Awareness Is Top Weapon Against Delirium

I expect that [insert patient name here] will have a hospital stay measured in a period of days. During that time we will do our best to prevent complications of hospitalization, which include things such as blood clots and infections. We will also do our best to quickly recognize and treat those complications that do occur such as confusion or pain." This is a conversation I have with the majority of patients’ families when their medically complicated loved one is hospitalized.

I was certain that one gentleman, who has esophageal cancer with metastasis to the spine causing cord compression, would suffer from delirium during his hospital stay. His advanced age, multiple comorbidities, urgent surgery, intensive-care unit stay, and the medications he required to control his pain -- which initially included a fentanyl PCA (patient-controlled analgesia) and was later augmented by a ketamine infusion -- all seemed to put him at high risk for this. Yet, even during his time on our ketamine protocol he had clear and appropriate conversations with our team.

Photos courtesy Marc M. Swendner

Another elderly woman, with previously undiagnosed dementia, was living at home with family assistance until coming to the hospital after suffering from a fall at home. During her hospital course she experienced side effects of pain medications and also developed a urinary tract infection. The delirium that ensued was severe. She required ICU admission because of the intense nursing supervision she needed to keep her out of physical restraints.

Eventually, when it was appropriate, she was discharged to a skilled nursing facility rather than home because of the persistent cognitive problems she was experiencing. The emergency room physician who called me about the admission anticipated that the patient could return home less than 24 hours after coming in. She left the hospital almost 2 weeks later.

Delirium in hospitalized patients is a common problem. Its presence is often partnered with extended lengths of stay, escalation of care, and poorer outcomes. Once it occurs, we turn to screening tools and treatment protocols that evidence has shown to be useful. Therefore, it should come as no surprise that a hospital’s approach to delirium management is now recognized as a quality-of-care marker.

Two new studies highlight the impact of delirium and provide a new tool for predicting this condition. They expand our body of knowledge, and one of them may even empower us to possibly head off delirium before it occurs.

The first study is a prospective cohort enrolled between 1991 and 2006 into a patient registry for Alzheimer’s disease (AD). Participants were over the age of 65 years with a clinical diagnosis of AD in this community setting, which included 771 patients. Databases identified those who were hospitalized, experienced delirium, died, or were institutionalized. Cognitive decline was also evaluated and based upon a validated test score.

Forty-eight percent (n = 367) were hospitalized and 25% (n = 194) developed delirium. Patients who did not experience delirium in the hospital had an increased risk of death or requiring institutionalization (relative risks of 4.7 and 6.9, respectively). An even more dramatic increase in risk was noted in those with delirium (RRs of 5.4 and 9.3). Delirium was associated with 6% of deaths, 15% of institutionalizations, and 21% of cognitive declines in hospitalized patients with AD.

This is the first time the relative contributions of hospitalizations and episodes of delirium to adverse outcomes for AD patients have been evaluated. The investigators’ goal of observing outcomes for at least 1 year clearly shows that hospitalization is a danger to this patient population and that the outcomes are worse for those with delirium. At least one in eight patients with AD will have an adverse event or death from hospitalization. This clinical cohort was created by merging multiple databases, so incomplete medical records were a problem. Two other aspects of the study are worth noting. As this study was nonrandomized, the hospitalized patients had lower baseline cognitive function than those who avoided admission. Also, ethnic minorities made up only 5% of the study population and therefore do not represent the U.S. Alzheimer’s community in that regard.

The second work is a multicenter observational study. This entailed the development of the Prediction of Delirium in ICU Patients (PRE-DELIRIC) model in a prospective cohort of 1,613 patients, a temporal validation in a second prospective cohort in the same hospital using 549 patients, and external validation with a total of 894 patients in four separate hospitals.

The PRE-DELIRIC model contains 10 risk factors: age, APACHE-II (Acute Physiology and Chronic Health Evaluation) score, admission group (consisting of medical, surgical, trauma, and neurological patients), coma, infection, metabolic acidosis, use of sedating medications, morphine use, blood urea nitrogen levels, and urgent admission. The main outcome measured was development of delirium within the ICU. The model’s ability to predict delirium was compared with that of ICU physicians and nurses to independently predicting delirium within 24 hours of admission.

