The potential benefit of metformin to reduce delirium risk and mortality

A new research paper titled "The potential benefit of metformin to reduce delirium risk and mortality: a retrospective cohort study" has been published in Aging.

17 jan 2023--Metformin has been reported to improve age-related disorders, including dementia, and to lower mortality. This study was conducted to investigate whether metformin use lowers delirium risk, as well as long-term mortality.

In the current retrospective cohort study, researchers from Stanford University School of Medicine, University of Iowa Carver College of Medicine, University of Iowa College of Public Health, and Tottori University Faculty of Medicine analyzed 1,404 previously recruited subjects. The relationship between metformin use and delirium, and the relationship between metformin use and 3-year mortality were investigated.

The researchers state, "Thus, in this report we aimed to investigate the relationship between DM [diabetes mellitus] and delirium risk with a focus on the influence from metformin. We hypothesized that history of metformin use is associated with lower risk for delirium. We were also interested in testing if history of metformin use can alter one of the most important patient outcomes, mortality."

In total, 242 subjects were categorized into a type 2 diabetes mellitus (DM)-without-metformin group, and 264 subjects were categorized into a DM-with-metformin group. Prevalence of delirium was 36.0% in the DM-without-metformin group, and 29.2% in the DM-with-metformin group. A history of metformin use reduced the risk of delirium in patients with DM (OR, 0.50 [95% CI, 0.32 to 0.79]) after controlling for confounding factors.

The 3-year mortality in the DM-without-metformin group (survival rate, 0.595 [95% CI, 0.512 to 0.669]) was higher than in the DM-with-metformin group (survival rate, 0.695 [95% CI, 0.604 to 0.770]) (p=0.035). A history of metformin use decreased the risk of 3-year mortality after adjustment for confounding factors (HR, 0.69 [95% CI, 0.48 to 0.98]). The researchers concluded that metformin use may lower the risk of delirium and mortality in DM patients.

"In this report, we showed the potential benefit of metformin in decreasing the risk of delirium and mortality in DM subjects," the researchers conclude.

More information: Takehiko Yamanashi et al, The potential benefit of metformin to reduce delirium risk and mortality: a retrospective cohort study, Aging (2022). DOI: 10.18632/aging.204393

 

To prevent delirium, increase mobility, connection and sleep

by Suzanne Leigh, University of California, San Francisco

Credit: Pixabay/CC0 Public Domain

Accelerated cognitive decline in patients with and without existing dementia is one of the most disturbing outcomes of hospitalizations for older adults, affecting at least 2.6 million Americans every year.

12 jun 2021--But the condition, known as delirium, is believed to be preventable in up to 40 percent of hospital-acquired cases, and researchers at UC San Franciso wanted to see if simple tweaks, like avoiding nighttime interruptions to promote sleep, nixing certain prescription drugs, and promoting exercise and social engagement, could decrease its incidence.

In a June 8, 2021, study in the Journal of Hospital Medicine, the researchers followed approximately 22,700 inpatients aged 50 and over who had been admitted to and discharged from the same non-intensive care unit at UCSF Medical Center. Half of the patients were admitted after the hospital had implemented a comprehensive delirium prevention and treatment care pathway, which included screening on admission as well as during each 12-hour nursing shift.

Since the screening did not take place prior to the study, the researchers could not confirm the interventions' impact on delirium prevention. However, data comparing outcomes pre- and post-intervention showed an overall 2 percent drop in length of hospital stay. Remarkably, for the approximate 20 percent of study participants in the medicine unit, where patients require less specialized care, the researchers found a 9 percent drop in length of stay, together with a 7 percent reduction in cost savings, for an average of $1,237 less per hospitalization.

Some specialty patients less likely to respond to interventions

The difference in impact between patients in the medicine unit and those in specialty care can be explained by the fact that the former are more likely to be elderly patients who develop delirium due to sleep deprivation, restraints and certain drugs, said senior author Vanja Douglas, MD, of the UCSF Department of Neurology and the Weill Institute for Neurosciences. "Other patients, such as neurology and neurosurgery patients, are delirious due to factors like recent brain surgery, seizures or encephalitis, and are less likely to respond to the non-pharmacologic interventions that were part of the delirium care pathway."

Interventions for patients of all specialties also led to a 14 percent reduction in the number of 30-day readmissions, a sign that "patients at risk of delirium may not have developed delirium or that interventions reduced its duration," said first author Sara LaHue, MD, also from the UCSF Department of Neurology and the Weill Institute for Neurosciences.

The hallmarks of delirium include confused thinking, restlessness and agitation, together with reduced awareness of the environment and changes in attention ranging from confusion to withdrawal. Unlike dementia, which develops gradually, delirium starts rapidly and may be triggered by acute illness, as well as by hospitalization. Patients over 75 with hearing or vision impairments, who have been living in a nursing home or assisted living facility are at higher risk.

"Compared with non-delirious patients, delirious patients are more likely to consume more hospital staff time and life-support resources, stay longer and develop in-hospital complications," said LaHue.

The researchers found that 12.6 percent of the patients, whose average age was 67, had delirium on admission, and 5.6 percent developed the condition during their stay. The patients' risk for delirium was gauged by age, illness severity, orientation and ability to perform a simple word or math test. For patients at high risk, the researchers reviewed their medications and eliminated or substituted those that were "deliriogenic." They also revised nighttime routines to avoid interruptions, prescribed melatonin as a sleep aid, and in some cases scheduled consults with occupational and speech/language therapists to help with mobility and cognitive stimulation.

Bladder catheters, restraints linked to more delirium

Of note, bladder catheters were removed, an initiative that is a cornerstone of delirium prevention, according to LaHue. "Any kind of tether, like a bladder catheter or physical restraint, limits mobility and adds to the risk of disorientation," she said.

Similarly, the use of physical restraints was decreased in all study patients, from 17.1 restraint days per 1,000 patient days in the first three months of the intervention to 11 restraint days per 1,000 patient days in the last three months of the 12-month intervention. "As a result, one might expect a need for more frequent safety attendant use and an associated cost increase," said Douglas. "However, we found that safety attendant use decreased significantly with the intervention, in parallel to reduced restraint use."

Additionally, they recommended that nursing staff walk with higher-risk patients three times a day and engage in conversation, assist them with getting out of bed to eat their meals, ensure water was within reach at all times, and reinforce awareness of time by writing the date on the board in their room, and by lowering shades at night and opening them in the day.

