Journal of Gerontological Nursing

Feature Article 

Outcomes of Patients With Delirium in Long-Term Care Facilities: A Prospective Cohort Study

Kyoung Ja Moon, PhD, RN, APN; Heeok Park, PhD, RN

Abstract

A 6-month prospective cohort study was performed in patients with or without dementia admitted to two Korean long-term care (LTC) facilities. Participants were categorized into four groups: (a) no delirium or dementia, (b) dementia only, (c) delirium only, and (d) delirium superimposed on dementia (DSD). Delirium incidence, mortality, readmission, discharge placement, length of stay, and other associated factors were evaluated. The incidence of delirium was 48%. The largest number of patients belonged to the DSD group; outcomes associated with delirium were analyzed as covariates. The delirium-only group had a significantly higher mortality rate than other groups. Length of stay was the longest for the dementia-only group. On the Kaplan–Meier survival curve, the delirium-only group had the lowest probability of survival compared to other groups. The mortality rate of patients with delirium only was significantly higher than the mortality rates of all other groups. LTC facilities should provide preventive interventions for patients with delirium. [Journal of Gerontological Nursing, 44(9), 41–50.]

Abstract

A 6-month prospective cohort study was performed in patients with or without dementia admitted to two Korean long-term care (LTC) facilities. Participants were categorized into four groups: (a) no delirium or dementia, (b) dementia only, (c) delirium only, and (d) delirium superimposed on dementia (DSD). Delirium incidence, mortality, readmission, discharge placement, length of stay, and other associated factors were evaluated. The incidence of delirium was 48%. The largest number of patients belonged to the DSD group; outcomes associated with delirium were analyzed as covariates. The delirium-only group had a significantly higher mortality rate than other groups. Length of stay was the longest for the dementia-only group. On the Kaplan–Meier survival curve, the delirium-only group had the lowest probability of survival compared to other groups. The mortality rate of patients with delirium only was significantly higher than the mortality rates of all other groups. LTC facilities should provide preventive interventions for patients with delirium. [Journal of Gerontological Nursing, 44(9), 41–50.]

Delirium causes changes to consciousness, memory, logical reasoning, ability to focus, and activity trends, and is characterized by its sudden occurrence (American Psychiatric Association, 2013). Delirium occurs through a combination of diverse predisposing and precipitating factors (Avelino-Silva, Campora, Curiati, & Jacob-Filho, 2017; Inouye, Westendorp, & Saczynski, 2014). The incidence of delirium is related to higher mortality rates and rising medical costs, as well as longer duration of hospital stay (Brown et al., 2016; Moon & Lee, 2015; Moon, Piao, Jin, & Lee, 2014; Muresan, Adamis, Murray, O'Mahony, & McCarthy, 2016). Many studies have found that delirium occurs commonly in patients with acute symptoms or high-severity diseases, with the incidence of delirium in older adult patients in intensive care units being 59% to 87% (Falsini et al., 2017; Inouye, 2006).

Delirium is common not only among older adult patients in high-severity and acute settings, but also among older adult residents of community and long-term care (LTC) facilities; the poor outcomes associated with delirium, such as increased morbidity, mortality, burden for family, nursing time demands, and higher health care costs, cannot be overlooked (Fick, Steis, Waller, & Inouye, 2013; Leslie, Marcantonio, Zhang, Leo-Summers, & Inouye, 2008; Marcantonio et al., 2005). Moreover, one half of hospitalized older adults with dementia experience delirium superimposed on dementia (DSD), longer stay durations and higher rates of readmission within 30 days, nursing home placement, and mortality (Fong et al., 2012; Morandi et al., 2017; Steis & Fick, 2012). One study noted that the medical costs of patients with DSD are higher than those of patients with dementia only (Kim & Kim, 2011). However, DSD continues to be inadequately addressed despite evidence of poor associated outcomes (Fick, Agostini, & Inouye, 2002).

Older adults admitted to LTC facilities are usually of advanced age and at risk of delirium in relation to poor cognitive function, visual and hearing impairment, and multiple comorbidities (Marcantonio, 2017; Voyer et al., 2012). In addition, despite the high rates of delirium and associated poor outcomes, there is a lack of research on the incidence of delirium and DSD in patients of LTC facilities in Korea (McCusker et al., 2011a). Furthermore, the level of understanding about delirium and DSD among nurses caring for such patients remains low, with few interventions being conducted in this respect (Cole et al., 2012). However, nurses are key staff in the detection of the first manifestations of delirium and the provision of early interventions. As such, the current study aimed to investigate the incidence of delirium and DSD in patients of LTC facilities, as well as their associated outcomes, to provide evidence for interventions for these patients as well as those with dementia. Specific objectives of the current study included identifying: (a) delirium incidence among LTC patients, (b) outcomes related to delirium, (c) incidence of DSD, and (d) outcomes related to DSD. Thus, this descriptive study attempts to inform future development of interventions and the effects of nurses' perceptions on delirium to decrease the incidence of delirium in LTC facilities and improve the quality of delirium nursing care.