The model’s area under receiver operating characteristics curve (AUROC) was 0.85 pooled across three cohorts (0.87, 0.86, and 0.84 for the first, second, and third cohorts, respectively). The AUROC for both physicians’ and nurses’ predictions of delirium was 0.59. Providers’ predictive accuracy did not differ by level of clinical experience.

PRE-DELIRIC is the first predictive model published for the ICU population experiencing delirium. Study design makes sense for the intention. It is important to note that patients with a history of alcohol abuse and dementia were excluded. It was felt that their risk for developing delirium is high even without consideration of other factors.

The model clearly outperformed the physicians and nurses, who were equally inferior when it came to predicting delirium. It also appears that this could be an area of medicine where experience is not accompanied by improved accuracy. More experienced clinicians fared no better than their greener colleagues. Limitations included a varied case mix from multiple specialties and inclusion of risk factors that were not based on their systematic review for those associated with delirium.

Both of these studies move us forward. The first should heighten our level of awareness that hospitalization with delirium is a major marker for undesired outcomes. It also should prompt proactive communication with our AD patients’ families about expectations in this scenario. The second should help create a mindset of predicting and preventing delirium rather than our current model, which is to screen and then treat.

Dr. Bekanich is with the department of medicine and is medical director of palliative care at Seton Healthcare in Austin, Tex. To respond to this commentary, e-mail [email protected].

I expect that [insert patient name here] will have a hospital stay measured in a period of days. During that time we will do our best to prevent complications of hospitalization, which include things such as blood clots and infections. We will also do our best to quickly recognize and treat those complications that do occur such as confusion or pain." This is a conversation I have with the majority of patients’ families when their medically complicated loved one is hospitalized.

I was certain that one gentleman, who has esophageal cancer with metastasis to the spine causing cord compression, would suffer from delirium during his hospital stay. His advanced age, multiple comorbidities, urgent surgery, intensive-care unit stay, and the medications he required to control his pain -- which initially included a fentanyl PCA (patient-controlled analgesia) and was later augmented by a ketamine infusion -- all seemed to put him at high risk for this. Yet, even during his time on our ketamine protocol he had clear and appropriate conversations with our team.

Photos courtesy Marc M. Swendner

Another elderly woman, with previously undiagnosed dementia, was living at home with family assistance until coming to the hospital after suffering from a fall at home. During her hospital course she experienced side effects of pain medications and also developed a urinary tract infection. The delirium that ensued was severe. She required ICU admission because of the intense nursing supervision she needed to keep her out of physical restraints.

Eventually, when it was appropriate, she was discharged to a skilled nursing facility rather than home because of the persistent cognitive problems she was experiencing. The emergency room physician who called me about the admission anticipated that the patient could return home less than 24 hours after coming in. She left the hospital almost 2 weeks later.

Delirium in hospitalized patients is a common problem. Its presence is often partnered with extended lengths of stay, escalation of care, and poorer outcomes. Once it occurs, we turn to screening tools and treatment protocols that evidence has shown to be useful. Therefore, it should come as no surprise that a hospital’s approach to delirium management is now recognized as a quality-of-care marker.

Two new studies highlight the impact of delirium and provide a new tool for predicting this condition. They expand our body of knowledge, and one of them may even empower us to possibly head off delirium before it occurs.

The first study is a prospective cohort enrolled between 1991 and 2006 into a patient registry for Alzheimer’s disease (AD). Participants were over the age of 65 years with a clinical diagnosis of AD in this community setting, which included 771 patients. Databases identified those who were hospitalized, experienced delirium, died, or were institutionalized. Cognitive decline was also evaluated and based upon a validated test score.

Forty-eight percent (n = 367) were hospitalized and 25% (n = 194) developed delirium. Patients who did not experience delirium in the hospital had an increased risk of death or requiring institutionalization (relative risks of 4.7 and 6.9, respectively). An even more dramatic increase in risk was noted in those with delirium (RRs of 5.4 and 9.3). Delirium was associated with 6% of deaths, 15% of institutionalizations, and 21% of cognitive declines in hospitalized patients with AD.

