Association Between Psychomotor Activity Delirium
Subtypes and Mortality Among Newly Admitted
Postacute Facility Patients
Dan K. Kiely,1Richard N. Jones,1,3Margaret A. Bergmann,2and Edward R. Marcantonio2,3
1Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
2Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
3Harvard Medical School/Beth Israel Deaconess Interdisciplinary Center on Aging, Boston, Massachusetts.
Background. Delirium is common among hospitalized elders and may persist for months. Therefore, the adverse
impact of delirium on independence often occurs in the postacute care (PAC) setting. The effect of psychomotor subtypes
on delirium remains uncertain. The purpose of this study is to examine the association between psychomotor activity
delirium subtypes and 1-year mortality among 457 newly admitted delirious PAC patients.
Methods. Patients were screened for delirium on admission to PAC facilities after an acute hospitalization, and patients
with ‘‘Confusion Assessment Method’’-defined delirium were enrolled. Psychomotor activity was assessed using the
Memorial Delirium Assessment Scale, and patients were classified as to their delirium subtype (hyperactive, hypoactive,
mixed, or normal). One-year mortality data were obtained from the National Death Index. A Kaplan–Meier survival
analysis and a proportional hazards analysis using indicator (dummy) variables with normal psychomotor activity as the
referent were performed.
Results. The normal psychomotor activity group had the lowest 1-year mortality rate, followed by the hyperactive,
mixed, then hypoactive groups in increasing order. Independent of age, gender, comorbidity, dementia, and delirium
severity, hypoactive patients were 1.60 (95% confidence interval [CI], 1.09–2.35) times more likely to die during the
1-year follow-up period than were patients with normal psychomotor activity. The hyperactive (hazard ratio¼1.30; 95%
CI, 0.73–2.31) and mixed (hazard ratio¼1.25; 95% CI, 0.72–2.17) psychomotor groups had nonsignificant elevated risks
relative to the normal psychomotor behavior group.
Conclusions. All three psychomotor disturbance subtypes had an elevated risk of dying during the 1-year follow-up
relative to the normal psychomotor group, though the hypoactive group had the highest mortality risk and was the only
group with a statistically significantly elevated risk relative to the normal group.
hospitalized patients and associated with increased risk of
morbidity and mortality, increased health care costs, and
adverse events that lead to loss of independence (1–7).
Moreover, delirious patients are frequently discharged
quickly from acute care facilities despite mounting evidence
indicating that delirium may persist for months (5,8–10).
Many of these patients are discharged to postacute care
(PAC) facilities (rehabilitation hospitals and skilled nursing
facilities) due to incomplete resolution of cognitive and
functional problems that prevent their immediate return
home. Consequently, much of the long-term sequelae of
delirium may occur in the PAC setting rather than in acute
Recently, delirium has been studied in the PAC setting.
We reported that delirium affects 16% of new admissions to
PAC, that 51% of these patients are still delirious 1 month
later, and that persistent delirium is associated with poor
functional recovery (10–13).
Abnormal psychomotor behavior observed in delirious
patients has been described as varying from lethargy and
somnolence to restlessness, agitation, and hyperactivity.
Disturbed psychomotor activity delirium subtypes have
been commonly classified as hypoactive, hyperactive, and
ELIRIUM, a clinical syndrome characterized by acute
decline in attention and cognition, is common among
mixed (both hypoactive and hyperactive), and used in stud-
ies (14–24). Some of these studies have examined associ-
ations between psychomotor activity delirium subtypes and
mortality in the hospital setting (14–20), and results have
been inconsistent. We know of no studies that examined this
association in the PAC setting and beyond. Thus, the pur-
pose of this study is to examine the association between
psychomotor activity delirium subtypes and 1-year mortality
among 457 newly admitted delirious postacute facility pa-
tients. A secondary purpose is to compare percentages of
psychomotor disturbance delirium subtypes to percentages
reported in previous studies.
Patients and their caregivers were recruited between
October 1, 2000 and December 31, 2003 into a randomized
clinical trial of a Delirium Abatement Program (DAP) from
eight greater-Boston skilled nursing facilities specializing in
PAC. The facilities ranged in size from 81 to 224 beds, with
40–80 of the beds Medicare-certified. Because of the
impaired cognitive status of the patients, family caregivers
provided informed consent using a protocol approved by our
Journal of Gerontology: MEDICAL SCIENCES
2007, Vol. 62A, No. 2, 174–179
Copyright 2007 by The Gerontological Society of America
by guest on December 27, 2015
Dr. Marcantonio is a Paul Beeson Physician Faculty Scholar in Aging
We thank Monique Bussell, Kerry Clark, Kathryn Johnson, Maria
Kereshi, Jennifer Kettell, Melissa McKenna, Mary Michaels, and Sara Van
Valkenburg for their efforts to enroll and interview patients for this study,
and Judy Coulombre and Maryann Wallace for medical record review. We
also acknowledge Pamela A. Heidell and Ellen Gornstein for reviewing the
Address correspondence to Dan K. Kiely, MPH, MA, Hebrew
SeniorLife, Institute for Aging Research, 1200 Centre Street, Boston, MA
02131. E-mail: firstname.lastname@example.org
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Received June 14, 2006
Accepted August 4, 2006
Decision Editor: Darryl Wieland, PhD, MPH
ASSOCIATION BETWEEN PSYCHOMOTOR ACTIVITY AND MORTALITY
by guest on December 27, 2015