima de 65 anos internados em enfermaria de ortopedia com fratura de fêmur. Foi aplicada aos pacientes e/ou cuidadores uma entrevista elaborada pelos autores para levantamento de suas características clínicas, sendo posteriormente realizada a correlação entre o perfil e a taxa de delirium e mortalidade. Para análise estatística, foi usado o programa Statistical Package for the Social Sciences (SPSS), o teste t de Student e o teste do χ2. Foi considerado estatisticamente significativo o valor p < 0,05. RESULTADOS: Noventa pacientes com média de idade de 83 anos (65­99), sendo 77,8% mulheres. O tempo médio de internação foi de 19,7 dias, sendo identificado delirium em 39,9% dos pacientes, e a taxa de mortalidade foi de 17,8%. O delirium esteve significativamente associado à idade avançada (p = 0,046), ao uso de psicotrópicos ­ especialmente a quetiapina ­ , à maior taxa de mortalidade, ao diabetes mellitus, à síndrome demencial e à baixa funcionalidade. Mortalidade, por sua vez, apresentou associação com insuficiência renal crônica, menor funcionalidade e síndrome demencial. CONCLUSÃO: Encontramos que o delirium esteve associado a idades mais elevadas, à menor funcionalidade, ao diabetes mellitus, à síndrome demencial, ao maior desfecho de óbitos e ao uso de psicotrópicos; e a mortalidade, à síndrome demencial, à insuficiência renal crônica e à pior funcionalidade.

OBJECTIVE: To correlate the main clinical characteristics of geriatric patients hospitalized for femur fracture with delirium incidence and mortality during hospitalization. METHODS: Cross-sectional study in patients over 65 years old admitted to an orthopedics unit with femoral fracture. The authors interviewed patients and / or caregivers to investigate their clinical characteristics, and subsequently correlate their profiles to the rates of delirium and mortality. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), Student's t-test and χ2 test. Significance was established at p < 0.05. RESULTS: Participants included 90 patients with a mean age of 83 years (65­99), 77.8% women. The mean length of stay was 19.7 days, with delirium identified in 39.9% of patients, and a mortality rate of 17.8%. Delirium was significantly associated with advanced age (p = 0.046), use of psychotropic drugs ­ especially quetiapine ­ , higher mortality rate, diabetes mellitus, dementia syndrome, and low functionality. Mortality, in turn, was associated with chronic kidney disease, lower functionality, and dementia syndrome. CONCLUSION: We found that delirium was associated with advanced age, lower functionality, diabetes mellitus, dementia syndrome, higher death outcomes, and the use of psychotropic drugs; and mortality was associated to dementia syndrome, chronic kidney disease, and worse functionality. KEYWORDS: geriatrics; femoral fractures; delirium; mortality.

Delirium: una comorbilidad oculta asociada a mayor mortalidad / Delirium: a comorbility associated to higher mortality rates

Introducción: el delirium es un trastorno neurocomportamental de frecuencia variable presente en pacientes hospitalizados, asociado a mayor morbimortalidad. Objetivos: detectar pacientes con delirium internados en áreas médico-quirúrgicas de un hospital general. Material y método: se realizó un estudio descriptivo, observacional, transversal, utilizando el test CAM-ICU (Confusion Assessment Method for the Intensive Care Unit), test validado para ser realizado en español y en pacientes no críticos. Se evaluaron 160 pacientes, 58,7% hombres, 44,4% en sala de medicina. La media de edad de la muestra fue de 62 años. Resultados: se identificaron 12 pacientes con delirium, representando 7,5% del total. Las enfermedades subyacentes más frecuentes fueron las infecciosas. El delirium fue más frecuente en pacientes mayores de 65 años. En 7 casos (58%) el delirium no había sido diagnosticado por el equipo médico tratante al momento del estudio. A 100 días del estudio la mortalidad global fue de 5,4% (8 pacientes), de los cuales la mitad (4) presentó delirium al ser evaluada, en ninguno de los casos el diagnóstico había sido consignado en la historia. El 33,3% de los pacientes confusos había fallecido a 100 días, confiriendo la presencia del delirium durante la internación un riesgo de muerte al alta 16 veces mayor (OR 16,4, IC95%: 3,4-77,9; p 0,0015). Conclusiones: encontramos una prevalencia de delirium del 7,5%, asociando un riesgo de muerte 16 veces mayor, resultados que apuntan a implementar estrategias de detección precoz que puedan incidir en la disminución en la morbimortalidad del paciente hospitalizado

Introduction: delirium is a neurobehavioral disorder with varying frequency in hospitalized patients, being it associated to higher morbimortality. Objectives: to identify hospitalized patients who developed delirium in the medical-surgical areas of a general hospital. Method: a descriptive, observational, transversal study was conducted using the CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) test, which was validated to be used in Spanish and in non-critical patients. 160 patients were evaluated, 58.7% male and 44.4% in the medical ward. Median age of the sample was 62 years old. Results: 12 patients with delirium were identified, which represented 7.5% of the total number of patients studied. Infectious diseases were the most frequent underlying conditions. Delirium was more frequent in patients older than 65 years old. In 7 cases (58%) the delirium had not been diagnosed by the medical team involved in the treatment at the time of the study. 100 days after the study had been started, global mortality was 5.4% (8 patients), four (4) of which evidenced delirium upon assessment. In no case had diagnosis been entered in the medical record. 33.3% of confused patients had died 100 days after, what represented that presence of delirium during hospitalization is, upon discharge, a risk factor 16 times higher (OR 16.4, CI95%: 3.4-77.9:P 0.0015). Conclusions: we found a prevalence of 7.5% of delirium, associating a risk of death 16 times higher. Results suggest the need to implement strategies for early detection that may have an impact on reducing morbimortality of hospitalized patients.