COVID safety measures may mean future 'epidemic of cognitive impairment'

While the study was conducted prior to the pandemic, LaHue has since noted that patients hospitalized with COVID-19 join the ranks of those at high risk for delirium. In her perspective published last year, LaHue states that not only does COVID-19 lead to a "heightened inflammatory state" that raises risk, but aggressive efforts to prevent transmission of the virus in hospitals exacerbate those risks. These include less engagement with PPE-clad clinicians and bans on visitors, who may have played an essential role in reducing delirium risk by "encouraging physical and cognitive stimulation, protecting their loved ones from falls and advocating for their basic needs."

LaHue points to a study that found 9.5 percent of cognitively normal adults who developed delirium following surgery were diagnosed with mild cognitive impairment or dementia within one year, indicating that long-term effects may be at least partially irreversible even in those without existing dementia. For hospitals, efforts to curtail the spread of the virus may have resulted in collateral damage: an epidemic of a different nature.

"In addition to the physical and psychological challenges that COVID-19 survivors face," she said, "a surge in delirium during this pandemic may lead to a delayed epidemic of cognitive impairment."

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More information: Andrea Yevchak Sillner et al, Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults, Journal of Hospital Medicine (2020). DOI: 10.12788/jhm.3410

Provided by University of California, San Francisco 

 

Delirium a key sign of COVID-19 in frail, older people

by King's College London

Credit: Pixabay/CC0 Public Domain

A new analysis of data from researchers at King's College London using information from the COVID Symptom Study app and patients admitted to St Thomas' Hospital in London, has shown that delirium—a state of acute confusion associated with a higher risk of serious illness and death—is a key symptom of COVID-19 in frail, older people.

04 october 2020--The findings, published in the journal Age and Ageing, highlight that doctors and carers should be aware of delirium as a possible early warning sign of COVID-19 in the elderly, even in the absence of more typical symptoms such as cough or fever.

Led by clinical fellow and geriatrician Dr. Rose Penfold at King's College London, the researchers analyzed data from two groups of older people aged 65 or over from March through May. The first group included 322 patients admitted to hospital with COVID-19 who had tested positive for COVID-19, while the second comprised 535 users of the COVID Symptom Study app who reported having had a positive test result.

They found that older adults admitted to hospital who were classified as frail according to a standard scale were more likely to have had delirium as one of their symptoms than people of the same age who were not classed as frail. Delirium, along with tiredness and breathlessness, were also more common in frailer users of the COVID Symptom Study app with COVID-19, compared with fitter people of the same age.

A third of app users experiencing delirium did not report suffering the 'classic' COVID-19 symptoms of cough and fever, while delirium was the only symptom for around one in five (18.9%) of hospitalized patients.

Frailty in the group of hospitalized patients was measured using the Clinical Frailty Scale (CFS) test, which is administered by a doctor. COVID Symptom Study App users were asked to complete a short questionnaire asking about their health, which is comparable to the CFS.

This is the first study showing that delirium is a likely symptom of COVID-19 in frail older adults, although the precise biological connection between the two conditions still needs to be understood. The findings also highlight the need for systematic assessment of frailty for older people, along with awareness and screening for delirium for this vulnerable population in hospitals, care homes and the community.

Dr. Rose Penfold from King's College London said: "Older, frailer people are at greater risk from COVID-19 than those who are fitter, and our results show that delirium is a key symptom in this group. Doctors and carers should watch out for any changes in mental state in elderly people, such as confusion or strange behavior, and be alert to the fact that this could be an early sign of coronavirus infection."

Dr. Claire Steves from King's College London said: "The past six months have shown us that COVID-19 can spread catastrophically through care homes. Knowing that delirium is a symptom in frail, elderly people will help families and carers spot the signs earlier of COVID-19 and act appropriately and put in place infection control measures such as isolation, increased hygiene and personal protective equipment to protect this highly vulnerable group."

Professor Tim Spector, Professor of Genetic Epidemiology at King's College London and COVID Symptom Study lead, said: "In April we upgraded the COVID Symptom Study app to allow users to log health reports on behalf of friends and family who aren't able to access the app. This significantly increased the number of older people in the study, providing vital insights. We're hugely grateful to all our users and urge everyone to download the app and log their health and that of their loved ones on a daily basis as we move towards the winter months."

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More information: Maria Beatrice Zazzara et al, Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults, Age and Ageing (2020). DOI: 10.1093/ageing/afaa223

Journal information: Age and Ageing 

Predicting vulnerability to Alzheimer's disease and delirium

by Beth Israel Deaconess Medical Center

Credit: CC0 Public Domain

Marked by acute temporary confusion, disorientation and/or agitation, postoperative delirium is the most common post-surgical complication in older adults, striking as many as half of adults older than 65 who undergo high-risk procedures such as cardiac surgery or hip replacements. Postoperative delirium is also tightly linked to Alzheimer's disease (AD). Although each can occur independently, Alzheimer's is a leading risk factor for delirium, and an episode of delirium puts patients at increased risk for cognitive decline and Alzheimer's disease. However, the physiological mechanisms linking delirium and Alzheimer's disease remain largely unknown.

05 dec 2019--A paper published today in Alzheimer's & Dementia: The Journal of the Alzheimer's Association, researchers at Beth Israel Deaconess Medical Center (BIDMC) shed new light on a genetic risk factor for Alzheimer's disease that may indirectly influence patients' risk of postoperative delirium. In a study of older adults without dementia undergoing major non-cardiac surgery, researchers observed that patients carrying a specific variant of a gene appeared to be much more vulnerable to delirium under certain conditions than people without this genetic variant. The team's findings could open the door to future interventions to prevent or mitigate postoperative delirium in at-risk patients.

"Our findings confirmed our hypothesis that patients' risk of postoperative delirium differs by genetic predisposition," said Sarinnapha M. Vasunilashorn, Ph.D., an Assistant Professor of Medicine in the Division of General Medicine at BIDMC. "We observed a strong and significant association between high postoperative inflammation and delirium incidence, duration and severity among patients carrying a variant of the gene considered to be risky, while the association was weaker and non-significant among non-carriers."

Vasunilashorn and colleagues focused on a gene called APOE (short for apolipoprotein E). The risky version of the gene—notated as APOE ɛ4—is the strongest known genetic risk factor for late-onset Alzheimer's disease and a widely studied genetic risk marker for delirium. While recent studies have shown no direct relationship between APOE ɛ4 and delirium, Vasunilashorn's team hypothesized that the gene variant might indirectly influence risk of delirium by modifying the body's response to inflammation—part of the immune system's natural defense system—indicated by the presence of an inflammatory marker in the blood called CRP (C-reactive protein).

