Association Between Psychomotor Activity Delirium Subtypes and Mortality Among Newly Admitted Postacute Facility Patients

Article (PDF Available)inThe Journals of Gerontology Series A Biological Sciences and Medical Sciences 62(2):174-9 · March 2007with14 Reads
DOI: 10.1093/gerona/62.2.174 · Source: PubMed
Abstract
Delirium is common among hospitalized elders and may persist for months. Therefore, the adverse impact of delirium on independence often occurs in the post acute 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. 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. 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 ratio = 1.30; 95% CI, 0.73-2.31) and mixed (hazard ratio = 1.25; 95% CI, 0.72-2.17) psychomotor groups had nonsignificant elevated risks relative to the normal psychomotor behavior group. 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.
Association Between Psychomotor Activity Delirium
Subtypes and Mortality Among Newly Admitted
Postacute Facility Patients
Dan K. Kiely,
1
Richard N. Jones,
1,3
Margaret A. Bergmann,
2
and Edward R. Marcantonio
2,3
1
Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
2
Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
3
Harvard 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 ratio ¼ 1.30; 95%
CI, 0.73–2.31) and mixed (hazard ratio ¼ 1.25; 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.
D
ELIRIUM, a clinical syndrome characterized by acute
decline in attention and cognition, is common among
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
care facilities.
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
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.
M
ETHODS
Study Population
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
174
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2007, Vol. 62A, No. 2, 174–179
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Institutional Review Board. Depending on the randomized
facility, patients received either the intervention or usual care.
The DAP was designed as a unit-based intervention to be
implemented by PAC facility staff with initial training and
ongoing on-site consultation by a trained research nurse.
Methodological details of the DAP have been previously
published (25).
In addition to having delirium at PAC admission
(baseline), eligible patients in this study were 65 years
old, were admitted directly from an acute-care medical or
surgical hospitalization, spoke English, did not have
a significant hearing impairment, were communicative prior
to acute illness, were not admitted for terminal care (life
expectancy , 6 months), did not have end-stage dementia,
were not completely activities of daily living (ADL)–
dependent prior to hospitalization, and lived within 25 miles
of our research site. All interviews for delirium were
conducted by trained research assistants and completed
preferably within 72 hours (average time to interview ¼ 2.5
days), but not longer than 5 days after admission. A research
assistant completed a standardized mental status assessment.
Only baseline assessments were used in this study. Multiple
assessors were used, but inter-rater reliability of the
assessment team was excellent (kappa ¼ 0.95) (26).
Delirium Assessment
The Confusion Assessment Method (CAM) is a diagnostic
algorithm derived from Diagnostic and Statistical Manual of
Mental Disorders, Third Revision (DSM-III-R) criteria for
delirium. The CAM allows trained research assistants to
perform ratings of delirium presence that agree with
a psychiatrist’s diagnosis with greater than 95% sensitivity
and specificity, even in populations with a high prevalence
of dementia (27). The CAM diagnostic algorithm involves
four criteria: 1) an acute change in mental status with
a fluctuating course, 2) inattention, 3) disorganized thinking,
and 4) an altered level of consciousness (27). Delirium was
considered present if CAM criteria 1 and 2 were present,
and either criteria 3 or 4 was present.
Delirium Symptom Interview.—The Delirium Symptom
Interview (DSI) (28) is a valid and reliable structured
interview for diagnosing the presence of specific critical
symptoms of delirium in an objective and straightforward
manner, and can be administered by lay interviewers. The
DSI was used to determine the presence of specific critical
symptoms of delirium including the level of psychomotor
activity that interviewers used to complete the Memorial
Delirium Assessment Scale (MDAS).
Psychomotor activity disturbances: Delirium subtypes.—
The MDAS (29) allows trained research personnel to
quantify the severity of delirium based on 10 features,
scored from 0 to 3 for a maximum score of 30. The 10
MDAS features include reduced level of consciousness,
disorientation, short-term memory impairment, impaired
digit span, reduced ability to maintain and shift attention,
disorganized thinking, perceptual disturbance, delusions,
decreased or increased psychomotor activity, and sleep–
wake cycle disturbance. Psychomotor variants of delirium
were defined using the MDAS.