Introdução: o delirium é um distúrbio neurocomportamental com frequência variável presente em pacientes internados e está associado a uma maior morbimortalidade. Objetivos: identificar pacientes com delirium internados em áreas médicas-cirúrgicas de um hospital geral. Material e método: realizou um estudo descritivo, observacional, transversal, utilizando o teste CAM-ICU (Confusion Assessment Method for the Intensive Care Unit), teste validado para ser realizado em espanhol e em pacientes não críticos. 160 pacientes foram avaliados sendo 58,7% homens, estando 44,4% em enfermaria de medicina. A media de idade da amostra era 62 anos. Resultados: foram identificados 12 pacientes com delirium, representando 7,5% del total. As doenças infecciosas foram as doenças subjacentes mais frequentes. O delirium foi mais frequente no pacientes com mais de 65 anos. Em 7 casos (58%) o delirium não havia sido diagnosticado pela equipe de médicos que tratavam os pacientes no momento do estudo. Depois de 100 dias de realizado o estudo, a mortalidade global era de 5,4% (8 pacientes), dos quais a metade (4) apresentou delirium quando foi avaliada; o diagnóstico não havia sido registrado no expediente do paciente em nenhum dos casos. 33,3% dos pacientes confusos havia falecido a 100 dias, atribuindo a presença de delirium durante a internação um risco de morte na alta 16 vezes maior (OR 16,4, IC95%: 3,4-77,9; p 0,0015). Conclusões: encontramos uma prevalência de delirium de 7,5%, associando um risco de morte 16 vezes maior, resultados que orientam a implementação de estratégias de detecção precoce que possam influir na redução da morbimortalidade do paciente hospitalizado.

Prevalência e fatores associados com ocorrência de delirium em adultos e idosos internados / Prevalence and factors associated with delirium occurrence in hospitalized adults

JUSTIFICATIVA E OBJETIVOS: Delirium é uma complicação grave altamente prevalente em pacientes internados, com importante impacto sobre morbimortalidade hospitalar. O objetivo deste estudo foi verificar prevalência, incidência e fatores de risco de delirium em pacientes internados em hospital universitário. MÉTODO: Estudo observacional de coorte, avaliando-se 140 pacientes maiores de 18 anos entre admissão e alta. O instrumentode pesquisa foi o Método de Avaliação de Quadros Confusionais (Confusion Assessment Method). RESULTADOS: A prevalência de delirium foi 5,7% (8/140) e a incidência, 2,1%. Nos pacientes com delirium, observaram-se alteração do ciclo sono-vigília (6/75%), alteração do nível da consciência (6/75%), pensamento desorganizado (5/62,5%) e retardo psicomotor (5/62,5%). Houve associação significativa com idade, contenção mecânica no leito, antecedente de comprometimento cognitivo prévio, déficit sensorial auditivo e visual, internação psiquiátrica, mau estado geral e mortalidade hospitalar. CONCLUSÃO: A prevalência de delirium no momento da internaçãofoi menor que a encontrada em outros estudos, ocorrendo em pacientes com comprometimento sensorial e psiquiátrico prévio e contenção no leito. Evidenciou-se a importância da idade avançada como fator de risco para o seu desenvolvimento durante a internação e como fator preditivo de mortalidade hospitalar.

BACKGROUND AND OBJECTIVES: Delirium is a serious complication highly prevalent in hospitalized medical patients,with significant impact on hospital morbidity and mortality. The objective of this study was to determine prevalence, incidence and risk factors of delirium in patients hospitalized in a university hospital. METHOD: An observational cohort study evaluating 140 patients over 18 years between admission and discharge. The survey instrument was the Assessment Method Frame Confusion (ConfusionAssessment Method). RESULTS: The prevalence of delirium was 5.7% (8/140) and incidence, 2.1%. In patients with delirium were observed alteration of sleep-wake cycle (6/75%), altered level of consciousness (6/75%), disorganized thinking (5/62,5%) and psychomotor retardation (5/62.5%). It was observed a significant association of delirium and age, mechanical immobilization in bed, prior history of cognitive impairment, hearing and visual sensory deficit, psychiatric hospitalization, poor health status and mortality. CONCLUSION: The prevalence of delirium at admission was lower than that found in other studies, occurring in patients with sensory impairment and psychiatric prior restraint in bed. It was evidenced the importance of age as a risk factor for its development during hospitalization and as a predictor of hospital mortality.