Using data from the Successful Aging after Elective Surgery (SAGES) study, an ongoing prospective cohort study investigating risk factors and long-term outcomes of delirium, the scientists looked at the incidence, severity and duration of delirium in 560 patients 70 years or older who underwent major non-cardiac surgeries under general or spinal anesthesia. Patients were monitored for delirium, assessed by daily cognitive assessments of patients' attention, memory and orientation throughout their hospital stay.

Analyzing data from patients' blood (drawn before surgery, immediately after surgery, two days after and one month after) revealed that, among carriers of the APOE ɛ4 gene variant, patients with high levels of inflammation had an increased risk of postoperative delirium. However, among non-carriers of the APOE ɛ4 gene variant, the scientists found no such association.

"Our findings suggest that APOE ɛ4 may be an indicator of brain vulnerability," said Vasunilashorn, who also holds appointments at Harvard Medical School, and the Harvard T.H. Chan School of Public Health. "This work may inform the targeting of future interventions, such as anti-inflammatory treatments, for prevention of postoperative delirium and its associated adverse long-term cognitive outcomes in patients with this genetic susceptibility."

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More information: Sarinnapha M. Vasunilashorn et al, Apolipoprotein E genotype and the association between C-reactive protein and postoperative delirium: Importance of gene-protein interactions, Alzheimer's & Dementia (2019). DOI: 10.1016/j.jalz.2019.09.080

Provided by Beth Israel Deaconess Medical Center 

Common muscle relaxant causes severe confusion in patients with kidney disease

by University of Western Ontario

Credit: CC0 Public Domain

One in 25 patients with very low kidney function were admitted to hospital with severe confusion and other cognitive-related symptoms a few days after being prescribed a common muscle relaxant.

11 nov 2019--A new study from ICES Western, Western University and Lawson Health Research Institute has shown that patients with kidney dysfunction who were prescribed a high dose of the drug baclofen, were more likely to be admitted to hospital for disorientation and confusion, than those who weren't prescribed the drug. Their results are being published on November 9 in the high impact journal, JAMA and are being presented at the same time at the American Society of Nephrology meeting in Washington, D.C.

"When we looked at people with low kidney function (30 per cent or less) who received a high dose of baclofen from their prescriber, approximately one in 25 were being admitted to hospital with severe confusion, typically over the next few days, " said Dr. Amit Garg, Professor at Western's Schulich School of Medicine & Dentistry and Scientist at ICES and Lawson. "If you compare that to a group of people who had low kidney function who didn't get baclofen, that risk is less than one in 500, so it's quite a dramatic difference between the two groups."

The research was initiated because of observations that nephrologists were noting in clinic at London Health Sciences Centre.

Dr. Peter Blake, Professor at Schulich Medicine & Dentistry, Lawson scientist and coauthor on the study says this drug is commonly prescribed for muscle spasms and muscle pain, and is also prescribed off-label for alcoholism, gastro-esophageal reflex disease, and trigeminal neuralgia. He says it is widely prescribed because it has not previously been associated with serious side-effects.

More than eight million prescriptions for the drug were handed out in the United States in 2016, and despite numerous case reports linking baclofen with cognitive symptoms in patients with kidney disease, this is the first population-based clinical study to look at the association between the two.

"It came to my clinical attention dealing with patients with advanced kidney failure, that this drug that is generally thought to be relatively harmless, appeared to be the precipitant of severe confusion," said Dr. Blake. "These are patients who had previously been very oriented, and they were suddenly extremely confused and when you took a history, we understood that they had recently started this drug, baclofen."

Using ICES data, the research team looked at a group of approximately 16,000 people in Ontario with kidney disease who started a new dose of baclofen between 2007 and 2018. They divided the patients into two groups, a group that received a high dose, and a group that received a low dose of the drug and compared both to a group of almost 300,000 kidney disease patients who were not prescribed the drug at all.

About 20 per cent of older adults live with kidney function of less than 60 per cent. The research team found that 1.11 per cent of such patients (108/9707) who started a high dose of the drug baclofen were admitted to hospital with cognitive-related symptoms, versus 0.42 per cent (26/6235) with the low dose. They found that the group most at risk had the lowest kidney function, 3.78 per cent of patients with kidney function less than 30 per cent were hospitalized with these symptoms after starting a high dose of baclofen (26/687).

"We found that in current practice most patients are getting a similar dose of baclofen no matter what the level their kidney function is," said Dr. Garg who is concerned about this discrepancy in dosing because prescribing guidelines already suggest a lower dose for patients with kidney dysfunction that isn't being followed. "We also found that the risk for hospitalization for severe confusion was higher amongst patients who received doses that were higher versus doses that were lower."

The authors hope this study will better inform physicians and pharmacists about the use of baclofen for patients with kidney disease. "This study shows quite clearly the potential harm of this drug.

When a patient with low kidney function presents to the hospital with confusion, when their medication list is reviewed baclofen should be considered as a potential culprit. We're hoping regulatory agencies will now take a look at this and perhaps add a new black box warning for baclofen. With this new information prescribers should reconsider risk-benefit, and should be quite cautious before they prescribe this drug. When they believe the drug is indicated, a low dose should be considered, and patients and their families should be warned about what to look out for in terms of side effects."

The authors also say patients should not stop their prescription medications without talking to their doctor.

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More information: Flory T. Muanda et al, Association of Baclofen With Encephalopathy in Patients With Chronic Kidney Disease, JAMA (2019). DOI: 10.1001/jama.2019.17725

Journal information: Journal of the American Medical Association 

Provided by University of Western Ontario

With AGS Cocare, HELP, AGS expands reach of seminal delirium prevention program

by American Geriatrics Society

Credit: CC0 Public Domain

A seminal program for preventing delirium (the medical term for abrupt, rapid-onset confusion or altered mental state, affecting millions of older adults annually) and loss of function for hospitalized older adults stands poised for a major expansion thanks to the American Geriatrics Society (AGS). As the soon-to-be newest addition to the AGS "CoCare" portfolio, a suite of programs helping embed geriatrics expertise in broader care for older adults, AGS CoCare: HELP represents a new step forward for a program that has already taken significant strides.

13 oct 2019--"Empowering health systems to recognize, manage, and prevent delirium is one of the hallmarks of geriatrics, one that put the specialty on the map," notes Sharon K. Inouye, MD, MPH, who developed the original Hospital Elder Life Program (HELP), now known as AGS CoCare: HELP. "With this critical expansion of a key program that made delirium prevention possible, we now have bandwidth through the AGS to demonstrate to more health systems than ever before how collaborating with geriatrics leads to improved health, safety, and independence for us all," Dr. Inouye concluded.