At PAC admission, the severity of psychomotor distur-
bance was scored using the MDAS. The assessor rated
whether the patient’s behavior had increased or decreased
psychomotor activity during the interview and indicated
whether the patient had any of the following: (i) hypo-
activity, (ii) hyperactivity, or (iii) mixed features (both
hypoactivity and hyperactivity) (15). Every patient has some
level of psychomotor activity, and hypoactive or hyperac-
tive disturbances are considered ‘‘abnormal.’’ If neither was
present the assessor scored ‘none’ and considered the
patient to have ‘normal’’ psychomotor activity.
Mortality source: National Death Index.—The National
Death Index (NDI) (30) is a database of death records
maintained by the National Center for Health Statistics
(NCHS), which compiles mortality data submitted by state
vital statistics offices. We supplied the NCHS with a file that
contained the DAP participants’ name, gender, birth date,
and study identifier for those who were not known by us to
be dead. The NCHS provided a file of NDI matches to this
information (including death status, date of death, and
primary and secondary causes of death). In some cases,
more than one match was supplied in order of the best
match. We used additional information such as state of
residence, race, and marital status to determine the best
match.
Covariates
Several baseline patient characteristics were controlled for
in the adjusted analysis including age, gender, comorbidity,
dementia, and delirium severity. A brief interview has been
validated to obtain the data necessary to complete the
Charlson Comorbidity Score (CCS) from patients or care-
givers (31). This interview was administered to the family
caregiver (proxy) at study intake to assess current
comorbidity. Dementia was defined as a positive response
to the ‘Alzheimer’s disease’ or ‘‘dementia’ item on the
Charlson Comorbidity questionnaire or had an International
Classification of Diseases, Ninth Revision (ICD-9-CM)
diagnostic code indicating the presence of dementia on
medical record review. The total MDAS score, with the
exclusion of the decreased or increased psychomotor
activity item, was included to adjust for delirium severity.
A variable was created indicating whether a patient was in
a usual care or intervention facility. This variable was
included in an additional adjusted analysis to control for the
potential influence of the DAP on association between
psychomotor type and 1-year mortality.
Data Analyses
Descriptive statistics were provided to characterize the
entire sample, and each psychomotor activity delirium
subtype. A Kaplan–Meier survival analysis (32) was
performed, and the log-rank test and corresponding p value
were used to determine if survival differed by psychomotor
activity group. A corresponding plot was created to graph-
ically display the survival trajectories over time for the psy-
chomotor activity delirium subtypes. Unadjusted and
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adjusted Cox proportional hazards analyses (32) were
performed using indicator (dummy) variables with the
normal psychomotor activity group as the referent. An alpha
level of .05 was used in all analyses to determine statistical
significance. SAS (33) was used in data manipulation and
statistical analyses.
R
ESULTS
Among 7794 patient admissions, 6352 (81%) were eligi-
ble. A total of 4744 (75%) were screened, and 667 (14%)
were classified as delirious. Of the 667, 138 had proxies who
refused, 56 proxies did not respond within the enrollment
period (despite repeated efforts), 14 patients died before the
proxies were reached, and two proxies could not provide
consent. Thus, 457 patients were enrolled in the study.
Table 1 shows that the average age of patients in this
study was 84.0 years (standard deviation ¼ 7.3), and the
average comorbidity score was 2.6 (2.4). The average
delirium severity score was 11.5 (3.7). Women represented
64.5% of the sample, and 37.6% had dementia. The 1-year
mortality rate was 41.6%, which is consistent with other
studies of hospitalized delirious elders (7). Table 1 also
displays these patient characteristics stratified by psycho-
motor activity delirium subtype. Nearly half the patients had
hypoactive psychomotor activity at baseline, and almost one
third did not have disturbed psychomotor activity (normal).
The remaining proportion almost equally comprised hyper-
active and mixed subtypes.
