Jouko V. Laurila

Prognostic Significance of Delirium in Frail Older People

Our aim was to investigate the long-term prognosis of delirium in the frailest elderly, and to clarify whether delirium is just a marker of the underlying severe disease. We used logistic regression analysis to determine the independent prognostic significance of delirium. A representative sample of 425 patients (≥70 years) in acute geriatric wards and nursing homes were assessed at baseline and followed up for 2 years. DSM-IV was used for classification. The prevalence of delirium at baseline was 24.9% (106/425). The prognosis of delirium was poor: mortality at 1 year was 34.9 vs. 21.6% in nondelirious subjects (p = 0.006), and at 2 years 58.5 vs. 42.6% (p = 0.005). Among home-dwelling people at baseline, 54.4% of the delirious vs. 27.9% of others were permanently institutionalized within 2 years (p < 0.001). In logistic regression analysis, delirium was an independent predictor for mortality at 1 year (OR 1.86, 95% CI 1.1–3.1), at 2 years (OR 1.76, 95% CI 1.1–2.8), and for permanent institutionalization (OR 2.45, 95% CI 1.2–4.9). Delirious patients with prior dementia tended to have a better prognosis than those without.

Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards.

OBJECTIVES To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of psychotropic medications to these patients. METHODS 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient. RESULTS Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used. CONCLUSION Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.

Predisposing and precipitating factors for delirium in a frail geriatric population

OBJECTIVE The aim of this study was to assess the possible predisposing aetiologic and short-term precipitating factors for delirium in acutely ill hospital patients with a heavy burden of comorbidities and medications. METHODS Eighty-seven consecutive patients with acute delirium admitted to a general medicine unit were thoroughly examined, and the predisposing and precipitating factors of their delirium were assessed. RESULTS In this population, an average of 5.2 predisposing factors and 3.0 potential precipitating factors for delirium was revealed, meaning an average of over eight possible aetiological causes for each patient. The most common precipitating factors were infections (n=72), metabolic abnormalities (n=52), adverse drug effects (n=41), and cardiovascular events (n=38). In addition, a number of very rare conditions were diagnosed after thorough assessments. CONCLUSION Geriatric patients with acute delirium typically present with several concomitant predisposing factors for delirium exposing them to high vulnerability for the syndrome. In most patients, a number of possible etiological causes for delirium can be identified after a careful assessment, but their true pathogenetic pathway to the syndrome is unclear.

Impact of Different Diagnostic Criteria on Prognosis of Delirium: A Prospective Study

A 2-year follow-up study was performed to compare the prognosis of delirium defined according to 4 different diagnostic classifications (DSM-III, DSM-III-R, DSM-IV and ICD-10 clinical criteria) among 425 elderly geriatric hospital patients and nursing home residents. The proportion of delirium varied from 24.9% (DSM-IV) to 10.1% (ICD-10). The prognoses were similar particularly according to all DSM classifications: 31.3–36.3% of the delirious patients died within 1 year and 57.8–62.5% within 2 years. The number of subjects diagnosed as delirious according to the ICD-10 was small, and their prognosis did not differ significantly from the others either. The DSM-IV has simplified the criteria of delirium. It identifies new, acutely ill and relatively nondependent subjects as delirious who share the poor prognosis of patients diagnosed with the previous criteria.

Intensive care acquired infection is an independent risk factor for hospital mortality: a prospective cohort study

IntroductionThe aim of this study was to elucidate the impact of intensive care unit (ICU)-acquired infection on hospital mortality.MethodsPatients with a longer than 48 hour stay in a mixed 10 bed ICU in a tertiary-level teaching hospital were prospectively enrolled between May 2002 and June 2003. Risk factors for hospital mortality were analyzed with a logistic regression model.ResultsOf 335 patients, 80 developed ICU-acquired infection. Among the patients with ICU-acquired infections, hospital mortality was always higher, regardless of whether or not the patients had had infection on admission (infection on admission group (IAG), 35.6% versus 17%, p = 0.008; and no-IAG, 25.7% versus 6.1%, p = 0.023). In IAG (n = 251), hospital stay was also longer in the presence of ICU-acquired infection (median 31 versus 16 days, p < 0.001), whereas in no-IAG (n = 84), hospital stay was almost identical with and without the presence of ICU-acquired infection (18 versus 17 days). In univariate analysis, the significant risk factors for hospital mortality were: Acute Physiology and Chronic Health Evaluation (APACHE) II score >20, sequential organ failure assessment (SOFA) score >8, ICU-acquired infection, age ≥ 65, community-acquired pneumonia, malignancy or immunosuppressive medication, and ICU length of stay >5 days. In multivariate logistic regression analysis, ICU-acquired infection remained an independent risk factor for hospital mortality after adjustment for APACHE II score and age (odds ratio (OR) 4.0 (95% confidence interval (CI): 2.0–7.9)) and SOFA score and age (OR 2.7 (95% CI: 2.9–7.6)).ConclusionICU-acquired infection was an independent risk factor for hospital mortality even after adjustment for the APACHE II or SOFA scores and age.