Impacto del delirium en pacientes de edad avanzada hospitalizados: un estudio prospectivo de cohortes / Delirium in older medical inpatients: A one year follow up study

Background:Delirium is an important problem in older medical inpatients. Aim: To assess if delirium is associated with higher mortality, functional decline or higher rates of readmission or institutionalization in a one year follow-up period. Material and Methods: Prospective cohort study of consecutive patients 65 years and older, admitted to a general hospital medical ward. A psychogeriatric team assessed patients every 48 h using the Confusion Assessment Method (CAM), functionality, acute severity and comorbidity scores. Analysis of one year mortality and telephone functional assessment was performed. Results: Five hundred forty two patients were enrolled and 35.4% had delirium. After one year, mortality was 34.9 and 13% in delirium and non-delirium cohorts, respectively (p < 0.01). After adjustment for covariates, delirium was independently associated with higher mortality, and higher functional decline and institutionalization. No significant differences were seen in readmission rates. Conclusions: Delirium was significantly associated with higher mortality and functional decline over a one year follow up period in geriatric inpatients.

Predictors of in-hospital mortality among older patients

OBJECTIVE: The objective of this study was to determine predictors of in-hospital mortality among older patients admitted to a geriatric care unit. INTRODUCTION: The growing number of older individuals among hospitalized patients demands a thorough investigation of the factors that contribute to their mortality. METHODS: This was a prospective observational study implemented from February 2004 to October 2007 in a tertiary university hospital. A consecutive sample of 922 patients was evaluated for possible inclusion in this study. Patients hospitalized for palliative care, those who declined to participate, and those with incomplete data were excluded, resulting in a group of 856 patients aged 60 to 104 years. Bivariate and multivariate analyses were performed to determine associations between in-patient mortality and gender, age, length of stay, number of prescribed medications and diagnoses at admission, history of heart failure, neoplastic disease, immobility syndrome, delirium, infectious disease, and laboratory tests at admission (serum albumin and creatinine). RESULTS: The overall mortality rate was 16.4%. The following factors were associated with higher in-hospital mortality: delirium (OR=4.13, CI=2.65-6.44, P<.001), neoplastic disease (OR=3.38, CI=2.11-5.42, P<.001), serum albumin levels at admission <3.3mg/ dL (OR=3.23, CI=2.03-5.13, P<.001), serum creatinine levels at admission >1.3mg/dL (OR=2.39, CI=1.53-3.72, P<.001), history of heart failure (OR=1.97, CI=1.20-3.22, P=.007), immobility (OR=1.84, CI=1.16-2.92, P =.009), and advanced age (OR=1.03, CI=1.01-1.06, P=.019). CONCLUSIONS: This study strengthens the perception of delirium as a mortality predictor among older inpatients. Cancer, immobility, low albumin levels, elevated creatinine levels, history of heart failure and advanced age were also related to higher mortality rates in this population.

Subdiagnóstico de delirium en adultos mayores hospitalizados / Delirium in Chilean elderly inpatients: an overlooked problem

Background: Delirium is a common underdiagnosed and undertreated problem in elderly inpatients, associated to higher morbidity, mortality and health cost. Aim: To evaluate the prevalence of delirium at hospital admission in medically ill elderly patients and the attending physician's diagnosis and treatment of delirium. Patients and methods: In a prospective and descriptive study, consecutive patients aged 65 years or more, admitted to an internal medicine ward were evaluated by independent physicians, during the first 48 h of admission, to asses the presence of delirium. Diagnosis of delirium was based on the Confusion Assessment Method. Medical and nurse records were reviewed. Family was interviewed when necessary. Results: One hundred eight patients (52% women, age range 65-94 years) with an APACHE II score of 11.6±5, were evaluated. Fifty seven patients (53%) had delirium (32% hyperactive, 72% hypoactive and 5% mixed). Delirium prevalence was significantly higher in older patients (66% among those aged 75 years or older versus 30% in younger, p <0.05) and among patients with more severe conditions (88% among those with an APACHE score over 16 versus 47% below that value, p <0.05). Medical records of patients with delirium showed that this diagnosis was present only in 32% and cognitive deficit was described in 73%. Ten percent of patients with delirium received sedative medication and 38% were physically restricted. There were no environmental interventions to prevent or control delirium. Conclusions: Delirium in elderly inpatients at this unit is an extraordinarily prevalent problem, seriously under diagnosed (68%) and under treated. This study should alerts our medical community to improve the diagnosis and management of delirium in elderly inpatients.

Sindrome confusional agudo en pacientes internados / Acute confusional state in hospitalized patients

El síndrome confusional agudo (SCA) o delirio es uno de los trastornos mentales más frecuentes en pacientes hospitalizados por enfermedades médicas. Se analizan 278 pacientes de los cuales 30 (10.8%) presentaron SCA. Los pacientes que presentaron esta complicación eran mayores de 70 años, con antecedentes de accidente cerebrovascular y demencia, con un menor desempeño de la actividad diaria previo a la internación y requirieron mayor utilización de alimentación enteral. Las infecciones y la fractura de cadera fueron las causas de internación más frecuentes. La mortalidad fue significativamente superior en los pacientes com SCA que en pacientes sin SCA.

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.