Method

Design, Setting, Participants, and Data Collection

The current prospective cohort study was performed over 6 months between October 2016 and March 2017 at two Korean LTC facilities with 120 and 100 beds, respectively, in Daegu and Gyeong Buk. Participants were individuals older than 18 admitted to LTC who understood the purpose of the study. Consent to participate was provided by participants themselves or their guardians. Patients of LTC facilities in Korea tend to undergo primary treatment of their acute symptoms in university or large hospitals before receiving LTC. The specific environmental factors associated with LTC facilities in Korea are related to the fact that patients are beneficiaries of the National Health Insurance, which supports only patients with dementia diagnosed by a psychiatric physician and graded by the Ministry of Welfare. Consequently, dementia is one of the main conditions among patients in LTC facilities (Inouye, 2014; Jeon, Kim, & Kwon, 2016). Exclusion criteria were a consistent score of −4 or −5 on the Richmond Agitation and Sedation Scale (Tieges, McGrath, Hall, & Maclullich, 2013), severe issues associated with vision and hearing function preventing assessment using the Short Confusion Assessment Method (S-CAM) (Inouye, 2014), being transferred from the LTC facility within 12 hours of admission or deceased within the same timeframe, and not being accessible for delirium assessment due to unexpected circumstances (e.g., emergency situations). A total of 321 patients were admitted to the two institutions during the study period, of which 173 patients agreed to participate in the study and were eligible according to the above criteria; 148 patients were excluded from the study because they refused to participate or met one or more exclusion criteria. Delirium was measured twice per day for 3 months; data on relevant outcomes were collected and mortality was assessed at 6 months.

Participants were categorized as having delirium when the S-CAM (Inouye, 2014) assessment indicated trends similar to (a) acute onset, (b) inattention, and (c) disorganized thinking or altered consciousness. The CAM has been suggested to be the most appropriate method to measure delirium in LTC patients (McCusker et al., 2011b; Voyer, Richard, Doucet, & Carmichael, 2009) and has shown a sensitivity of 94% and specificity of 89% (Wei, Fearing, Sternberg, & Inouye, 2008).

Delirium measurements were performed by staff nurses in charge of patients between October and December 2016, with measurements performed every morning (between 8 a.m. and 10 a.m.) and afternoon (between 4 p.m. and 6 p.m.). These times coincided with the first round for shift nurses, with morning and afternoon measurements performed by morning-shift and afternoon-shift nurses, respectively. Moreover, when participants exhibited symptoms that suggested delirium outside measuring times, such as sudden changes in consciousness level or falling consciousness, delirium was measured using the S-CAM. According to delirium measured using the S-CAM, subtypes of delirium were classified as hypoactive, hyperactive, mixed, and non-motoric behavior.

To ensure accuracy of measurements, the S-CAM manual (Inouye et al., 2014) was used by the first author (K.J.M.) to train nurses over three 2-hour sessions. In a pilot study, interrater agreement on S-CAM measurements was assessed using 10% of the sample, and Cohen's kappa was found to be >0.99 (unpublished data). Authorization to use the S-CAM was obtained from the respective author prior to use.

Primary outcomes included delirium incidence and mortality. Secondary outcomes included 1-, 3-, and 6-month mortality rates, readmission rate, discharge placement, and length of stay. Six-month mortality was confirmed using hospital data at the 6-month mark; for patients who were discharged, the research assistant or charge nurse confirmed the mortality status through a phone call or face-to-face interview.

Patient data were collected from electronic medical records and patient records by a trained research assistant (K.J.M.), and delirium measurements were provided by the nurse in charge and head nurse. Delirium measurements and data collection were conducted after obtaining written consent from participants or their legal guardians. The study received approval from the Institutional Review Board of the authors' affiliation and respective LTC facilities. All study procedures were performed in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).

G power 3.3.10 was used to calculate the sample size; setting the effect size to 0.15, power to 0.90, and number of predictors to 8 for multiple regression analysis indicated a total of 135 participants. The study was conducted over 6 months with 173 participants.

Quantitative Variables

Cognitive status was the main independent variable, and individuals were categorized in the following groups: (a) no delirium or dementia, (b) dementia only, (c) delirium only, and (d) DSD. Descriptive and control variables selected for the current study were identified from the literature on delirium, dementia, and DSD; a literature review was performed to identify risk factors related to medical diagnosis and comorbidities. Risk factors used as covariates included age, gender, body mass index (BMI), pain, sleep disturbance, infection, bed sores, second facility, and Charlson Comorbidity Index (CCI) score according to previous studies (Inouye et al., 2014; Marcantonio, 2017; Moon, Jin, Jin, & Lee, 2018; Morandi et al., 2017), and participants were classified into the four cognitive status groups. Patients were considered to have dementia when they received a diagnosis of dementia from a physician, and the type of dementia at the time of admission to the LTC facility was recorded.

