Delirium risk factors in elderly hospitalized patients Authors
Cite this article as: Elie, M., Cole, M.G., Primeau, F.J. et al. J GEN INTERN MED (1998) 13: 204. doi:10.1046/j.1525-1497.1998.00047.x
OBJECTIVE: Delirium is frequent in elderly hospitalized patients. Many studies have examined its risk factors, but results have been quite variable. Thus, the goal of this study is to identify through systematic literature review the risk factors associated with the development of delirium in hospitalized geriatric patients.
MEASUREMENTS AND MAIN RESULTS: First, MEDLINE/CURRENT contents databases were screened for relevant articles published from 1966 to December 1995, and from bibliographies of identified articles additional reports were selected. Second, the reports were screened by two different investigators and retained only if meeting the five following criteria: (1) original research in French or English; (2) prospective study; (3) patients over age 50; (4) minimum of one risk factor examined; (5) acceptable definition of delirium. Third, the methodology of each study was graded according to specific criteria for risk factor studies. Fourth, risk factors were identified and tabulated, unadjusted odds ratios (ORs) were computed, and where appropriate a combined OR with the Mantel-Haenszel estimator was calculated. Twenty-seven articles were retained meeting all of the above criteria. Among these studies, 11 were done on medical patients, 9 on surgical patients, 2 on medical and surgical patients, and 5 on psychiatric patients. In total 1,365 subjects with delirium were studied. Sixty-one different risk factors were examined, the five most common being dementia, medication, medical illness, age, and male gender. Mantel-Haenszel estimator was calculated for 10 risk factors, the most strongly associated being dementia (OR 5.2; 95% confidence interval [CI] 4.2, 6.3), medical illness (OR 3.8; 95% CI 2.2, 6.4), alcohol abuse (OR 3.3; 95% CI 1.9, 5.5), and depression (OR 1.9; 95% CI 1.3, 2.6). Methodologic weaknesses were present in many studies.
CONCLUSIONS: Despite methodologic limitations, certain risk factors for delirium seem to be consistent and could help identify high-risk patients. These risk factors include dementia, advanced age, and medical illness. Other risk factors appear to play a contributory role in the development of delirium in elderly hospitalized patients.
Presented at the American Psychiatric Association annual meeting, New York, NY, May 1996.
The authors thank Brigitte Beaudet, Audiovisual Department, and Dr. Jane McCusker, Department of Clinical Epidemiology, for their assistance in completing this article.
Francis J. Delirium in older patients. J Am Geriatr Soc. 1992;40: 829–38.
Levkoff SE, Evans DA, Liptzin B, et al. Delirium: the occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med. 1992;152:334–40.
Cole MG, Primeau FJ. Prognosis of delirium in elderly hospitalized patients. Can Med Assoc J. 1993;149:41–6.
Thomas RI, Cameron DJ, Fahs MC. A prospective study of delirium and prolonged hospital stay. Arch Gen Psychiatry. 1998;45: 937–40.
Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995; 13:142–5.
Rockwood K, Cosway S, Stolee P, et al. Increasing the recognition of delirium in elderly patients. J Am Geriatr Soc. 1994;42:252–6.
Gustafson Y, Brannstrom B, Norbeg A, Butch G, Winblab B. Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc. 1991;39:760–5.
Cole MG, Primeau FJ, Bailey RF, et al. Systematic intervention for elderly inpatients with delirium: a randomized trial. Can Med Assoc J. 1994;151(7):965–70.
Williams MA, Campbell EB, Raynar WJ, et al. Reducing acute confusional states in elderly patients with hip fractures. Res Nurs Health. 1985;8:329–37.
Wanich CK, Sullivan-Marx FM, Gottlieb G, et al. Functional status outcomes of a nursing intervention in hospitalized elderly. Image. 1992;24:201–7.
Dyer CB, Ashton CM, Teasdale TA. Postoperative delirium, a review of 80 primary data-collection studies. Arch Intern Med. 1995; 155:461–5.
Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271:134–9.
Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993;119:474–81.
Eysenck HJ. Meta-analysis and its problems. BMJ. 1994;309:789–92.
Macarthur C, Foran PJ, Boilar JC III. Qualitative assessment of studies included in a meta-analysis: DES and the risk of pregnancy loss. J Clin Epidmiol. 1995;48(6):739–47.
Squires BP, Elmslie TJ. Reports of case-control studies: what editors want from authors and peer reviewers. Can Med Assoc J. 1989;141:17–9.
Prendiville W, Elbourne D, Chalmers I. The effects of routine oxytocic administration in the management of the third stage of labour: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1988;95:3–16.
Cooper H, Hedges L. Combining estimate of effect size: In: The Handbook of Research Synthesis. New York, NY: Russell Sage Foundation; 1994.