Defining delirium for the International Classification of Diseases, 11th Revision

OBJECTIVE The development of ICD-11 provides an opportunity to update the description of delirium according to emerging data that have added to our understanding of this complex neuropsychiatric syndrome. METHOD Synthetic article based on published work considered by the authors to be relevant to the definition of delirium. RESULTS The current DSM-IV definition of delirium is preferred to the ICD-10 because of its greater inclusivity. Evidence does not support major changes in the principal components of present definitions but a number of key issues for the updated definition were identified. These include better account of non-cognitive features, more guidance for rating contextual diagnostic items, clearer definition regarding the interface with dementia, and accounting for illness severity, clinical subtypes and course. CONCLUSION Development of the ICD definition of delirium can allow for more targeted research and clinical effort.

Use of inappropriate medications and their prognostic significance among in-hospital and nursing home patients with and without dementia in Finland.

BackgroundAlthough the Beers criteria have been frequently utilised to describe the use of inappropriate medications in various elderly populations, less is known about the use of such medications among patients with dementia, and nor have many studies dealt with their impact on mortality or use of healthcare services. This study examines the use of inappropriate drugs and their impact on mortality and use of health services among Finnish elderly nursing home and hospital patients. Patients with dementia were studied as a special subgroup.MethodsA total of 425 patients consecutively admitted to seven Finnish nursing homes and two hospitals in 1999–2000 were examined. Details of all medications prescribed and administered were retrieved from medical records and coded according to the Beers 1997 criteria. Mortality data as well as days in acute hospital were obtained from central registers and all area hospitals during 2 years of follow-up.ResultsThe entire population was old and frail (mean age 86 years, 82% females), 60% had dementia and 36.2% received at least one potentially inappropriate drug (PID). No differences existed in the proportion of users of PIDs among those 60% of patients with dementia compared with those without. The most common PID was temazepam, with 14% of all patients on high doses. Other commonly used PIDs were oxybutynin and dipyridamole. Amitriptyline was more commonly used among patients without dementia (4.7%) compared with those with dementia (0.8%). Nevertheless, in this very old and frail study population, use of inappropriate drugs did not predict mortality or use of health services.ConclusionUse of PIDs is common in nursing homes and hospitals in Finland but has no impact on mortality or hospital admissions. Use of high-dose temazepam as a hypnotic accounted for most of the high use of PIDs.

Anticholinergic Drugs and Their Effects on Delirium and Mortality in the Elderly

Aim: To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities. Methods: 425 patients (≧70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria. Results: Of the 341 patients (80.2%) treated with multiple DAPs (≧2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87–3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75–1.68). Conclusion: The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.

Apathy: Prevalence, Associated Factors, and Prognostic Value Among Frail, Older Inpatients

OBJECTIVES The association of apathy with Alzheimer disease and other dementias and caregiver burden has been examined in a number of studies; however, less is known about its relationship with delirium and mortality. We aimed to investigate the prevalence, relationship with delirium and dementia, and prognostic value of apathy in an elderly and frail inpatient population. SETTING AND PARTICIPANTS The cohort included 425 patients in acute geriatric wards and in 7 nursing homes in Helsinki (1999-2000). Demographic factors, physical functioning, diagnoses, and drugs were assessed with special reference for dementia, delirium, and apathy. Mortality was registered from central registers. RESULTS Of the patients, 98 (23.1%) suffered from apathy, and it was more frequent among men (32% versus 21% women, P = .037 ). There was no difference in mean age, number of comorbidities, or in the mean number of medications between those with and without apathy; however, those with apathy had lower mean MMSE points (9.2 versus 14.0 without apathy, P < .001), more often severe dementia according to Clinical Dementia Rating, and higher dependence in activities of daily living (P = .001). Furthermore, patients with apathy were more often suffering from delirium (37.8% versus 21.1%, P ≤ .001). Mortality during the 1-year follow-up was 34.7% (n = 34) and 22.0% (n = 72) among individuals with and without apathy, respectively (P = .011). In the Cox proportional hazard model with age, gender, activities of daily living, and delirium as covariates, apathy significantly predicted mortality (HR 1.89, 95% CI 1.24 to 2.89; P = .003). CONCLUSIONS Apathy is a common and serious neuropsychiatric symptom associated with cognitive decline, delirium, and disability, and it also independently predicts mortality.

The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta‐analysis

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta‐analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non‐cardiac surgery patients and 502 population‐based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre‐existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta‐analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2–0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta‐analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6–1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4–1.0, P = 0.06) and 0.8 (95% C.I. 0.5–1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.