Statistical Analysis

General characteristics and risk factors were compared between groups using chi-square and analysis of variance (ANOVA). Their influence on delirium incidence, mortality, and readmission was analyzed using logistic regression analysis. One- and 3-month in-hospital mortality and 6-month mortality data were analyzed using Kaplan–Meier survival curves and Cox proportional hazard regression. The influence of cognitive status on length of stay was analyzed using linear regression analysis.

Results

Average patient age was 76 years (SD = 11.44 years; range = 46 to 102), and there was a higher percentage of women and normal range of BMI in all four groups. CCI score was highest in the delirium-only group (7.21 [SD = 3.38]), followed by the DSD group. Polypharmacy (i.e., number of medications > 5) was noted in all groups of patients, and the path of admission common to all groups was hospital transfer (Table 1).

Participant Characteristics

Table 1:

Participant Characteristics

A total of 39.9% and 8.1% patients were in the DSD and delirium-only groups, respectively, amounting to a total delirium incidence of 48%; the incidence of dementia was approximately 71%. The DSD group showed generally higher results for most clinical items and risk factors; in terms of delirium type for this group, hypoactive delirium (27.5%) was found to be more frequent than hyperactive delirium (18.8%), whereas the mixed type was the most common (52.2%). Onset of delirium was more frequent in the morning (i.e., between 8 a.m. and 10 a.m.), and most residents were found to experience delirium in the mornings and afternoons rather than in the morning or afternoon alone. This timing of onset indicates that residents experiencing delirium in the morning usually experienced delirium continuing into the afternoon. The average number of delirium episodes was approximately two per patient; the number of days with delirium was 15 for the delirium-only group and 13 for the DSD group. In terms of dementia stage, mid-late was most common in the DSD group (82.6%), with Alzheimer's disease (76.8%) being the most common type of dementia overall (Table 2).

Patient Risk Factors and Presence of Delirium and DementiaPatient Risk Factors and Presence of Delirium and Dementia

Table 2:

Patient Risk Factors and Presence of Delirium and Dementia

Mortality was highest in the delirium-only group, at 50% (p = 0.001). Home was the least frequent discharge placement in the DSD group, with other placements being the most common (98.6%, p = 0.006). Average length of stay for all patients was 325 days, with the dementia-only group having the longest length of stay at 436 days (p = 0.001) (Table 3).

Patient Outcomes

Table 3:

Patient Outcomes

In the multivariate analysis, overall mortality was significantly higher in the delirium-only group (hazard ratio = 5.91; 95% confidence interval [1.03, 33.95]), with gender, age, BMI, pain score, sleep disturbance, infection, bed sores, second facility, and CCI scores as covariates; in the analysis of length of stay, the dementia-only group was significantly higher than all other groups (β = 88.44, standard error = 2.43, p = 0.016) (Table 4). On the Kaplan–Meier survival curve, the delirium-only group had the lowest probability of survival rate among all groups (log-rank test: χ2 = 8.13, df = 3, p = 0.043) (Figure).

Multivariate Analyses of Patient Outcomes

Table 4:

Multivariate Analyses of Patient Outcomes

Kaplan–Meier survival curves of mortality stratified by cognitive status group.

Figure.

Kaplan–Meier survival curves of mortality stratified by cognitive status group.

Discussion

Results indicated that the overall incidence of delirium among LTC patients was 48%, with 8.1% of patients having delirium only and 39.9% having DSD. The mortality of patients with delirium only was significantly higher than that of the other groups, and patients with dementia only had the longest length of stay. On the Kaplan–Meier survival curve, patients with delirium only had the lowest survival probability rate compared with other groups.

Previous studies suggested older age as a risk factor of delirium, and the prevalence of delirium was found to be 33.3% in LTC facilities (Cole et al., 2012) and varied between 32% and 92% in older patients in community hospitals and post-surgery (Fick et al., 2002; Fick et al., 2013; Mosk et al., 2017). These results are comparable to the 48% delirium incidence in LTC facilities found in the current study. In addition, a high prevalence of delirium in community and hospital populations has been found to be associated with higher mortality and costs (Fick et al., 2013).

Several studies have shown that delirium is associated with mortality as well as higher rates of admission to LTC facilities (Fick et al., 2013; Mosk et al., 2017; Witlox et al., 2010). Moreover, the current study suggests that the mortality of patients with delirium only was the highest at 50%, and this group showed significantly higher mortality in the multivariate analysis and scored the lowest on the survival analysis. Analysis of the CCI score revealed that the overall group average was 4.82, with the delirium-only group having the highest score (7.21). This result is in accordance with results of previous studies (Korc-Grodzicki et al., 2015; Kuswardhani & Sugi, 2017), showing that this index is a predictor of delirium in older adult patients with cancer. Comorbidity is considered to affect the mortality rate, which was significantly higher for the delirium-only group in the current study.