Figure 1 presents the Kaplan–Meier survival curves for
the three psychomotor disturbance subtypes and the normal
psychomotor activity group. The normal group had the
lowest 1-year mortality rate, followed by the hyperactive
group, then the mixed group, in increasing order. The
hypoactive group had the highest mortality rate. Differences
in the survival trajectory of the delirium subtypes were
statistically significant (log-rank ¼ 10.9; p ¼ .01).
We found no evidence that the proportional hazards
assumption was violated. The unadjusted Cox proportional
hazards analysis revealed that the hypoactive psychomotor
group was 1.73 (95% confidence interval [CI], 1.22–2.45)
times more likely to die during the 1-year follow-up relative
to the normal psychomotor activity group (Table 2).
A similar relationship was found in the adjusted analysis
(Table 3). Independent of age, gender, comorbidity, de-
mentia, and delirium severity, hypoactive patients were 1.62
(95% CI, 1.11–2.37) times more likely to die over the 1-year
follow-up period than were patients with normal psycho-
motor activity. The hyperactive (hazard ratio ¼ 1.23; 95%
CI, 0.70–2.18) and mixed (hazard ratio ¼ 1.26; 95% CI,
0.73–2.14) psychomotor groups had less elevated risks
relative to the normal psychomotor behavior group, and
these risk estimates were not statistically significant. Twenty
patients (4%) were excluded from the adjusted model due to
missing values of covariates (n ¼ 437).
The Cox proportional hazards adjusted model mentioned
above was rerun with the inclusion of a variable indicating
whether the patient received intervention or usual care. The
results indicated that there was no intervention effect (p ¼
.55) and the effect estimates were virtually identical to the
estimates from the model without the intervention variable
included (data not shown).
D
ISCUSSION
The results of this prospective study of 457 PAC patients
indicate that delirious patients who entered the PAC with
hypoactive psychomotor behavior had the highest risk of
dying during the 1-year follow-up compared to the mixed,
hyperactive, and normal psychomotor activity groups.
Furthermore, unlike the mixed and hyperactive groups, the
hypoactive group remained significantly more likely to die
during the 1-year follow-up than was the normal psycho-
motor behavior group after adjusting for age, gender,
comorbidity, dementia, and delirium severity.
In a recent review article of psychomotor activity delirium
subtype studies, De Rooij and colleagues (24) emphasized
the importance of understanding the different methods used
to define and assess psychomotor activity. All studies in-
cluded in their review used a different method for subtype
classification, thus illustrating that there is no consensus
concerning the optimal classification system for delirium
subtypes.
Table 4 displays the percentages of the psychomotor
activity delirium subtypes for our study and 10 other studies,
and highlights three important points. First, the percentages
Table 1. Descriptive Statistics for Patient Characteristics of the Entire Sample and by Psychomotor Activity Delirium Subtype
for 457 Postacute Patients Who Had Confusion Assessment Method (CAM)-Defined Delirium at Baseline Assessment
Patient Characteristic
Overall
(N ¼ 457)
(100%)
Normal*
(N ¼ 143)
(31.3%)
Hyperactive
(N ¼ 47)
(10.3%)
Mixed
(N ¼ 55)
(12.0%)
Hypoactive
(N ¼ 212)
(46.4%) p Value
Age 84.0 (7.3) 84.6 (7.6) 83.1 (8.6) 83.8 (7.2) 83.9 (6.9) .61
CCS 2.6 (2.4) 2.5 (2.2) 2.4 (2.4) 2.5 (2.0) 2.7 (2.5) .88
Delirium severity
y
11.5 (3.7) 10.1 (2.9) 11.0 (3.6) 13.0 (3.5) 12.3 (3.9) .0001
Female 64.5% 69.9% 61.7% 56.4% 63.7% .30
Dementia 37.6% 31.5% 42.5% 47.3% 38.2% .17
Mortality, 1 y 41.6% 32.2% 36.2% 41.8% 49.1% .01
Notes: The mean (standard deviation) are given for continuous variables.
