The Incidence and Related Risk Factors of Delirium in the Older Inpatients with Neurological Disorders in a Tertiary Hospital

Mi Sun Kim; Ji Yoon Jun; Hyun Ju Chun; Yun Ok Kim

doi:10.7475/kjan.2018.30.3.255

Journal List > Korean J Adult Nurs > v.30(3) > 1099905

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Kim, Jun, Chun, and Kim: The Incidence and Related Risk Factors of Delirium in the Older Inpatients with Neurological Disorders in a Tertiary Hospital

Original Article

Korean J Adult Nurs 2018;30(3):255-265.

Published online: 21 June 2018

DOI: https://doi.org/10.7475/kjan.2018.30.3.255

The Incidence and Related Risk Factors of Delirium in the Older Inpatients with Neurological Disorders in a Tertiary Hospital

Mi Sun Kim, Ji Yoon Jun, Hyun Ju Chun, Yun Ok Kim

Department of Nursing, Asan Medical Center, Seoul, Korea

Corresponding author: Kim, Yun Ok https://orcid.org/0000-0002-8444-1545 Department of Nursing, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-7351, Fax: +82-2-474-4691, E-mail: amckyo@hanmail.net

Received 21 February 201812 April 2018 Accepted 22 May 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Although there is a high incidence of delirium with increased age, the risk factors have been too various. We investigated the incidence and risk factors in the older inpatient with neurological disorders.

Methods

We reviewed the Electronic Medical Records (EMR) of older patients admitted to a neurology unit from August 2016 to January 2017. We analyzed the incidence and risk factors of delirium in 382 patients in a tertiary hospital. Delirium was determined daily using the Nursing Delirium Screening Scale (Nu-DESC). Demographic, disease, and envi-ronmental characteristics were obtained by using structured EMR data.

Results

The incidence rate of delirium was 6.0%(n=23). Delirium was prevalent in patients who were older, had a lower serum hemoglobin, had hypertension or had diabetes mellitus. Delirium was also observed in patients on antibiotics, having a higher number of drugs or catheters, or receiving mechanical monitoring. A longer hospital stay, being admitted to a sub-intensive care unit, and sleep deprivation were significantly associated with delirium. Multiple logistic regression analysis found older age, having sleep deprivation, a higher number of catheters placed, and having diabetes mellitus to be significant predictors of delirium.

Conclusion

This study shows that age, sleep deprivation, number of catheters, and comorbidity of diabetes mellitus were identified as a risk factor for delirium. And it will guide the development of algorithms through its possible applications for the future in hospitalized older adults.

Keywords: Delirium, Risk factors, Incidence, Older adults, Neurology

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed.Washington, DC: American Psychiatric Association;2000.

2. Kukreja D, Gunther U, Popp J. Delirium in the elderly: current problems with increasing geriatric age. Indian Journal of Medical Research. 2015; 142(6):655–62. https://doi.org/10.4103/0971-5916.174546.

3. Khurana V, Gambhir IS, Kishore D. Evaluation of delirium in elderly: a hospital-based study. Geriatrics & Gerontology International. 2011; 11(4):467–73. https://doi.org/10.1111/j.1447-0594.2011.00710.x.

4. Yang YH. Prevalence and precipitating factors for delirium in elderly patients admitted to longterm care hospitals or to general hospital. The Korean Journal of Fundamentals of Nursing. 2010; 17(1):26–34.

5. Im CS, Cha SM, Kim JH, Lee JM, Kim JL. Retrospective study on the development and outcome of delirium in elderly inpatient. Journal of The Korean Society of Biological Therapies in Psychiatry. 2012; 18(2):186–93.

6. Rizzo JA, Bogardus ST Jr, Leo-Summers L, Williams CS, Acampora D, Inouye SK. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Medical Care. 2001; 39(7):740–52. https://doi.org/10.1097/00005650-200107000-00010.

7. Kaplan NM, Palmer BF, Roche V. Etiology and management of delirium. The American Journal of the Medical Sciences. 2003; 325(1):20–30. https://doi.org/10.1097/00000441-200301000-00005.