The strengths of this study include, first, the analysis of delirium incidence and associated outcomes in Korean LTC facilities, including data from patients with DSD. These data allowed for identification of the incidence of delirium among patients admitted to these facilities, suggesting the importance of early intervention for delirium and prevention for patients in LTC facilities as well as intensive care units or acute wards (McPherson et al., 2013; Schiemann, Hadzidiakos, & Spies, 2011). Second, the current study involved trained RNs who measured delirium twice per day at pre-set times, monitored suddenly occurring symptoms, and performed additional delirium measurements in these cases. These nursing tasks take into account the acute characteristics of delirium reported in the existing literature (Moon & Lee, 2015), recommending that delirium measurements be performed at least twice per day, as well as the fact that LTC facility nurses often fail to recognize delirium and record changes in the state of consciousness of patients (Steis et al., 2015; Voyer et al., 2014). Therefore, in LTC facilities, where there is no regular delirium assessment and systematic intervention, the current results could increase awareness of delirium among nurses and encourage regular delirium assessment, including early assessment, thereby increasing delirium care in LTC facilities.

Moreover, the current study categorized delirium as hypoactive, hyperactive, mixed, and nonmotoric behavior, and the results indicated that hypoactive delirium (28.9%) was more common than hyperactive delirium (20.5%), and mixed type was the most common. These results are in agreement with those from previous studies, which suggest that hypoactive delirium remains underrecognized by nurses and health professionals, and therefore deserves more attention (Hosker & Ward, 2017; Inouye, 2006). This lack of recognition is of particular importance when considering that the assessment of delirium is crucial for its prevention and related interventions. However, in addition to its low detection, delirium is not regularly assessed in LTC facilities or critical care units (Rowley-Conwy, 2018). If nurses do not have knowledge about or awareness of delirium, it is difficult to identify the subtypes of delirium (Peritogiannis, Bolosi, Lixouriotis, & Rizos, 2015), and it is unlikely that they will assess the degree of cognitive function while performing routine care (Voyer et al., 2012). It is also important that nurses regularly assess delirium and its subtypes, as they may be mistaken for other nursing problems. In the current study, onset was more likely to be in the morning and afternoon than in the morning or afternoon alone; thus, the need for routine assessment of delirium is emphasized in LTC facilities.

The current results emphasize the important role of nurses who provide bedside care in delirium prevention and interventions not only in dynamic environments, such as acute wards or intensive care units, but also in LTC facilities, where physicians are not always present. Moreover, the importance of systematic detection and monitoring is also underscored.

Limitations

A limitation of the current study is its lack of measurement of delirium severity. This measurement was excluded because the nurses caring for patients were trained to measure delirium and engaged in its measurement for the first time; thus, the additional measurement of delirium severity while providing patient care appeared to be too burdensome. As such, future studies should include the measurement of delirium severity. Moreover, previous studies (Fick et al., 2013; McCusker et al., 2011b; Mosk et al., 2017) have evaluated the level of cognitive impairment and functional status using the Mini-Mental State Examination; however, in the current study, patients with dementia did not undergo additional measurements as it was deemed unnecessary. Another study limitation is that delirium-related mortality was measured up to 6 months; however, the average length of stay of patients was >300 days; therefore, measuring 12-month mortality may also be meaningful in future studies. Lastly, although BMI was used as a covariate due to previous study findings indicating that lower BMI is independently associated with mortality (Chan et al., 2017), the current study population had a normal BMI overall, with the lowest BMI reported in the delirium only group. This finding could have impacted the multivariate analysis.