*Normal psychomotor activity (no evidence of hyperactive or hypoactive activity).
y
Memorial Delirium Assessment Scale (excluding the ‘decreased or increased psychomotor activity’ item). This is a measure of delirium severity.
CCS ¼ Charlson Comorbidity Score.
Dementia ¼ either International Classification of Diseases, Ninth Revision (ICD-9) code for dementia or positive CCS dementia item.
176 KIELY ET AL.
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of the psychomotor activity delirium subtypes vary dra-
matically across different studies. Second, many of these
studies did not include a normal (no psychomotor distur-
bances) category or a mixed category (both hypoactivity and
hyperactivity). Finally, differences in methods used to
define psychomotor activity and the inclusion of patients
from different settings (i.e., surgical, general medical,
intensive care unit, neuropsychiatry clinic, case series)
may partially explain the differences in percentages of
delirium subtypes, and make it difficult to compare and
generalize findings across these studies.
Liptzin and Levkoff (15) studied 325 patients admitted
for medical or surgical care and reported that, among the
125 patients with DSM-III-defined delirium, the hyperactive
patients had the lowest mortality rate in the hospital and at
Figure 1. Kaplan–Meier survival curves for the three psychomotor disturbance subtypes (hypoactive, hyperactive, mixed) and the normal (no psychomotor
disturbances) psychomotor activity group. Differences in the survival trajectory of the delirium subtypes were statistically significant (log-rank ¼ 10.9; p ¼ .01). N ¼
Normal; M ¼ mixed; H ¼ hypoactive; R ¼ hyperactive.
Table 3. Adjusted Hazard Ratios and 95% Confidence Intervals
Estimating the Risk of Dying During the 1-Year Follow-Up Period
for Patients With Psychomotor Activity Delirium Subtypes Relative
to Normal Psychomotor Activity (Reference Group) (N ¼ 437)
Patient Characteristic Hazard Ratio 95% CI p Value
Normal 1.00
Hyperactive 1.23 0.70, 2.18 .47
Mixed 1.26 0.73, 2.14 .40
Hypoactive 1.62 1.11, 2.37 .01
Age 1.06 1.04, 1.08 .0001
Female 0.61 0.45, 0.82 .001
CCS 1.09 1.03, 1.15 .004
Dementia 0.74 0.54, 1.02 .07
Delirium severity* 1.05 1.01, 1.09 .02
Notes: *Memorial Delirium Assessment Scale (excluding the ‘decreased or
increased psychomotor activity’ item). This is a measure of delirium severity.
CI ¼ Confidence interval; CCS ¼ Charlson Comorbidity Score; Dementia ¼
either International Classification of Diseases, Ninth Revision (ICD-9) code for
dementia or CCS dementia item positive.
Table 2. Unadjusted Hazard Ratios and 95% Confidence Intervals
(CI) Estimating the Risk of Dying During the 1-Year Follow-Up
Period for Patients With Abnormal Psychomotor Activity
(Hyperactive, Mixed, Hypoactive) Relative to Normal
Psychomotor Activity (Reference Group) (N ¼ 457)
Psychomotor Activity Hazard Ratio 95% CI p Value
Normal 1.00
Hyperactive 1.12 0.64, 1.95 .70
Mixed 1.42 0.86, 2.34 .17
Hypoactive 1.73 1.22, 2.45 .002
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the 6-month follow-up. Kobayashi and colleagues (16)
retrospectively characterized the clinical features of psy-
chomotor activity delirium subtypes in 106 patients and
stated that 37.5% of patients with mixed, 30.1% with
hyperactive, and 28.6% with hypoactive psychomotor
activity died during their study period. O’Keefe and Lavan
(34) prospectively examined 94 hospital patients and
reported that a higher percentage of hypoactive (21%)
patients died compared to hyperactive (15%), mixed (16%),
and neither (0%). Camus and colleagues (18) compared the
etiologic and outcome profiles in a case series of 183 elderly
patients and found that hypoactive patients had the highest
mortality (10%) followed by hyperactive (9%) and mixed
(6%). The findings of these last two studies are consistent
with the results of our study, though, unlike our study, the
differences in both of these studies were not statistically
significant.