Through AGS CoCare: HELP (which will launch later this year at help.agscocare.org), more health systems than ever before will have access to tools and hands-on guidance for making delirium prevention actionable locally and for individual patients. Institutional subscriptions offer access to a comprehensive implementation toolkit, an online educational curriculum for HELP staff and volunteers, a certification program, scheduling for routine coaching calls, and access to an online community available 24-7.

Perhaps more importantly, they also help standardize best practices while supporting work to keep these practices at the cutting-edge of delirium-prevention science. The program ultimately promotes a growing trend toward "age-friendly health systems" in the U.S.—so named because they help promote unique expertise on geriatrics focal points, such as care for the mind, medications, mobility, and what "matters most" to patients as people.

And behind it all is an evidence-based program with decades of experience and proven results improving the health and care of hospitalized older adults.

For millions of older adults, HELP has made health systems safer—and health care more effective. Delirium affects more than 2.6 million older adults per year in the U.S., accounting for more than $164 billion annually in excess Medicare expenditures. HELP set out to change that—and did so with resounding success. On average, delirium cases dropped by more than 30 percent among the more than 200 hospitals employing HELP, which also reduced costs by more than $7 million annually at participating hospitals (a savings of more than $1,000 per patient).

According to Dr. Inouye, HELP's success rests on its streamlined, stepwise approach, particularly when it comes to embedding fundamental geriatrics principles into the fabric of existing care structures.

"To the untrained eye, delirium can happen without warning—but there are tell-tale signs that point to risk, and proven interventions to reduce its likelihood," Dr. Inouye observes. "Health systems just need to know how, which is where HELP offers critical assistance."

HELP does so by providing an organized system to manage markers of delirium and delirium prevention—from maintaining physical and cognitive function to maximizing independence in the transition from hospital to home. This system includes training to understand the value and practical implementation of daily patient visits, therapeutic activities, early mobilization programs, protocols to optimize sleep and hearing/vision, and opportunities for smoothing transitions between care settings. Using comprehensive HELP resources and training, whole health systems can implement delirium prevention protocols, provider education, and audio-visual tools, while individual HELP staff and a network of specially trained volunteers can work with patients one-on-one to reduce personal risks and prevent lengthier stays.

Soon to be available 24-7 at help.agscocare.org, AGS CoCare: HELP joins an established roster of AGS programs to increase collaboration between geriatrics experts and their colleagues. AGS CoCare: Ortho, the first in the AGS CoCare series, for example, has been implemented at health systems across the U.S. to improve health outcomes for older adults hospitalized with hip fractures.

More information: For more information, visit AmericanGeriatrics.org/Programs/AGS-CoCare-HELPTM.

Provided by American Geriatrics Society 

Common use of antipsychotics shown ineffective for delirium in intensive care patients

Critically ill patients in intensive care units (ICUs) did not benefit from two antipsychotic drugs used to treat delirium, according to a large clinical trial funded by the National Institute on Aging, part of the National Institutes of Health. The multi-site team that conducted the trial found no evidence that treatment with antipsychotic medicines—haloperidol or ziprasidone—affected delirium, survival, length of ICU or hospital stay or safety. The findings from the Modifying the Incidence of Delirium USA (MIND USA) study were published online Oct. 22, 2018 in the New England Journal of Medicine.

10 nov 2018--"This is strong evidence from what we consider a 'gold standard' clinical trial showing that these two antipsychotics don't work to treat delirium during a critical illness," said NIA Deputy Director Marie A. Bernard, M.D. "Antipsychotics have often been used to treat delirium. The evidence from this study suggests the need to reexamine that practice." Bernard is also NIA's senior geriatrician.
Delirium is an acute disturbance in attention and awareness with symptoms that can include disorganized thinking and agitation. More than 7 million hospitalized Americans per year experience delirium. It can affect patients of any age but is more common among older adults who experience major illness—especially involving an ICU stay—or have major surgery. Delirium is also associated with higher ICU costs and multiple adverse outcomes, such as longer hospital stays, long-term cognitive impairment and death.
Antipsychotic medications have been used to treat delirium in ICU patients for 40 years without definitive understanding of their effectiveness. To address the question of benefit versus risk of the use of antipsychotics for delirium, the MIND USA investigators, led by E. Wesley Ely, M.D., M.P.H., professor of medicine at Vanderbilt University Medical Center, Nashville, Tennessee, associate director of Research for the VA Geriatric Research Education Clinical Center, and co-director of the CIBS (Critical Illness, Brain dysfunction, and Survivorship) Center, screened nearly 21,000 patients at 16 U.S. medical centers. Of the 1,183 patients on mechanical ventilation or in shock enrolled, 566 became delirious and were randomized into three groups: those who received intravenous haloperidol, ziprasidone or placebo (saline). The researchers then measured for endpoints including delirium and coma duration, time on mechanical ventilation, successful discharge from ICU and hospital, as well as 30- and 90-day mortality.
Researchers found no significant difference in duration of delirium or coma among those participants on haloperidol or ziprasidone compared to placebo. Similarly, there were no significant differences among participants on either antipsychotic medication compared to placebo in 30-day and 90-day mortality or time on the ventilator, or in the ICU and hospital.
The study population included participants with a wide range of ages, conditions and admission diagnoses. Overall, they had a 73-percent 30-day survival rate and 64-percent 90-day survival rate, which reflects the severe nature of their illnesses. The research team also found no evidence of major harm from the antipsychotics but did note other research suggesting safety concerns—including increased mortality—associated with antipsychotic use in non-ICU geriatric populations.
"This research joins other important studies on delirium showing that there clearly is need for improvement in treating and managing this complicated condition," said Molly Wagster, Ph.D. chief of the Behavioral and Systems Neuroscience Branch in the NIA's Division of Neuroscience. "Large randomized trials like this can inform clinicians and help guide care."

More information: Gerard et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. NEJM. 2018 Oct. 22. DOI: 10.1056/NEJMoa1808217


Provided by National Institutes of Health

Caregivers can help assess whether older adults are dealing with delirium

Delirium is a sudden change in mental status that often occurs when older adults are in the hospital or after they have surgery. More than 20 percent of older adults may experience delirium. The condition can lead to longer hospital stays, the need to be placed on a respirator (a machine that helps you breathe), long-term changes in your cognitive (mental) health, physical disability, and even death.