Conclusion

Delirium incidence in LTC patients in Korea was found to be approximately twice as high as that in patients in intensive care units and hospitals (Kang, Suh, & Oh, 2011; Moon et al., 2014). Particularly, the incidence of DSD was found to be 40%, and the mortality of patients with delirium was significantly higher than that of patients without delirium. These results suggest that delirium in LTC patients significantly influences poor outcomes and emphasizes the need for preventive interventions, as well as specialized and systematic preventive interventions for DSD.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
  • Avelino-Silva, T.J., Campora, F., Curiati, J.A. & Jacob-Filho, W. (2017). Association between delirium superimposed on dementia and mortality in hospitalized older adults: A prospective cohort study. PLoS Medicine, 14, e1002264. doi:10.1371/journal.pmed.1002264 [CrossRef]
  • Brown, C.H., LaFlam, A., Max, L., Wyrobek, J., Neufeld, K.J., Kebaish, K.M. & Riley, L.H. (2016). Delirium after spine surgery in older adults: Incidence, risk factors, and outcomes. Journal of the American Geriatrics Society, 64, 2101–2108. doi:10.1111/jgs.14434 [CrossRef]
  • Chan, K.Y., Cheng, L.S., Mak, I.W., Ng, S.W., Yiu, M.G. & Chu, C.M. (2017). Delirium is a strong predictor of mortality in patients receiving non-invasive positive pressure ventilation. Lung, 195, 115–125. doi:10.1007/s00408-016-9955-3 [CrossRef]
  • Cole, M.G., McCusker, J., Voyer, P., Monette, J., Champoux, N., Ciampi, A. & Belzile, E. (2012). The course of delirium in older long-term care residents. International Journal of Geriatric Psychiatry, 27, 1291–1297. doi:10.1002/gps.3782 [CrossRef]
  • Falsini, G., Grotti, S., Porto, I., Toccafondi, G., Fraticelli, A., Angioli, P. & Bolognese, L. (2017). 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. Advance online publication. doi:10.1177/2048872617695235 [CrossRef]
  • Fick, D.M., Agostini, J.V. & Inouye, S.K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50, 1723–1732. doi:10.1046/j.1532-5415.2002.50468.x [CrossRef]
  • Fick, D.M., Steis, M.R., Waller, J.L. & Inouye, S.K. (2013). Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. Journal of Hospital Medicine, 8, 500–505. doi:10.1002/jhm.2077 [CrossRef]
  • Fong, T.G., Jones, R.N., Marcantonio, E.R., Tommet, D., Gross, A.L., Habtemariam, D. & Inouye, S.K. (2012). Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Annals of Internal Medicine, 156, 848–856. doi:10.7326/0003-4819-156-12-201206190-00005 [CrossRef]
  • Hosker, C. & Ward, D. (2017). Hypoactive delirium. BMJ, 357, j2047. doi:10.1136/bmj.j2047 [CrossRef]
  • Inouye, S.K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. doi:10.1056/NEJMra052321 [CrossRef]
  • Inouye, S.K. (2014). The Short Confusion Assessment Method (Short CAM): Training manual and coding guide. Boston, MA: Hospital Elder Life Program.
  • Inouye, S.K., Westendorp, R.G. & Saczynski, J.S. (2014). Delirium in elderly people. Lancet, 383, 911–922. doi:10.1016/S0140-6736(13)60688-1 [CrossRef]
  • Jeon, B., Kim, H. & Kwon, S. (2016). Comparative study of long-term residence at care facilities, related elderly individuals and institutions. Health Policy and Management, 26, 39–50. doi:10.4332/KJHPA.2016.26.1.39 [CrossRef]
  • Kang, K., Suh, D. & Oh, S. (2011). Delirium after intertrochanteric fractures of femur in elderly patients. Journal of the Korean Fracture Society, 24, 131–137. doi:10.12671/jkfs.2011.24.2.131 [CrossRef]
  • Kim, D. & Kim, M. (2011). Review of dementia policies under the long-term care insurance system for the elderly. Journal of the Korean Association, 3, 33–43.
  • Korc-Grodzicki, B., Sun, S.W., Zhou, Q., Iasonos, A., Lu, B., Root, J.C. & Tew, W.P. (2015). Geriatric assessment as a predictor of delirium and other outcomes in elderly patients with cancer. Annals of Surgery, 261, 1085–1090. doi:10.1097/SLA.0000000000000742 [CrossRef]
  • Kuswardhani, R.A.T. & Sugi, Y.S. (2017). Factors related to the severity of delirium in the elderly patients with infection. Gerontology & Geriatric Medicine, 13, 2333721417739188. doi:10.1177/2333721417739188 [CrossRef]
  • Leslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L. & Inouye, S.K. (2008). One-year health care costs associated with delirium in the elderly population. Archives of Internal Medicine, 168, 27–32. doi:10.1001/archinternmed.2007.4 [CrossRef]
  • Marcantonio, E.R. (2017). Delirium in hospitalized older adults. New England Journal of Medicine, 377, 1456–1466. doi:10.1056/NEJMcp1605501 [CrossRef]
  • Marcantonio, E.R., Kiely, D.K., Simon, S.E., Orav, J.E., Jones, R.N., Murphy, K.M. & Bergmann, M.A. (2005). Outcomes of older people admitted to postacute facilities with delirium. Journal of the American Geriatrics Society, 53, 963–969. doi:10.1111/j.1532-5415.2005.53305.x [CrossRef]