Marcantonio and colleagues (20) prospectively studied
122 hip fracture surgery patients and found that hyperactive
patients (including mixed-type patients who were combined
with the hyperactive types) were more likely to die after hip
fracture compared to hypoactive patients, though this
difference was not statistically significant. Kelly and
colleagues (19) studied a series of nursing facility delirium
patients and reported that psychomotor activity delirium
subtype did not predict mortality during or subsequent to the
patient’s hospitalization. However, they report that hypo-
active patients were more likely to have persistent delirium
and that patients with persistent delirium were more likely to
die in the hospital compared with patients who resolved
their delirium. Our study significantly adds to the above
literature by following a large cohort of delirious patients
admitted to PAC skilled nursing facilities for up to 1 year
after the delirium episode.
This study has strengths and limitations to consider.
Trained research personnel, using an established and
validated diagnostic algorithm (CAM), performed assess-
ments. The inter-rater reliability of our study team of
assessors was excellent. NDI data were successfully linked
to our PAC data allowing for the study of 1-year mortality.
Concerning limitations, our data were collected from a single
metropolitan region and may not generalize to rural
locations. Results of our study involving PAC skilled
nursing facility patients may not generalize to individuals
receiving PAC in a rehabilitation hospital or community
setting. Although our assessments were performed within
2.5 days of PAC admission, we cannot be sure if some
patients developed delirium after admission to the PAC
facility. Some mismatching could have occurred when
linking the NDI data to our database, though we would
expect that this misclassification is nondifferential and
would likely increase the association if removed. Finally,
the relatively small sample sizes in the hyperactive (n ¼ 47)
and mixed (n ¼ 55) subgroups may have contributed to
a lack of power in detecting statistically significant differ-
ences in the mortality analysis.
Our findings have substantial clinical significance. The
literature has documented that physicians and nurses are less
likely to detect cases of hypoactive delirium than other
psychomotor disturbance subtypes (6). These patients are
not immediately disruptive to their medical care, yet their
delirium makes them unlikely to engage in activities that
will promote recovery from acute illness. Our findings
associating this class of delirium with the highest mortality
risk emphasize the need for systematic case finding effects
to detect hypoactive delirium. These efforts will ensure that
(i) hypoactive delirium is promptly recognized, (ii) the
underlying causes of the delirium are properly addressed,
and (iii) a plan for ADL support and functional reha-
bilitation is developed. These steps are imperative to reduce
mortality risk and promote functional recovery among these
highly vulnerable patients.
Conclusion
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
statistically significantly different group relative to the
normal group. This finding has additional importance
considering that the hypoactive form of delirium is common
among older persons and often goes unrecognized (7,37).
ACKNOWLEDGMENTS
This work was supported in part by grants R01AG17649 (to E. R. M.)
and R03AG025262 (to R. N. J.) from the National Institute on Aging.
Table 4. Percentages of Psychomotor Activity Delirium Subtypes by Study (Chronologically)
Authors (Ref No.), Year Hypoactivity (%) Hyperactivity (%) Mixed Activity (%) Normal Activity (%)
Ross et al. (14), 1991 67 33 0 0
Liptzin and Levkoff (15), 1992 19 15 52 14
Kobayashi et al. (16), 1992 6.6 78.3 15.1 0
O’Keefe and Lavan (34), 1999 29 21 43 7
Sandberg et al. (35), 1999 26 22 42 11
Meagher et al. (36), 2000 24 30 46 0
Camus et al. (18), 2000 26.2 46.5 0 27.3
Kelly et al. (19), 2001 55.7 3.3 41 0
Marcantonio et al. (20), 2002* 71 29 0 0
Peterson et al. (22), 2006 43.5 1.6 54.9 0
Kiely et al. (current study) 46.4 10.3 12.0 31.3
Notes: Mixed is sometimes referred to as ‘‘both.’ Normal is sometimes referred to as ‘neither’’ in some studies.
*The hyperactivity group included both hyperactivity and mixed psychomotor activity delirium subtypes.
