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      Delirium in Hospitalized Older Adults

      , M.D.

      The New England journal of medicine

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          Abstract

          A 75-year-old man is admitted for scheduled major abdominal surgery. He is functionally independent, with mild forgetfulness. His intraoperative course is uneventful, but on postoperative day 2, severe confusion and agitation develop. What is going on? How would you manage this patient’s care? Could his condition have been prevented?

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          Most cited references 27

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          Delirium in older persons.

           Sharon Inouye (2006)
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            Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability.

            To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability. Two prospective cohort studies, in tandem. General medical wards, university teaching hospital. For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients. New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria. Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant. A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating and baseline vulnerability factors are highly interrelated and contribute to delirium in independent substantive, and cumulative ways.
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              A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics.

              To prospectively develop and validate a predictive model for the occurrence of new delirium in hospitalized elderly medical patients based on characteristics present at admission. Two prospective cohort studies done in tandem. University teaching hospital. The development cohort included 107 hospitalized general medical patients 70 years or older who did not have dementia or delirium at admission. The validation cohort included 174 comparable patients. Patients were assessed daily for delirium using a standardized, validated instrument. The predictive model developed in the initial cohort was then validated in a separate cohort of patients. Delirium developed in 27 of 107 patients (25%) in the development cohort. Four independent baseline risk factors for delirium were identified using proportional hazards analysis: These included vision impairment (adjusted relative risk, 3.5; 95% Cl, 1.2 to 10.7); severe illness (relative risk, 3.5; Cl, 1.5 to 8.2); cognitive impairment (relative risk, 2.8; Cl, 1.2 to 6.7); and a high blood urea nitrogen/creatinine ratio (relative risk, 2.0; Cl, 0.9 to 4.6). A risk stratification system was developed by assigning 1 point for each risk factor present. Rates of delirium for low- (0 points), intermediate- (1 to 2 points), and high-risk (3 to 4 points) groups were 9%, 23%, and 83% (P < 0.0001), respectively. The corresponding rates in the validation cohort, in which 29 of 174 patients (17%) developed delirium, were 3%, 16%, and 32% (P < 0.002). The rates of death or nursing home placement, outcomes potentially related to delirium, were 9%, 16%, and 42% (P = 0.02) in the development cohort and 3%, 14%, and 26% (P = 0.007) in the validation cohort. Delirium among elderly hospitalized patients is common, and a simple predictive model based on four risk factors can be used at admission to identify elderly persons at the greatest risk.
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                Author and article information

                Contributors
                Journal
                0255562
                5985
                N Engl J Med
                N. Engl. J. Med.
                The New England journal of medicine
                0028-4793
                1533-4406
                24 November 2017
                12 October 2017
                12 October 2018
                : 377
                : 15
                : 1456-1466
                Affiliations
                Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School — both in Boston
                Author notes
                Address reprint requests to Dr. Marcantonio at Beth Israel Deaconess Medical Center, 330 Brookline Ave., CO-216, Boston, MA 02215, or at emarcant@ 123456bidmcf.harvard.edu
                Article
                PMC5706782 PMC5706782 5706782 nihpa922097
                10.1056/NEJMcp1605501
                5706782
                29020579
                Categories
                Article

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