This is the first time the relative contributions of hospitalizations and episodes of delirium to adverse outcomes for AD patients have been evaluated. The investigators’ goal of observing outcomes for at least 1 year clearly shows that hospitalization is a danger to this patient population and that the outcomes are worse for those with delirium. At least one in eight patients with AD will have an adverse event or death from hospitalization. This clinical cohort was created by merging multiple databases, so incomplete medical records were a problem. Two other aspects of the study are worth noting. As this study was nonrandomized, the hospitalized patients had lower baseline cognitive function than those who avoided admission. Also, ethnic minorities made up only 5% of the study population and therefore do not represent the U.S. Alzheimer’s community in that regard.

The second work is a multicenter observational study. This entailed the development of the Prediction of Delirium in ICU Patients (PRE-DELIRIC) model in a prospective cohort of 1,613 patients, a temporal validation in a second prospective cohort in the same hospital using 549 patients, and external validation with a total of 894 patients in four separate hospitals.

The PRE-DELIRIC model contains 10 risk factors: age, APACHE-II (Acute Physiology and Chronic Health Evaluation) score, admission group (consisting of medical, surgical, trauma, and neurological patients), coma, infection, metabolic acidosis, use of sedating medications, morphine use, blood urea nitrogen levels, and urgent admission. The main outcome measured was development of delirium within the ICU. The model’s ability to predict delirium was compared with that of ICU physicians and nurses to independently predicting delirium within 24 hours of admission.

The model’s area under receiver operating characteristics curve (AUROC) was 0.85 pooled across three cohorts (0.87, 0.86, and 0.84 for the first, second, and third cohorts, respectively). The AUROC for both physicians’ and nurses’ predictions of delirium was 0.59. Providers’ predictive accuracy did not differ by level of clinical experience.

PRE-DELIRIC is the first predictive model published for the ICU population experiencing delirium. Study design makes sense for the intention. It is important to note that patients with a history of alcohol abuse and dementia were excluded. It was felt that their risk for developing delirium is high even without consideration of other factors.

The model clearly outperformed the physicians and nurses, who were equally inferior when it came to predicting delirium. It also appears that this could be an area of medicine where experience is not accompanied by improved accuracy. More experienced clinicians fared no better than their greener colleagues. Limitations included a varied case mix from multiple specialties and inclusion of risk factors that were not based on their systematic review for those associated with delirium.

Both of these studies move us forward. The first should heighten our level of awareness that hospitalization with delirium is a major marker for undesired outcomes. It also should prompt proactive communication with our AD patients’ families about expectations in this scenario. The second should help create a mindset of predicting and preventing delirium rather than our current model, which is to screen and then treat.

Dr. Bekanich is with the department of medicine and is medical director of palliative care at Seton Healthcare in Austin, Tex. To respond to this commentary, e-mail [email protected].

I expect that [insert patient name here] will have a hospital stay measured in a period of days. During that time we will do our best to prevent complications of hospitalization, which include things such as blood clots and infections. We will also do our best to quickly recognize and treat those complications that do occur such as confusion or pain." This is a conversation I have with the majority of patients’ families when their medically complicated loved one is hospitalized.

I was certain that one gentleman, who has esophageal cancer with metastasis to the spine causing cord compression, would suffer from delirium during his hospital stay. His advanced age, multiple comorbidities, urgent surgery, intensive-care unit stay, and the medications he required to control his pain -- which initially included a fentanyl PCA (patient-controlled analgesia) and was later augmented by a ketamine infusion -- all seemed to put him at high risk for this. Yet, even during his time on our ketamine protocol he had clear and appropriate conversations with our team.

Photos courtesy Marc M. Swendner

Another elderly woman, with previously undiagnosed dementia, was living at home with family assistance until coming to the hospital after suffering from a fall at home. During her hospital course she experienced side effects of pain medications and also developed a urinary tract infection. The delirium that ensued was severe. She required ICU admission because of the intense nursing supervision she needed to keep her out of physical restraints.

Eventually, when it was appropriate, she was discharged to a skilled nursing facility rather than home because of the persistent cognitive problems she was experiencing. The emergency room physician who called me about the admission anticipated that the patient could return home less than 24 hours after coming in. She left the hospital almost 2 weeks later.