Gustafson Y, Berggen D, Brannstrom B, et al. Acute confusional states in elderly patients treated for femoral fracture. J Am Geriatr Soc. 1988;36:525–30.
Rogers MP, Liang MH, Daltroy LH, et al. Delirium after elective orthopedic surgery: risk factors and natural history. Int J Psychiatr Med. 1989;19(2):109–21.
Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME. Postoperative delirium: predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc. 1992;40:759–67.
Bowman AM. The relationship of anxiety to development of postoperative delirium. J Gerontol Nurs. 1992;18(1):24–30.
Marcantonio ER, Juarez G, Goldman L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518–22.
Seymour DG, Vaz FC. A prospective study of elderly general surgical patients, II: post-operative complications. Age Ageing. 1989; 18:316–26.
Williams M, Campbell EB, Raynor WJ, Musholt MA, Mlynarczyk SM, Crane LF. Predictors of acute confusional states in hospitalized elderly patients. Res Nurs Health. 1985;8:329–37.
Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43:175–8.
Jitapunkul S, Pilloy I, Ebrahim S. Delirium in newly admitted elderly patients: a prospective study. Q J Med. 1992;83:307–14.
Kolbeinsson H, Jonsson A. Delirium and dementia in acute medical admissions of elderly patients in Iceland. Acta Psychiatr Scand. 1993;83:123–7.
Rockwood K. Acute confusion in elderly medical patients. J Am Geriatr Soc. 1989;37:150–4.
Seymour DG, Henschke RD, Cape T, Campbell AJ. Acute confusional states and dementia in the elderly: the role of dehydration/volume depletion, physical illness and age. Age Ageing. 1980;9:137–46.
Bergmann K, Eastham EJ. Psychogeriatric ascertainment and as sessment for treatment in an acute medical ward setting. Age Ageing. 1974;3:174–88.
Foreman MD. Confusion in the hospitalized elderly: incidence, onset and associated factors. Res Nurs Health. 1989;12:21–9.
Hodkinson HM. Mental impairment in the elderly. J R Coll Physicians Lond. 1973;7:305–17.
Francis J, Martin D, Kapoor WN. Prospective study of delirium in hospitalized elderly. JAMA. 1990;263:1097–1101.
Foy A, O’Connell D, Henry D, Kelly J, Cocking S, Halliday J. Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients. J Gerontol Med Sci. 1995;50A:M99–106.
Erkinjuntti T, Wirstrom J, Palo J, Autio L. Dementia among medical inpatients: evaluation of 2000 consecutive admissions. Arch Intern Med. 1986;146:1923–6.
Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994;42:809–15.
Schor J, Levkoff SE, Lipsitz LA, et al. Risk factors for delirium in hospitalized elderly. JAMA. 1992;267:827–31.
Koponen H, Hurri L, Stenback U, Mattila E, Soininen H, Riekkinen PJ. Computed tomography findings in delirium. J Nerv Ment Dis. 1989;177:226–31.
40._Koponen H, Stenback V, Mattila E, Soininen H, Reinikainen K, Riekkinen PJ. Delirium among elderly persons admitted to a psychiatric hospital: clinical course during the acute stage and one year follow-up. Acta Psychiatr Scand. 1989;79:579–85.
Koponen H, Riekkinen PJ. A longitudinal study of cerebrospinal fluid beta-endorphin-like, immunoreactivty in delirum: changes at the acute stage and at one year follow-up. Acta Psychiatr Scand. 1990;82:323–6.
Figiel GS, Coffey CE, Djang WT, Hoffman G Jr, Doraiswamy PM. Brain magnetic resonance imaging findings in ECT-induced delirium. J Neuropsychiatry Clin Neurosci. 1990;2:53–8.
Martin M, Figiel GS, Mattingly G, Zorumski CF, Jarvis MR. ECTinduced interictal delirium in patients with a history of a CVA. J Geriatr Psychiatry Neurol. 1992;5:149–55.
Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989;320:578–81.
Angell M. Negative studies. N Engl J Med. 1989;321:464–6.
Charlson ME, Sax FL, MacKenzie R, et al. Assessing illness severity: does clinical judgment work? J Chronic Dis. 1986;39:439–52.
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1983;17:37–49.
Katz S, Ford AG, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL, a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.
Oxman AD, Cook DJ, Guyatt GH. User’s guide to the medical literature, VI: how to use an overview. JAMA. 1994;272:1367–71.
Mach JR, Dysken MW, Kuskowski M, et al. Serum anticholinergic activity in hospitalized older persons with delirium: a preliminary study. J Am Geriatr Soc. 1995;43:491–5.
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