05 may 2018--Acute illness (illnesses that happen suddenly, as opposed to chronic conditions that you live with over a longer period of time), surgery, and medications can contribute to delirium. In addition, disrupting regular routines may trigger sudden confusion or changes in behavior for certain people.
When healthcare professionals don't recognize or diagnose delirium, it can delay an older person's recovery. Prolonged delirium can have a lasting impact on health and well-being. What's more, delirium is distressing for caregivers—the family or friends involved in caring for an older adult. In hospitals, healthcare professionals screen ("test") for delirium. However, despite routine screening, more than 60 percent of older adults with delirium are not diagnosed in hospitals.
In a new study, published in the Journal of the American Geriatrics Society, researchers set out to learn whether caregivers could use existing questionnaires and other tools to detect delirium on their own. The researchers reviewed 6,056 scientific papers about delirium screening. They specifically were looking for proven methods that caregivers could use in home settings.
The researchers identified six tools that caregivers could use. Each one took just several minutes or less to use and had 11 items or fewer to complete. Three tools could be completed by the caregiver alone.
According to the researchers, using these caregiver-centered delirium detection tools, caregivers are generally able to identify delirium symptoms more easily than healthcare professionals who may be less familiar with the person being evaluated. Having caregivers test a person for delirium also makes it easier for the caregiver to be alert for delirium throughout a person's hospital stay. As a result, caregivers may be able to notify healthcare professionals of changes in mental status sooner, potentially leading to earlier and more frequent diagnoses for older people under their care. Engaging caregivers in delirium detection may also decrease caregiver distress. Many studies have shown that caregiver involvement in health care helps improve patient and caregiver outcomes.
Overall, caregiver-centered delirium detection tools enable caregivers to improve delirium detection. The tools can help to reduce the challenges that can accompany undiagnosed delirium. No risks associated with these tools have been reported. The researchers suggest that future studies should monitor caregiver use of delirium detection tools.

More information: Brianna Rosgen et al, Validation of Caregiver-Centered Delirium Detection Tools: A Systematic Review, Journal of the American Geriatrics Society (2018). DOI: 10.1111/jgs.15362


Provided by American Geriatrics Society

Haloperidol does not prevent delirium or improve survival rates in ICU patients

Prophylactic use of the drug haloperidol does not help to prevent delirium in intensive care patients or improve their chances of survival. Therefore, there is no reason anymore to administer the drug as a preventive measure to reduce the burden of delirium. This was revealed following a three-year, large-scale study among 1,800 patients in 20 Dutch ICUs, headed by Radboud university medical center. The results of this world's largest research project into delirium prevention in the ICU have been published on February 20 in the Journal of the American Medical Association (JAMA).

22 feb 2018--Acute confusion, or delirium, occurs in approximately one third to half of all patients in the intensive care unit (ICU), and hasserious short-term and long-term consequences. Patients who develop delirium need mechanical ventilation for a longer time and their stay in the ICU and in the hospital is also longer. Also, patients with delirium are more likely to die compared to patients without delirium. If a patient develops delirium, the drug haloperidol is often used to treat it.

Large-scale research

There were indications that haloperidol could be effective not only to treat, but also to prevent delirium. A large-scale trial, headed by Mark van den Boogaard from the Radboud university medical center, was conducted in 20 Dutch ICUs to investigate if prophylactic use of haloperidol could reduce delirium and its consequences. A total of 1,800 ICU patients with a high risk of delirium were included in this trial and received a low dose of haloperidol, or a placebo. This trial, funded by ZonMw (the Netherlands Organisation for Health Research and Development), is worldwide the largest trial in this field.
As mortality rates among patients with delirium are higher, the researchers tried to find out whether using prophylactic haloperidol would reduce the mortality and delirium and its sequelae.
The conclusions of this trial were crystal clear: prophylactic therapy with haloperidol did not affect any of the endpoints being studied. Principal investigator Mark van den Boogaard: "This large-scale study shows indisputably that use of prophylactic haloperidol in ICU patients has no beneficial effects whatsoever. These findings will lead to fewer unnecessary drugs being prescribed to ICU patients."
Head of the research, Professor Peter Pickkers: "The scope of the study and the fact that the results are so unambiguous make the message from our research abundantly clear: there is absolutely no point in administering haloperidol to ICU patients as a preventive measure."

More information: Mark van den Boogaard et al. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium, JAMA (2018). DOI: 10.1001/jama.2018.0160 Mark van den Boogaard et al. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium, JAMA (2018). DOI: 10.1001/jama.2018.0160


Provided by Radboud University

Delirium is associated with five-fold increased mortality in acute cardiac patients

Delirium is associated with a five-fold increase in mortality in acute cardiac patients, according to research published today in European Heart Journal: Acute Cardiovascular Care. Delirium was common and affected over half of acute cardiac patients aged 85 years and older.

16 mar 2017--Delirium is a clinical syndrome caused by a disturbance in the normal functioning of the brain. Delirious patients are less aware of, and responsive to, their environment. They can be disorientated, incoherent, and in a dream-like state, with hallucinations, disordered speech and memory disturbances.
Delirium affects at least one in ten hospitalised patients and is more common in the elderly. These patients have worse long-term prognosis and more complications during their hospital stay.
"Among hospitalised patients, those admitted to an intensive care unit are more likely to develop delirium and there are strategies to limit its consequences," said lead author Dr Giovanni Falsini, interventional cardiologist, San Donato Hospital, Arezzo, Italy. "Less is known about delirium and its significance in patients admitted to cardiac intensive care units. This study investigated the incidence and clinical impact of delirium in patients with acute cardiac diseases."
The study included all patients aged 65 years and older admitted to two cardiac intensive care units during a period of 15 months. Only non-intubated patients were enrolled. Validated score systems and questionnaires were used to detect and diagnose the presence of delirium at admission or during the hospital stay.
Delirious patients were closely followed by nursing and medical staff who used a flowchart for delirium treatment. This included treating pain and anxiety, and discontinuing medications known to cause delirium. Patient survival at six months was determined by telephone call.
The investigators found that delirium was a frequent condition among elderly patients with acute cardiac diseases. The study population consisted of 726 patients with an average age of 79 years, of whom 15% had delirium (at admission or during the hospital stay). More than half (52%) of patients aged 85 years and older were delirious.
Patients with delirium had a worse prognosis, with a five-fold increase in both in-hospital and 30-day mortality and a two-fold increase in six-month mortality. Delirium was not only a strong and independent factor in predicting mortality, but was also associated with longer hospital stay and more frequent rehospitalisations during follow-up.
"Delirium is a common and serious condition in acute cardiac patients," said Dr Falsini. "They stay in hospital longer, return to hospital more often, and are more likely to die in the short- and long-term."
Dr Falsini said elderly patients may be at higher risk because they usually have pre-existing issues that can predispose to delirium such as dementia, visual and hearing impairments, depression, use of psychoactive drugs, infections, or electrolyte disturbances.
He said: "The more complex and frail the patient is, the higher the rate of delirium and subsequent worse outcomes. It is unknown whether delirium can be treated to improve prognosis in critically ill patients, or whether it is a marker of organ dysfunction or systemic disease and an early sign that complications are likely. Monitoring delirium has been linked with reduced in-hospital mortality in mechanically ventilated patients and it is possible that similar benefit might occur in acute non-intubated patients."
Dr Falsini concluded: "Delirium is common, serious, costly and under-recognised. A protocol is needed to identify and treat delirium in high-risk settings, like cardiac intensive care units."