  • McCusker, J., Cole, M.G., Voyer, P., Monette, J., Champoux, N., Ciampi, A. & Belzile, E. (2011a). Prevalence and incidence of delirium in long-term care. International Journal of Geriatric Psychiatry, 26, 1152–1161. doi:10.1002/gps.2654 [CrossRef]
  • McCusker, J., Cole, M.G., Voyer, P., Monette, J., Champoux, N., Ciampi, A. & Belzile, E. (2011b). Use of nurse-observed symptoms of delirium in long-term care: Effects on prevalence and outcomes of delirium. International Psychogeriatrics, 23, 602–608. doi:10.1017/S1041610210001900 [CrossRef]
  • McPherson, J.A., Wagner, C.E., Boehm, L.M., Hall, J.D., Johnson, D.C., Miller, L.R. & Pandharipande, P.P. (2013). Delirium in the cardiovascular ICU: Exploring modifiable risk factors. Critical Care Medicine, 41, 405–413. doi:10.1097/CCM.0b013e31826ab49b [CrossRef]
  • Moon, K.J., Jin, Y., Jin, T. & Lee, S.M. (2018). Development and validation of an automated delirium risk assessment system (Auto-DelRAS) implemented in the electronic health record system. International Journal of Nursing Studies, 77, 46–53. doi:10.1016/j.ijnurstu.2017.09.014 [CrossRef]
  • Moon, K.J. & Lee, S.M. (2015). The effects of a tailored intensive care unit delirium prevention protocol: A randomized controlled trial. International Journal of Nursing Studies, 52, 1423–1432. doi:10.1016/j.ijnurstu.2015.04.021 [CrossRef]
  • Moon, K.J., Piao, J., Jin, Y. & Lee, S.M. (2014). Is delirium an unrecognized threat to patient safety in Korean intensive care units?Journal of Nursing Care Quality, 29, 91–98. doi:10.1097/NCQ.0b013e31829f828b [CrossRef]
  • Morandi, A., Davis, D., Bellelli, G., Arora, R.C., Caplan, G.A., Kamholz, B. & Rudolph, J.L. (2017). The diagnosis of delirium superimposed on dementia: An emerging challenge. Journal of the American Medical Directors Association, 18, 12–18. doi:10.1016/j.jamda.2016.07.014 [CrossRef]
  • Mosk, C.A., Mus, M., Vroemen, J.P., van der Ploeg, T., Vos, D.I., Elmans, L.H. & van der Laan, L. (2017). Dementia and delirium, the outcomes in elderly hip fracture patients. Clinical Interventions in Aging, 12, 421–430. doi:10.2147/CIA.S115945 [CrossRef]
  • Muresan, M.L., Adamis, D., Murray, O., O'Mahony, E. & McCarthy, G. (2016). Delirium, how does it end? Mortality as an outcome in older medical inpatients. International Journal of Geriatric Psychiatry, 31, 349–354. doi:10.1002/gps.4332 [CrossRef]
  • Peritogiannis, V., Bolosi, M., Lixouriotis, C. & Rizos, D.V. (2015). Recent insights on prevalence and correlations of hypoactive delirium. Behavioural Neurology, 2015, 416792. doi:10.1155/2015/416792 [CrossRef]
  • Rowley-Conwy, G. (2018). Barriers to delirium assessment in the intensive care unit: A literature review. Intensive Critical Care Nursing, 44, 99–104. doi:10.1016/j.iccn.2017.09.001 [CrossRef]
  • Schiemann, A., Hadzidiakos, D. & Spies, C. (2011). Managing ICU delirium. Current Opinion in Critical Care, 17, 131–140. doi:10.1097/MCC.0b013e32834400b5 [CrossRef]
  • Steis, M.R., Behrens, L., Colancecco, E.M., Mogle, J., Mulhall, P.M., Hill, N.L. & Kolankowski, A.M. (2015). Licensed nurse and nursing assistant recognition of delirium in nursing home residents with dementia. Annals of Long-Term Care, 23, 15–20.
  • Steis, M.R. & Fick, D.M. (2012). Delirium superimposed on dementia: Accuracy of nurse documentation. Journal of Gerontological Nursing, 38(1), 32–42. doi:10.3928/00989134-20110706-01 [CrossRef]
  • Tieges, Z., McGrath, A., Hall, R.J. & Maclullich, A.M. (2013). Abnormal level of arousal as a predictor of delirium and inattention: An exploratory study. American Journal of Geriatric Psychiatry, 21, 1244–1253. doi:10.1016/j.jagp.2013.05.003 [CrossRef]
  • Voyer, P., McCusker, J., Cole, M.G., Monette, J., Champoux, N., Ciampi, A. & Richard, S. (2014). Nursing documentation in long-term care settings: New empirical evidence demands changes be made. Clinical Nursing Research, 23, 442–461. doi:10.1177/1054773813475809 [CrossRef]
  • Voyer, P., Richard, S., Doucet, L. & Carmichael, P.H. (2009). Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents. Journal of the American Medical Directors Association, 10, 181–188. doi:10.1016/j.jamda.2008.09.006 [CrossRef]
  • Voyer, P., Richard, S., McCusker, J., Cole, M.G., Monette, J., Champoux, N. & Belzile, E. (2012). Detection of delirium and its symptoms by nurses working in a long term care facility. Journal of the American Medical Directors Association, 13, 264–271. doi:10.1016/j.jamda.2010.11.002 [CrossRef]
  • Wei, L.A., Fearing, M.A., Sternberg, E.J. & Inouye, S.K. (2008). The Confusion Assessment Method: A systematic review of current usage. Journal of the American Geriatrics Society, 56, 823–830. doi:10.1111/j.1532-5415.2008.01674.x [CrossRef]
  • Witlox, J., Eurelings, L.S., de Jonghe, J.F., Kalisvaart, K.J., Eikelenboom, P. & van Gool, W.A. (2010). Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA, 304, 443–451. doi:10.1001/jama.2010.1013 [CrossRef]