Delirium in hospitalized patients is a common problem. Its presence is often partnered with extended lengths of stay, escalation of care, and poorer outcomes. Once it occurs, we turn to screening tools and treatment protocols that evidence has shown to be useful. Therefore, it should come as no surprise that a hospital’s approach to delirium management is now recognized as a quality-of-care marker.

Two new studies highlight the impact of delirium and provide a new tool for predicting this condition. They expand our body of knowledge, and one of them may even empower us to possibly head off delirium before it occurs.

The first study is a prospective cohort enrolled between 1991 and 2006 into a patient registry for Alzheimer’s disease (AD). Participants were over the age of 65 years with a clinical diagnosis of AD in this community setting, which included 771 patients. Databases identified those who were hospitalized, experienced delirium, died, or were institutionalized. Cognitive decline was also evaluated and based upon a validated test score.

Forty-eight percent (n = 367) were hospitalized and 25% (n = 194) developed delirium. Patients who did not experience delirium in the hospital had an increased risk of death or requiring institutionalization (relative risks of 4.7 and 6.9, respectively). An even more dramatic increase in risk was noted in those with delirium (RRs of 5.4 and 9.3). Delirium was associated with 6% of deaths, 15% of institutionalizations, and 21% of cognitive declines in hospitalized patients with AD.

This is the first time the relative contributions of hospitalizations and episodes of delirium to adverse outcomes for AD patients have been evaluated. The investigators’ goal of observing outcomes for at least 1 year clearly shows that hospitalization is a danger to this patient population and that the outcomes are worse for those with delirium. At least one in eight patients with AD will have an adverse event or death from hospitalization. This clinical cohort was created by merging multiple databases, so incomplete medical records were a problem. Two other aspects of the study are worth noting. As this study was nonrandomized, the hospitalized patients had lower baseline cognitive function than those who avoided admission. Also, ethnic minorities made up only 5% of the study population and therefore do not represent the U.S. Alzheimer’s community in that regard.

The second work is a multicenter observational study. This entailed the development of the Prediction of Delirium in ICU Patients (PRE-DELIRIC) model in a prospective cohort of 1,613 patients, a temporal validation in a second prospective cohort in the same hospital using 549 patients, and external validation with a total of 894 patients in four separate hospitals.

The PRE-DELIRIC model contains 10 risk factors: age, APACHE-II (Acute Physiology and Chronic Health Evaluation) score, admission group (consisting of medical, surgical, trauma, and neurological patients), coma, infection, metabolic acidosis, use of sedating medications, morphine use, blood urea nitrogen levels, and urgent admission. The main outcome measured was development of delirium within the ICU. The model’s ability to predict delirium was compared with that of ICU physicians and nurses to independently predicting delirium within 24 hours of admission.

The model’s area under receiver operating characteristics curve (AUROC) was 0.85 pooled across three cohorts (0.87, 0.86, and 0.84 for the first, second, and third cohorts, respectively). The AUROC for both physicians’ and nurses’ predictions of delirium was 0.59. Providers’ predictive accuracy did not differ by level of clinical experience.

PRE-DELIRIC is the first predictive model published for the ICU population experiencing delirium. Study design makes sense for the intention. It is important to note that patients with a history of alcohol abuse and dementia were excluded. It was felt that their risk for developing delirium is high even without consideration of other factors.

The model clearly outperformed the physicians and nurses, who were equally inferior when it came to predicting delirium. It also appears that this could be an area of medicine where experience is not accompanied by improved accuracy. More experienced clinicians fared no better than their greener colleagues. Limitations included a varied case mix from multiple specialties and inclusion of risk factors that were not based on their systematic review for those associated with delirium.

Both of these studies move us forward. The first should heighten our level of awareness that hospitalization with delirium is a major marker for undesired outcomes. It also should prompt proactive communication with our AD patients’ families about expectations in this scenario. The second should help create a mindset of predicting and preventing delirium rather than our current model, which is to screen and then treat.

Dr. Bekanich is with the department of medicine and is medical director of palliative care at Seton Healthcare in Austin, Tex. To respond to this commentary, e-mail [email protected].