More information: Falsini G, et al. Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: a prospective study (DELIRIUM CORDIS). European Heart Journal: Acute Cardiovascular Care. 2017. DOI: 10.1177/2048872617695235


Provided by European Society of Cardiology

Delirium at nursing home admission a risky sign for seniors

Seniors with delirium who enter the nursing home after hospitalization are at greater risk than patients who make that transition without the condition, according to new research. Credit: Graphicstock

Brown University public health researchers who analyzed the medical records of more than 5.5 million seniors admitted to nursing homes between 2011 and 2014 found that approximately 240,000 had delirium. Those patients faced serious additional health risks compared to those without the condition.

29 jun 2016--"Upon admission to post-acute care, there are at least 4 percent of patients who have delirium," said Cyrus Kosar, a graduate student who led the research and presented the results June 25 at the AcademyHealth Annual Research Meeting in Boston. "We should make an effort to improve care for these specific patients since they are high risk."
The research was selected as one of the best student abstracts in AcademyHealth's Long Term Services and Supports Interest Group. The honor includes a $550 award as well as a one year AcademyHealth student membership.
Delirium is sometimes misunderstood, even among health care providers. Often observed among hospitalized patients – particularly older ones – it's an acute decline in cognitive functioning that may appear to come and go, sometimes within matters of hours. It's not chronic, which is a key distinction from dementia, a long-term, progressive, terminal degeneration of brain function.
Delirium may result from severe illnesses such as lingering infections, dehydration, sedation, or an improper blending or administration of medications.
"Delirium essentially is a good signal of a sicker patient or for a patient who is not getting the care that they need," said Kosar, who worked with Vince Mor and Kali Thomas professor and research assistant professor respectively of health services, policy and practice in the School of Public Health.
Other researchers have found that health outcomes among patients with delirium are worse while they are in the hospital than for people without delirium. In this case, Kosar and Thomas wanted to look into the impact of delirium on post-acute care outcomes, which has rarely been studied.
"There is a good chance that the patients who are admitted to post-acute care with delirium came from acute care with delirium, so we might be capturing a group of patients with unresolved delirium," Kosar said.
Kosar, Thomas and Mor performed their analysis by looking in the Minimum Data Set 3.0, a national dataset of nursing home care that recently began requiring structured assessments of delirium. To compile the records, nursing home personnel measured a variety of demographic and health characteristics in incoming patients, including delirium using the standard Confusion Assessment Method. In all, their sample included 5.58 million patients aged 65 or older admitted to nursing homes for post-acute care.
Of all the patients, more than 1.1 million had dementia, but even after a statistical accounting for that form of cognitive decline and other health problems (as well as age, gender and other factors) the patients with delirium faced greater health risks.
The mortality rate after 30 days was 16 percent among those with delirium compared to 6 percent (a statistically adjusted 2.3 times greater risk). The risk of readmission to the hospital within a month was also higher: 21 percent for seniors with delirium vs. 15 percent among those without (a 1.4 times risk). Among those delirium patients who went home after the nursing home admission, their rate of functional recovery (a decrease in dependency for daily living activities as measured by a standard scale) was lower: 49 percent vs. 60 percent (a statistically adjusted 17 percent lower chance).
The results can help nursing home care providers become aware that a significant number of their patients likely arrive with delirium and that the stakes for those patients are especially high, the researchers said. Identifying and addressing it could save lives and spare patients (and their insurers) from unnecessary readmissions to the hospital.
"I do believe there are patients we can target to address their delirium more effectively," Kosar said. "There are going to be times when we can address the issues."


Provided by Brown University

Antipsychotic drugs may not be effective against delirium

A recent review of the medical literature does not support the use of antipsychotic medications for preventing or treating delirium in hospitalized patients.

23 mar 2016--Investigators analyzed 19 relevant studies. In seven studies comparing antipsychotics with placebo or no treatment for delirium prevention in postoperative patients, there was no significant effect on delirium incidence. Using data reported from all 19 studies including medical and surgical patient populations, antipsychotic use was not associated with change in delirium duration, severity, hospital length of stay, or mortality. There was considerable variability in design and outcome measures among studies, however.
"When we combine all available evidence right now, there is no compelling signal to support the routine use of antipsychotic medications to reduce delirium," said Dr. Karin Neufeld, co-author of the Journal of the American Geriatrics Societystudy.

More information: Journal of the American Geriatrics Society, dx.doi.org/10.1111/jgs.14076

Provided by Wiley

Study identifies challenges of delirium detection in older adults in emergency department

27 july 2015--An estimated one to two million older adults with delirium visit hospital emergency departments in the United States annually. Yet about two-thirds of the cases of this sudden and potentially lethal change in mental status are unrecognized by emergency department clinicians who are under time pressure and almost always managing multiple patients at once. Half a year later, those with undetected delirium who were discharged from the emergency department have significantly higher mortality rates than those whose delirium was recognized.

Researchers from the Indiana University Center for Aging Research and the Regenstrief Institute have conducted what is believed to be the first study to interview providers to identify the barriers and possible catalysts to delirium detection in emergency care situations.

"Delirium is a serious condition that is too often missed in the ambulance and emergency department and we need to improve its detection," said Michael LaMantia, M.D., MPH, an Indiana University Center for Aging Research scientist, Regenstrief Institute investigator and assistant professor of medicine at IU School of Medicine. "Patients sent home from the emergency department with undetected delirium have six-month mortality rates almost three times greater than their counterparts in whom delirium is detected. Unrecognized delirium presents a major health challenge to older adults and an increased burden on caregivers and the health care system."

The researchers, led by Dr. LaMantia, report that the hectic emergency department environment, typically focusing on accident victims and acutely ill individuals rather than older adults with multiple chronic illnesses who are experiencing a sudden need for emergency care, is the largest challenge to delirium recognition and treatment. They also found that emergency department medical staffers were more likely to think of delirium in older adults when patients exhibit agitation, rather than in those who are more withdrawn.