Participant Characteristics

VariableGroupTotal (N = 173)p Value
No Delirium or Dementia (n = 36) (20.8%)Dementia Only (n = 54) (31.2%)Delirium Only (n = 14) (8.1%)DSD (n = 69) (39.9%)
Mean (SD) (Range)
Age (years)62 (10.77) (46 to 90)79.87 (6.53) (60 to 92)76 (7.82) (61 to 91)82.59 (8.3) (46 to 102)76.92 (11.44) (46 to 102)<0.0001
BMI (kg/m2)21.64 (2.93) (14.67 to 28.89)21.37 (3.54) (12.27 to 30.80)18.47 (6.81) (12.98 to 26.30)19.85 (4.35) (12.82 to 31.25)20.58 (4.19) (12.27 to 31.25)0.019
CCI1.75 (2.17) (0 to 8)4.02 (3.36) (0 to 11)7.21 (3.38) (0 to 14)6.55 (2.92) (0 to 12)4.82 (3.54) (0 to 14)<0.0001
Number of medications5.31 (2.92) (0 to 12)7.72 (3.18) (0 to 16)6.64 (3.69) (1 to 13)7.83 (3.26) (1 to 14)7.17 (3.33) (0 to 16)0.001
n (%)
Female20 (55.56)43 (79.63)8 (57.41)57 (82.61)80 (46.24)0.008
Smoke (yes)11 (30.56)7 (12.96)2 (14.29)9 (13.04)29 (16.76)0.128
Alcohol (yes)4 (11.11)4 (7.41)2 (14.29)8 (11.59)18 (10.4)0.801*
Cognitive impairmenta1 (2.78)31 (57.41)4 (28.57)46 (66.67)82 (47.4)<0.0001
Sensory impairmenta4 (11.11)7 (12.96)1 (7.14)8 (11.59)20 (11.56)1*
Admission path
  Home17 (47.22)17 (31.48)2 (14.29)19 (27.54)55 (31.79)0.079*
  Hospital12 (33.33)21 (38.89)11 (78.57)36 (52.17)80 (46.24)
  Other facility7 (19.44)15 (27.78)1 (7.14)14 (20.29)37 (21.39)
  Other0 (0)1 (1.85)0 (0)0 (0)1 (0.58)

Patient Risk Factors and Presence of Delirium and Dementia

VariableGroup (n [%])Total (N = 173)p Value
No Delirium or Dementia (n = 36)Dementia Only (n = 54)Delirium Only (n = 14)DSD (n = 69)
History of brain disease3 (8.33)5 (9.26)2 (14.29)6 (8.7)16 (9.25)0.9*
Nutritional deficiency2 (5.56)9 (16.67)10 (71.43)29 (42.03)50 (28.9)<0.0001
Fluid imbalance0 (0)1 (1.85)3 (21.43)4 (5.8)8 (4.62)0.018*
Dehydration0 (0)3 (5.56)0 (0)3 (4.35)6 (3.47)0.605*
Surgery2 (5.56)1 (1.85)1 (7.14)6 (8.7)10 (5.78)0.392*
Infection6 (16.67)5 (9.26)4 (28.57)7 (10.14)22 (12.72)0.199*
Sleep disturbance5 (13.89)6 (11.11)1 (7.14)29 (42.03)41 (23.7)0
Restraint0 (0)1 (1.85)1 (7.14)0 (0)2 (1.16)0.133*
Immobility1 (2.78)2 (3.7)1 (7.14)2 (2.9)6 (3.47)0.745*
Fall25 (69.44)24 (44.44)3 (21.43)23 (33.33)75 (43.35)0.001
Bed sores1 (2.78)8 (14.81)4 (28.57)21 (30.43)34 (19.65)0.002
Delirium medicationa0 (0)3 (5.56)1 (7.14)14 (20.29)18 (10.4)0.004
Foley catheter0 (0)4 (7.41)3 (21.43)7 (10.14)14 (8.09)0.046*
Nasogastric feeding0 (0)4 (7.41)4 (28.57)7 (10.14)15 (8.67)0.015*
Diaper use2 (5.56)21 (38.89)9 (64.29)41 (59.42)73 (42.2)<0.0001
Delirium type0.587
  Hypoactive5 (35.71)19 (27.54)24 (28.92)
  Hyperactive4 (28.57)13 (18.84)17 (20.48)
  Mixed5 (35.71)36 (52.17)41 (49.4)
  Non-motoric behavior0 (0)1 (1.45)1 (1.2)
Delirium onset time0.726
  Morning (8 to 10 a.m.)1 (7.14)8 (11.59)9 (10.84)
  Afternoon (4 to 6 p.m.)0 (0)6 (8.7)6 (7.23)
  Morning and afternoon13 (92.86)55 (79.71)68 (81.93)
Dementia stage<0.0001
  Not diagnosed36 (100)14 (100)50 (28.9)
  Early stage16 (29.63)12 (17.39)28 (16.18)
  Mid-late stage38 (70.37)57 (82.61)95 (54.91)
Dementia type<0.0001*
  Alzheimer's45 (83.33)53 (76.81)99 (57.23)
  Vascular2 (3.7)10 (14.49)12 (6.94)
  Mixed1 (1.85)1 (1.45)2 (1.16)
  Lewy body1 (1.85)0 (0)1 (0.58)
  Frontotemporal0 (0)1 (1.45)1 (0.58)
  Other5 (9.26)4 (5.8)9 (5.2)
Mean (SD) (Range)
Pain scoreb3.5 (1.46) (0 to 6)3 (1.06) (0 to 5)2.93 (1.86) (0 to 6)2.9 (1.24) (0 to 6)3.06 (1.31) (0 to 6)0.15
Delirium frequency (episodes)2.58 (1.75) (1 to 6)2.07 (1.44) (1 to 8)2.49 (1.71) (1 to 8)0.31
Delirium days15 (20.69) (1 to 73)13.3 (15.01) (1 to 57)13.59 (15.97) (1 to 73)0.72