178 KIELY ET AL.
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Dr. Marcantonio is a Paul Beeson Physician Faculty Scholar in Aging
Research.
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
manuscript.
Address correspondence to Dan K. Kiely, MPH, MA, Hebrew
SeniorLife, Institute for Aging Research, 1200 Centre Street, Boston, MA
02131. E-mail: kiely@hrca.harvard.edu
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Received June 14, 2006
Accepted August 4, 2006
Decision Editor: Darryl Wieland, PhD, MPH
179ASSOCIATION BETWEEN PSYCHOMOTOR ACTIVITY AND MORTALITY
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    • "In particular, according to Inouye's model [46], we found that both predisposing (i.e., age, disability, dementia, and malnutrition ) and precipitating factors (i.e., use of antipsychotics, feeding tubes, peripheral venous and urinary catheters, and physical restraints) were associated with delirium occurrence in the whole population, thus confirming the multifactorial nature of this syndrome. The frequency of the delirium motoric subtypes in our study is in keeping with previous ones carried out on smaller populations [47, 48]. Because the most prevalent delirium subtype was the hypoactive one, which is at highest risk of underdetection [28], we also claim the importance of an active case finding in clinical practice using standardized tools in order to avoid misdetection. "
    [Show abstract] [Hide abstract] ABSTRACT: Background To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods This is a point prevalence study (called “Delirium Day”) including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01–1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12–1.27), dementia (OR 3.25, 95 % CI 2.41–4.38), malnutrition (OR 2.01, 95 % CI 1.29–3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45–2.82), feeding tubes (OR 2.51, 95 % CI 1.11–5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06–1.87), urinary catheters (OR 1.73, 95 % CI 1.30–2.29), and physical restraints (OR 1.84, 95 % CI 1.40–2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29–3.14), while admission to other settings was not. Conclusions Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The “Delirium Day” project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
    Full-text · Article · Dec 2016
    • "Long period of stay in critical care has also been found to contributing to the prevalence of delirium as, 70–80% of these category patients experience delirium [7,2829. Also contributing to the high prevalence are those patient place on mechanical ventilators, studies has shown that 87% of these patients experience delirium [7,242526. It is also pertinent to know that among all these cases of prevalence 50% of them result from poor detection or missed diagnosis in clinical practice [18, 30]. "
    Full-text · Article · Dec 2015 · International Psychogeriatrics
    • "However, despite these methodological limitations, hypoactive subtypes have been found to have a significantly poorer prognosis (Yang et al., 2009). In particular, hypoactive motor profiles have been found to have highest associated mortality independent of factors such as comorbidity , age, delirium, and dementia severity (Kiely et al., 2007). However, the association between hypoactive delirium and elevated mortality may be reflective of delayed detection of delirium, and hence more prolonged episodes (Gonzalez et al., 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Delirium is a common neuropsychiatric syndrome that includes clinical subtypes identified by the Delirium Motor Subtyping Scale (DMSS). We explored the concordance between the DMSS and an abbreviated 4-item version in elderly medical inpatients. Methods: Elderly general medical admissions (n = 145) were assessed for delirium using the Revised Delirium Rating scale (DRS-R98). Clinical subtype was assessed with the DMSS (which includes the four items included in the DMSS-4). Motor subtypes were generated for all patient assessments using both versions of the scale. The concordance of the original and abbreviated DMSS was examined. Results: The agreement between the DMSS and DMSS-4 was high, both at initial and subsequent assessments (κ range 0.75-0.91). Intraclass Correlation Coefficient (ICC) for all three raters for the DMSS was high (0.70) and for DMSS-4 was moderate (0.59). Analysis of the agreement between raters for individual DMSS items found higher concordance in respect of hypoactive features compared to hyperactive. Conclusions: The DMSS-4 allows for rapid assessment of clinical subtype in delirium and has high concordance with the longer and well-validated DMSS, including over longitudinal assessment. There is good inter-rater reliability between medical and nursing staff. More consistent clinical subtyping can facilitate better delirium management and more focused research effort.
    Full-text · Article · Nov 2015
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