Effects of a Medication Review on Delirium in Older Hospitalised Patients: A Comparative Retrospective Cohort Study

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Abstract

Background

Delirium in older hospitalised patients is a common and serious disorder. Polypharmacy and certain medications are risk factors for developing delirium. A medication review could benefit older hospitalised patients with delirium.

Objectives

(1) Evaluate the effects of medication review on length of delirium, length of hospital stay, mortality, and discharge destination; and (2) describe and analyse the proposed changes to medication and its implementation by the treating physician.

Setting

The study was conducted at Maastricht University Medical Centre+.

Methods

We compared two cohorts of older patients with delirium: the first cohort from before introducing the medication review, and a second cohort 5 months after introduction of the medication review. Data were extracted from the patients’ digital medical records.

Results

A significant interaction effect of cohort and number of medications taken by the patient was found for duration of delirium: patients from the second cohort taking between zero and six medications had significantly shorter delirious episodes than patients in the first cohort. This effect bordered on significance for patients taking between seven and 11 medications, but disappeared for patients taking 12 or more medications. No other statistically significant differences were found between the cohorts. The proposed changes in medication were implemented for 71% of the patients.

Conclusion

A medication review seems to significantly decrease the length of an older patient’s delirious episode. Given the clinical relevance of these findings, we advise medication reviews for all older patients who are delirious or are at risk of developing delirium.

Electronic supplementary material

The online version of this article (10.1007/s40266-018-0523-9) contains supplementary material, which is available to authorized users.

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Most cited references 25

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Delirium in elderly people.

Sharon Inouye, Rudi Westendorp, Jane S. Saczynski (2014)

Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium. Copyright © 2014 Elsevier Ltd. All rights reserved.

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Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis.

Milton Uzeda, Piet Eikelenboom, Odile van den Heuvel … (2010)

Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease. To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders. A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL. Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language. Titles, abstracts, and articles were reviewed independently by 2 of the authors. Of 2939 references in the original search, 51 relevant articles were identified. Information on study design, characteristics of the study population, and outcome were extracted. Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies. The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia. Pooled-effect estimates were calculated with random-effects models. The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 22.7 months (7 studies; 271/714 patients [38.0%] with delirium, 616/2243 controls [27.5%]; HR, 1.95 [95% confidence interval {CI}, 1.51-2.52]; I(2), 44.0%). Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 14.6 months; 176/527 patients [33.4%] with delirium and 219/2052 controls [10.7%]; odds ratio [OR], 2.41 [95% CI, 1.77-3.29]; I(2), 0%) and dementia (2 studies; average follow-up, 4.1 years; 35/56 patients [62.5%] with delirium and 15/185 controls [8.1%]; OR, 12.52 [95% CI, 1.86-84.21]; I(2), 52.4%). The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results. This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia.

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One-year health care costs associated with delirium in the elderly population.

Douglas Leslie, Edward R. Marcantonio, Ying. Zhang … (2008)

While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium. Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics. During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.

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Author and article information

Contributors

Eveline L. van Velthuijsen:

ORCID: http://orcid.org/0000-0002-2875-7684

+31433881703 , e.vanvelthuijsen@maastrichtuniversity.nl

Journal

Journal ID (nlm-ta): Drugs Aging

Journal ID (iso-abbrev): Drugs Aging

Title: Drugs & Aging

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1170-229X

ISSN (Electronic): 1179-1969

Publication date (Electronic): 2 February 2018

Publication date PMC-release: 2 February 2018

Publication date (Print): 2018

Volume: 35

Issue: 2

Pages: 153-161

Affiliations

[1 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), , Maastricht University, ; P.O. Box 616, 6200 MD Maastricht, The Netherlands

[2 ]ISNI 0000 0004 0480 1382, GRID grid.412966.e, Department of Internal Medicine, , Maastricht University Medical Centre+, ; Maastricht, The Netherlands

[3 ]ISNI 0000 0004 0480 1382, GRID grid.412966.e, Department of Clinical Pharmacy and Toxicology, , Maastricht University Medical Centre+, ; Maastricht, The Netherlands

[4 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Department of Methodology and Statistics, , Maastricht University, ; Maastricht, The Netherlands

[5 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Department of Psychiatry and Neuropsychology, Alzheimer Centre Limburg, MHeNS School for Mental Health and NeuroScience, , Maastricht University, ; Maastricht, The Netherlands

Author information

Eveline L. van Velthuijsen http://orcid.org/0000-0002-2875-7684

Article

Publisher ID: 523

DOI: 10.1007/s40266-018-0523-9

PMC ID: 5847150

PubMed ID: 29396715

SO-VID: 061ab52b-8aab-4130-8e47-b274f792ffb8

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Effects of a Medication Review on Delirium in Older Hospitalised Patients: A Comparative Retrospective Cohort Study

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Abstract

Background

Objectives

Setting

Methods

Results

Conclusion

Electronic supplementary material

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NTT Journal for Theology and the Study of Religion

Most cited references 25

Delirium in elderly people.

Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis.

One-year health care costs associated with delirium in the elderly population.

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