Patient Outcomes

VariableGroup (n [%])Total (N = 173)p Value
No Delirium or Dementia (n = 36)Dementia Only (n = 54)Delirium Only (n = 14)DSD (n = 69)
Mortality2 (5.56)9 (16.67)7 (50)24 (34.78)42 (24.28)0.001
In-hospital mortality
  1 month1 (2.78)1 (1.85)2 (14.29)5 (7.25)9 (5.2)0.172*
  3 months1 (2.78)3 (5.56)3 (21.43)9 (13.04)16 (9.25)0.09*
  6 months2 (5.56)4 (7.41)4 (28.57)11 (15.94)21 (12.14)0.070
Readmission4 (11.11)4 (7.41)2 (14.29)10 (14.49)20 (11.56)0.663*
Discharge placement0.006*
  Home7 (19.44)3 (5.56)0 (0)1 (1.45)11 (6.36)
  Other29 (80.56)51 (94.44)14 (100)68 (98.55)162 (93.64)
Length of stay (days) (mean, SD [range])149.47(234.8) (18 to 1,077)436.52 (402.27) (16 to 1,660)200.43 (252.15) (4 to 672)357.04 (363.32) (5 to 1,531)325.98 (360.7) (4 to 1,660)0.001

Multivariate Analyses of Patient Outcomes

OutcomeGroupMultivariate Logistic/Linear Regressionp Value
OR/HR [95% CI]ßSE
MortalityaDelirium only5.91 [1.03, 33.95]0.046
Dementia only1.62 [0.30, 8.71]0.577
DSD3.21 [0.60, 17.11]0.173
1-month in-hospital mortalitybDelirium only0.73 [0.03, 18.19]0.845
Dementia only0.32 [0.02, 6.76]0.463
DSD1.02 [0.07, 15.72]0.991
3-month in-hospital mortalitybDelirium only3.41 [0.26, 45.27]0.353
Dementia only1.53 [0.13, 17.58]0.731
DSD3.41 [0.30, 38.42]0.321
6-month in-hospital mortalitybDelirium only2.01 [0.25, 15.91]0.509
Dementia only0.97 [0.14, 6.58]0.975
DSD1.45 [0.21, 10.09]0.706
ReadmissionaDelirium only1.31 [0.13, 13.62]0.822
Dementia only1.66 [0.26, 10.66]0.595
DSD3.35 [0.48, 23.18]0.221
Discharge other than homeaDementia only0.23 [0.02, 2.44]0.224
DSD0.56 [0.03, 10.01]0.694
Length of staycDelirium only−11.99119.57−0.10.920
Dementia only214.9688.442.430.016
DSD79.2095.980.830.411
Authors

Dr. Moon is Assistant Professor, and Dr. Park is Associate Professor, Keimyung University, Daegu, Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by a 2016 Keimyung University research grant.

Address correspondence to Kyoung Ja Moon, PhD, RN, APN, Assistant Professor, Keimyung University, 1095 Dalgubeol-daero, Junkapgukwan 520, Daegu 42601, Korea; e-mail: kjm2150@gw.kmu.ac.kr or Kjmoon2150@gmail.com.

Received: March 20, 2018
Accepted: May 30, 2018

10.3928/00989134-20180808-08

Sign up to receive

Journal E-contents