Postdischarge Clinical Outcomes in Older Medical Patients with an Emergency Department Stay–Associated Delirium Onset
2016; Wiley; Volume: 64; Issue: 9 Linguagem: Inglês
10.1111/jgs.14276
ISSN1532-5415
AutoresMario Bo, Martina Bonetto, Giuliana Bottignole, Paola Porrino, Eleonora Coppo, Michela Tibaldi, Giacomo Ceci, Silvio Raspo, Giorgetta Cappa, Giuseppe Bellelli,
Tópico(s)Healthcare Decision-Making and Restraints
ResumoJournal of the American Geriatrics SocietyVolume 64, Issue 9 p. e18-e19 Letters to the EditorFree Access Postdischarge Clinical Outcomes in Older Medical Patients with an Emergency Department Stay–Associated Delirium Onset Mario Bo MD, PhD, Mario Bo MD, PhD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMartina Bonetto MD, Martina Bonetto MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuliana Bottignole MD, Giuliana Bottignole MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorPaola Porrino MD, Paola Porrino MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorEleonora Coppo MD, Eleonora Coppo MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMichela Tibaldi MD, Michela Tibaldi MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorGiacomo Ceci MD, Giacomo Ceci MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorSilvio Raspo MD, Silvio Raspo MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiorgetta Cappa MD, Giorgetta Cappa MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuseppe Bellelli MD, Giuseppe Bellelli MD Dipartimento di Scienze della Salute, Università Milano-Bicocca, Milan, Italy Acute Geriatric Unit, San Gerardo Hospital, Monza, ItalySearch for more papers by this author Mario Bo MD, PhD, Mario Bo MD, PhD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMartina Bonetto MD, Martina Bonetto MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuliana Bottignole MD, Giuliana Bottignole MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorPaola Porrino MD, Paola Porrino MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorEleonora Coppo MD, Eleonora Coppo MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMichela Tibaldi MD, Michela Tibaldi MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorGiacomo Ceci MD, Giacomo Ceci MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorSilvio Raspo MD, Silvio Raspo MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiorgetta Cappa MD, Giorgetta Cappa MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuseppe Bellelli MD, Giuseppe Bellelli MD Dipartimento di Scienze della Salute, Università Milano-Bicocca, Milan, Italy Acute Geriatric Unit, San Gerardo Hospital, Monza, ItalySearch for more papers by this author First published: 18 August 2016 https://doi.org/10.1111/jgs.14276Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this 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Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat To the Editor: Current evidence suggests that the most successful strategy to prevent delirium includes a multicomponent approach to modifiable risk factors.1 Identification of correctable hospitalization-related conditions that predispose to delirium might be useful in daily clinical practice.2, 3 It was recently found that an emergency department (ED) length of stay of longer than 10 hours was associated with greater risk of delirium in older hospitalized adults.4 However, whether occurrence of delirium in these individuals results in greater risk of adverse outcomes was not assessed. The current study prospectively evaluated whether individuals with delirium onset within 72 hours after ward admission are more likely to die or be rehospitalized after discharge than those without. Four geriatric postgraduate students (GC, MT, EC, MB) screened individuals aged 75 and older consecutively admitted to the ED of two university teaching hospitals (Città della Salute e della Scienza, Molinette, Torino; Azienda Ospedaliera Santa Croce e Carle, Cuneo, Piemonte, Northern Italy) for the presence of delirium using the 4AT, a rapid assessment test for delirium;5 at the same time, two senior geriatricians (MZ, MB) supervised the administration of 4AT at ED arrival and diagnosed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.6 The 4AT has recently been validated in older hospitalized adults.5 In the validation study, which included the short Confusion Assessment Method (CAM), a score greater than 4 out of 12 on the 4AT had sensitivity of 89.7% and sensitivity of 84.1% for delirium (sensitivity of 83.3% and sensitivity of 91.3% in individuals without dementia, sensitivity of 94.1% and sensitivity of 64.9% in individuals with dementia). The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in individuals without dementia, and 0.89 in individuals with dementia, suggesting good specificity for delirium in a population without dementia and good sensitivity to delirium in a population with dementia. Individuals without delirium and without exclusion criteria at ED entry who were admitted to an acute medical or geriatric ward were assessed daily for the presence of delirium, which was diagnosed in 52 of 330 (15.8%) during the first 72 hours after admission; ED stay of longer than 10 hours was found to be associated with significantly greater risk of delirium. The current study compared the 6-month postdischarge incidence of a composite end-point (all-cause death and rehospitalization) in individuals who developed delirium within the first 72 hours with that of all other