"Emergency Medical Service, Nursing, and Physician Providers' Perspectives on Delirium Identification and Management" appears online ahead of print in Dementia: The International Journal of Social Research and Practice, a peer-reviewed journal.

In focus groups convened by the researchers, emergency physicians, emergency department nurses, and emergency medical service personnel indicated that delirium recognition is hampered by not having a sense of the baseline cognitive state of the patient, particularly among those with pre-existing cognitive impairment such as Alzheimer's disease.

Doctors indicated a need for a delirium screening test that could be rapidly administered. One physician volunteered. "We're comfortable with obvious delirium. We're all petrified, and we, at least I know my own limitations is that I guarantee you I'm missing patients who have it. And so what would make me comfortable is that when you come back to me and you said, hey we've got a thirty second test that is pretty good at screening for delirium."

Other physicians added that an emergency department dementia screening tool had to be "physician proof," simple to document, not open to interpretation, brief to administer, and "better than our judgment."

Some nurses admitted to more discomfort with treating delirium. Other nurses admitted to feeling overwhelmed by the burden of caring for an older adult with delirium in the busy emergency department environment.

"Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms by which the medical staff can easily learn about the patient's mental status from family or friends, the adoption of a systematized approach to recognizing delirium, and the institution of protocols to treat the condition when it's identified," Dr. LaMantia said. "The efforts of emergency providers, geriatricians, brain scientists, and implementation experts will be needed to further develop and test these responses to this challenging clinical condition."

Provided by Indiana University

The price of delirium: New study finds nearly half of patients have delirium

A new study presented today at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) found that 48 percent of hip fracture patients, age 65 and older, had delirium, or acute confusion, before, during and after surgery (perioperative), resulting in significantly longer hospital stays and higher costs for care.

24 mar 2015--Approximately 300,000 Americans are hospitalized with hip fractures each year. The risk is particularly high in post-menopausal women who face an increased risk for osteoporosis, a disease that diminishes bone mass and increases fracture risk. Delirium is common among older hip fracture patients, and multiple studies have found that patients with postoperative delirium are more likely to have complications, including infections, and less likely to return to their pre-injury level of function. Delirium patients also are more frequently placed in nursing homes following surgery, and have an increased rate of mortality.

In this study, researchers at the University of Toronto sought to determine the economic implications of perioperative delirium in older orthopaedic patients by reviewing hip fracture records between January 2011 and December 2012. A total of 242 hip fracture patients with a mean age of 82 (ages 65 to 103) were studied. Demographic, clinical, surgical and adverse events data were analyzed. Perioperative delirium was assessed using the Confusion Assessment Method (CAM).The study found that 116 patients (48 percent) experienced delirium during hospital admission. The patients with delirium were significantly older (mean age 85), and were more likely to have a higher American Society of Anesthesiologists (ASA) score ("one" represents a "completely healthy fit patient," and "five," a patient not expected to live beyond 24 hours without surgery). After controlling for these differences, perioperative delirium was associated with 7.4 additional hospital days and $8,282 ($8,649 in U.S. dollars) in additional hospital costs (1.5 times the cost of patients who did not experience delirium).There were no differences in mean time between triage or admission and surgery, length of surgery, or anesthesia type between groups. A significantly greater proportion of patients who experienced perioperative delirium required long-term and/or skilled care facility admission follow their hospital stay (8 percent versus 0 percent).

"Older patients are at high risk of developing delirium during hospitalization for a hip fracture, which is associated with worse outcomes," said orthopaedic surgeon and lead study author Michael G. Zywiel, MD. "Our work demonstrates that delirium also markedly increases the cost of elderly patient care while in the hospital. Given the high number of patients hospitalized every year with a hip fracture, there is a real need to develop and fund improved interventions to prevent in-hospital delirium in these patients.

"Our research suggests that reducing the rate of delirium would simultaneously increase the quality of care while decreasing costs, presenting hospitals, surgeons and other stakeholders with promising opportunities to improve the value of hip fracture care," said Dr. Zywiel.

The American Academy of Orthopaedic Surgeons' (AAOS) new clinical practice guideline, "Management of Hip Fractures in the Elderly", makes a series of recommendations to reduce delirium in older hip fracture patients. They include:

• Preoperative regional analgesia to reduce pain.
• Hip fracture surgery within 48 hours of hospital admission.
• Intensive physical therapy following hospital discharge to improve functional outcomes.
• An osteoporosis evaluation, as well as vitamin D and calcium supplements, for patients following a hip fracture.

Provided by American Academy of Orthopaedic Surgeons

Three-minute assessment successfully identifies delirium in hospitalized elders

Delirium is a state of confusion that develops suddenly, often following an acute medical illness, a surgical procedure or a hospitalization. Although delirium is estimated to complicate hospital stays for over 2.5 million elderly individuals in the U.S. each year, this common condition often goes undetected. The end result can be serious complications with sometimes devastating consequences for vulnerable hospitalized elders.

21 oct 2014--Now, investigators at Beth Israel Deaconess Medical Center (BIDMC) have developed a three-minute diagnostic assessment for delirium and demonstrated that it is extremely accurate in identifying the condition in a group of older hospital patients.

In a study that appears in the October 21 issue of the Annals of Internal Medicine, the authors report that the assessment, the 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM), detected delirium with greater-than-90-percent specificity and sensitivity when compared with a reference standard. Of particular note, the 3D-CAM was shown to be highly accurate in identifying delirium in patients with dementia, a group for whom diagnosis can be particularly challenging.

"Prompt recognition of delirium is the first step to timely evaluation and treatment, preventing complications and keeping older patients safe while in the hospital," says lead author Edward Marcantonio, MD, SM, Director of the Aging Research Program in the Division of General Medicine and Primary Care at BIDMC and Professor of Medicine at Harvard Medical School. "As growing numbers of older adults are being hospitalized, it's critically important that doctors, nurses and other hospital care providers be able to recognize delirium. We wanted to develop a brief and simple method to make this easier to accomplish, and we are extremely happy with the 3D-CAM results. It appears that this easy-to-administer interview could significantly improve detection of this common and morbid condition in vulnerable older hospital patients. "

Delirium affects 30 to 40 percent of older medical patients and between 15 and 50 percent of older surgical patients. The condition remains distressingly under-recognized, with average detection rates of only 12 to 35 percent in most clinical settings. Moreover, the cases of delirium that are identified tend to be agitated patients who are disruptive to patient care, while the patients with hypoactive delirium, who are quiet and lethargic, often are undiagnosed.