discharged individuals. Death and rehospitalization were ascertained through telephone interview (participants or proxy respondents were used as the primary source of information) and medical chart review. Clinical variables associated with the composite end-point were identified using the Mann–Whitney U test and chi-square test for categorical variables. Multivariate analysis was used to test the association between delirium associated with an ED stay and the composite end-point. Thirty of the 330 individuals admitted died in the hospital (9.1%, including 13 of 52 with early delirium), leaving a sample of 300, including 39 with delirium onset within the first 72 hours after ward admission and 14 with later delirium onset. The main demographic and clinical variables of the individuals are reported in Table 1. At 6-month follow-up, 38 of 300 discharged participants (12.7%) had died, and 99 (33.3%) had had at least one rehospitalization. Of participants with delirium onset within 72 hours, all-cause death and rehospitalization rates were not significantly more frequent, and the composite end-point (n = 28, 71.8%) was significantly more frequent than in other participants (n = 102, 28.2%) (P < .001). Delirium occurrence within 72 hours (odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.13–1.67), functional dependence (OR = 1.37, 95% CI = 1.05–1.71), greater Cumulative Illness Rating Scale severity (OR = 1.18, 95% CI = 1.08–1.89), low hematocrit (OR = 0.79, 95% CI = 0.53–0.98) and serum albumin levels (OR = 0.69, 95% CI = 0.38–0.97) were significantly associated with greater incidence of the composite end-point. Table 1. Main Demographic and Clinical Variables in the Overall Sample of Discharged Individuals (N = 300) Variable Value Age, median (IQR) 81.9 (78.3–86.9) Male, n (%) 147 (49.0) Location, median (IQR) Home 258 (86.1) Nursing home 42 (13.9) Number of drugs/d, n (%) <5 78 (26.0) 5–10 195 (65.0) ≥11 27 (9.0) ADL score, median (IQR) 2.0 (0.0–5.0) Functional dependence (ADL score ≥3), n (%) 163 (54.3) Instrumental ADL score, median (IQR) 7.0 (4.0–10.0) SPMSQ score, median (IQR) 4.0 (1.0–7.0) Moderate to severe cognitive impairment (SPMSQ score ≥6), n (%) 103 (34.3) CIRS score, median (IQR) 3.0 (2.0–5.0) Severe comorbidity (CIRS score ≥5), n (%) 91 (30.3) Hematocrit, %, mean ± SD 41.3 ± 3.7 Serum creatinine, mg/dL, mean ± SD 1.1 ± 0.6 Serum albumin, g/dL, mean ± SD 3.4 ± 0.3 Length of stay in ward, days, median (IQR) 10.0 (5.6–15.1) IQR = interquartile range; ADL = activity of daily living; SPMSQ = Short Portable Mental Status Questionnaire; CIRS = Cumulative Illness Rating Scale; SD = standard deviation. These results provide evidence that individuals who experience delirium within 72 hours after ward admission have a greater risk of death and rehospitalization; the association between delirium occurrence and the composite end-point remained significant after multivariate adjustment. In keeping with previous studies that have reported greater postdischarge mortality and worse clinical outcomes in individuals who develop delirium during a hospital stay,7-10 these findings add to the current evidence demonstrating that ED length of stay, by increasing the risk of delirium onset, might contribute to postdischarge death and rehospitalizations. Therefore, whether interventions designed to shorten the length of ED stay (or to make it more comfortable) may reduce the incidence of delirium in older vulnerable adults and result in a better overall prognosis, including lower mortality and rehospitalization rates, should be evaluated. Acknowledgments The ethics committees approved the research protocol, and written consent was obtained from all participants. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Mario Bo: expert geriatrician, writing the manuscript. Martina Bonetto: study design. Bottignole, Porrino, Coppo, Tibaldi, Ceci: data collection. Raspo: statistical analysis. Cappa: expert geriatrician. Bellelli: reviewer. Sponsor's Role: None. References 1Inouye SK, Holford TR, Cooney LM Jr et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669– 676. 2Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med 2013; 29: 31– 47. 3Carpenter CR, Bromley M, Caterino JM et al. Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. J Am Geriatr Soc 2014; 62: 1360– 1363. 4Bo M, Bonetto M, Bellelli G et al. Length of stay in the emergency department and occurrence of delirium in older medical patients. J Am Geriatr Soc 2015; 63 doi: 10.1111/jgs.14103 5Bellelli G, Annoni G, MacLullich AMJ et al. Validation of the 4AT, a new instrument for rapid delirium screening: A study in 234 hospitalized older people. Age Ageing 2014; 43: 496– 502. 6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC: American Psychiatric Association, 2013. 7Siddiqi N, House A, Holmes J. Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age Ageing 2006; 35: 350– 364. 8McCusker J, Cole M, Abrahamovicz M et al. Delirium predicts 12 month mortality. Arch Intern Med 2002; 162: 457– 463. 9McAvay GJ, van Ness PH, Bogardus ST et al. Older adults discharged from hospital with delirium: One year outcomes. J Am Geriatr Soc 2006; 54: 1245– 1250. 10Isaia G, Astengo M, Aimonino Ricauda N et al. Delirium in elderly home-treated patients: A prospective study with 6-month follow-up. Am Aging Assoc 2009; 31: 109– 117. Citing Literature Volume64, Issue9September 2016Pages e18-e19 ReferencesRelatedInformation
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