The CAM algorithm was originally developed in 1990 by the study's senior author Sharon K. Inouye, MD, MPH, Director of the Aging Brain Center in the Institute for Aging Research at Hebrew Senior Life and HMS Professor of Medicine in the Division of Gerontology at BIDMC. To date, the CAM has been used in over 4,000 original studies and has been translated into more than 14 languages. The CAM diagnostic algorithm requires that the assessor determine the presence or absence of four key features of delirium: 1) acute change and fluctuating course; 2) inattention; 3) disorganized thinking; and 4) altered level of consciousness. To be diagnosed with delirium, a patient must have features 1 and 2 and either 3 or 4.

"We have found that there are many different cognitive tests that the person rating the CAM can use to assess for these four features, and we've shown that the quality of the assessment makes a big difference in the accuracy of identification of delirium," explains Inouye. "The 3D-CAM is a major advance since it provides a brief, easy-to-administer approach that operationalizes the CAM algorithm in three minutes, and provides highly accurate results compared to a gold standard clinical assessment."

To develop the 3D-CAM assessment tool, the investigators reduced an original list of 160 questions and observations down to 20 items. To do this, each item was evaluated using a modern measurement approach called Item Response Theory, which is also used to create educational tests such as the Scholastic Aptitude Test (SAT). Only the most informative items for delirium diagnosis were selected for inclusion in the final 3D-CAM assessment. Examples included patient questions about symptoms ("Have you been feeling confused?"), structured observations ("Did the patient fall asleep during the interview?") and cognitive testing of attention and orientation.

After selecting the 20 best items and assembling the 3D-CAM interview, the authors embarked on a prospective validation study by enrolling 201 patients over age 75 who were hospitalized in BIDMC's General Medicine Service between 2010 and 2012.

The authors first conducted a "gold standard" clinical assessment for delirium and dementia, in which an experienced clinician conducted a full patient evaluation including a cognitive exam, a review of the patient's medical records and conversations with the patient's nurse and family caregiver. This assessment took between 60 and 90 minutes and resulted in data similar to a doctor's initial evaluation.

An expert panel then reviewed all of the data and made a judgment as to the presence or absence of delirium and dementia. The "gold standard" assessment, determined that 42 of 201 participants (21 percent) had delirium, 88 percent of which was hypoactive or "quiet." They also found that 56 patients (28 percent) had dementia prior to being admitted to the hospital. In some cases, patients had both delirium and dementia. Research assistants subsequently administered the 3D-CAM assessment without knowledge of the gold-standard results.

"First, we timed the test, and found that, on average, it did indeed take only three minutes to administer," says Marcantonio. The researchers then compared the results of the 3D-CAM with the gold standard assessment and found that the 3D-CAM correctly identified 95 percent of the patients with delirium (95 percent sensitivity) while correctly identifying 94 percent of patients without delirium (94 percent specificity). When a second research assistant went back and administered the 3D-CAM without knowledge of the first test results, the answer was the same 95 percent of the time (95 percent reproducibility.) Importantly, the 3D-CAM performed nearly as well in patients with dementia, which is a particularly challenging group in which to diagnose delirium.

"Given its brevity, ease of use, and excellent accuracy and reproducibility, the 3D-CAM could be an important component of a program to improve recognition and management of delirium in older hospitalized adults," says Marcantonio. Adds Inouye, "Hospitals throughout the world are increasingly recognizing the importance of delirium as a major preventable adverse event. The 3D-CAM holds great promise as an important advance for delirium care specifically, and for acute care of elders more generally."

More information: The 3D-CAM instrument and instructions are available at www.hospitalelderlifeprogram.org

Provided by Beth Israel Deaconess Medical Center

Boston-area researchers develop new delirium severity measure for older adults

A new method for measuring delirium severity in older adults has been developed by researchers from Harvard, Brown, and UMASS. The new scoring system, CAM-S, is based on the Confusion Assessment Method (CAM) and standardizes the measurement of delirium severity for both clinical and research uses. Details of this study are published in Annals of Internal Medicine.

20 april2014-Delirium is defined as the sudden onset of confusion or change in mental status that is often brought about by physical illness, surgery, or hospitalization. Delirium is a common and often costly condition that is a leading complication among older adults who are hospitalized. In fact, studies suggest that delirium in adults ages 65 and older is associated with hospital mortality rates of up to 33%, with estimated annual healthcare costs of more than $182 billion per year.

"Currently, the CAM is the most widely used tool in the world to screen for delirium," says Sharon K. Inouye, M.D., M.P.H., Director of the Aging Brain Center at the Harvard Medical School (HMS)–affiliated Hebrew SeniorLife Institute for Aging Research (IFAR) in Boston and HMS Professor of Medicine. "Our study is the first to develop and test this important new methodology, and to demonstrate the validity and reliability of the CAM-S, a novel approach to measure delirium severity."

The team developed and validated the CAM-S in two groups of patients. The first was a group of 300 patients 70 years of age or older who were scheduled for major surgery as part of the Successful Aging after Elective Surgery (SAGES) study. The second group was part of the Project Recovery study and included 919 older adults (70 or older) who were admitted to the hospital on the medical service. Researchers developed the CAM-S from the 4-item short form and 10-item long form versions of the CAM, and examined the impact of the CAM-S scores on hospital and post-hospital clinical outcomes.

CAM-S scores displayed a strong association with all clinical outcomes including length of hospital stay, nursing home placement, functional and cognitive decline, death, and hospital and post-hospital costs. The study found that length of hospital stay increases with the degree of delirium severity measured by the CAM-S short form from seven days for no delirium symptoms to 13 days for patients with severe delirium; the CAM-S long form showed similar increases in length of stay from six days to 12 days between no and severe symptom groups.

Additionally, mean hospital costs increase with the degree of delirium severity measured by the CAM-S short form from $5,100 for patients without delirium symptoms to $13,200 for those with severe symptoms. Similar results were seen across all levels of the CAM-S long form scores with mean costs increasing from $4,200 to $11,400 across delirium symptom groups ranging from none to severe.

Dr. Inouye concludes, "Our findings demonstrate that the CAM-S provides a new standardized severity measure with high inter-rater reliability, and a strong association with clinical outcomes related to delirium. We believe that this measure holds great promise to improve understanding of the effects of delirium on clinical care, prognosis, pathophysiology, and response to treatment. Ultimately, we hope that this measure will help to prevent the effects of this devastating condition and improve quality of life for older adults."

Provided by Hebrew SeniorLife Institute for Aging Research