8. Torpy JM, Burke AE, Glass RM. Delirium. JAMA. 2008; 300(24):2936. https://doi.org/10.1001/jama.300.24.2936.

9. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agi-tation, and delirium in adult patients in the intensive care unit. Critical Care Medicine. 2013; 41(1):263–306. https://doi.org/10.1097/CCM.0b013e3182783b72.

10. Ahmed S, Leurent B, Sampson EL. Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and metaanalysis. Age and Ageing. 2014; 43(3):326–33. https://doi.org/10.1093/ageing/afu022.

11. Michaud L, Bula C, Berney A, Camus V, Voellinger R, Stiefel F, et al. Delirium: guidelines for general hospitals. Journal of Psychosomatic Research. 2007; 62(3):371–83. https://doi.org/10.1016/j.jpsychores.2006.10.004.

12. Kim KN, Kim CH, Kim KI, Yoo HJ, Park SY, Park YH. Development and validation of the Korean nursing delirium scale. Journal of Korean Academy of Nursing. 2012; 42(3):414–23. https://doi.org/10.4040/jkan.2012.42.3.414.

13. Schuurmans MJ, Duursma SA, Shortridge Baggett LM. Early recognition of delirium: review of the literature. Journal of Clinical Nursing. 2008; 10(6):721–9. https://doi.org/10.1111/j.1365-2702.2001.00548.x.

14. Gaudreau JD, Gagnon P, Harel F, Tremblay A, Roy MA. Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale. Journal of Pain and Symptom Management. 2005; 29(4):368–75. https://doi.org/10.1016/j.jpainsymman.2004.07.009.

15. Kim SJ, Song JA. Evaluation of clinical usefulness of delirium assessment tools for elderly patients after neurosurgery. Journal of Korean Gerontological Nursing. 2015; 17(1):38–47. https://doi.org/10.17079/jkgn.2015.17.1.38.

16. Spedale V, Di Mauro S, Del Giorno G, Barilaro M, Villa CE, Gaudreau JD, et al. Delirium assessment in hospitalized elderly patients: Italian translation and validation of the nursing delirium screening scale. Aging Clinical and Experimental Research. 2017; 29(4):675–83. https://doi.org/10.1007/s40520-016-0621-7.

17. Bo M, Martini B, Ruatta C, Massaia M, Ricauda NA, Varetto A, et al. Geriatric ward hospitalization reduced incidence delirium among older medical inpatients. The American Journal of Geriatric Psychiatry. 2009; 17(9):760–8. https://doi.org/10.1097/JGP.0b013e3181a315d5.

18. Yu KD, Lee TJ, Suh YW, Chung SH, Kim EY, Kim HY, et al. Delirium in acute elderly care unit; prevalence, clinical characteristics, risk factors and prognostic significance. Journal of the Korean Geriatrics Society. 2005; 9(3):182–9.

19. Winter A, Steurer MP, Dullenkopf A. Postoperative delirium assessed by post anesthesia care unit staff utilizing the Nursing Delirium Screening Scale: a prospective observational study of 1000 patients in a single Swiss institution. BioMed Central Anesthesiology. 2015; 15:184. https://doi.org/10.1186/s12871-015-0168-8.

20. Xin X, Xin F, Chen X, Zhang Q, Li Y, Huo S, et al. Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery. Journal of Neuroinflammation. 2017; 14(1):221. https://doi.org/10.1186/s12974-017-0999-y.

21. Foroughan M, Delbari A, Said SE, AkbariKamrani AA, Rashe-di V, Zandi T. Risk factors and clinical aspects of delirium in elderly hospitalized patients in Iran. Aging Clinical and Experimental Research. 2016; 28(2):313–9. https://doi.org/10.1007/s40520-015-0400-x.

22. Hsieh SJ, Madahar P, Hope AA, Zapata J, Gong MN. Clinical deterioration in older adults with delirium during early hospitalisation: a prospective cohort study. British Medical Journal Open. 2015; 5(9):e007496. https://doi.org/10.1136/bmjopen-2014-007496.

23. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine. 1999; 340(9):669–76. https://doi.org/10.1056/nejm199903043400901.

24. Terzaghi M, Sartori I, Rustioni V, Manni R. Sleep disorders and acute nocturnal delirium in the elderly: a comorbidity not to be overlooked. European Journal of Internal Medicine. 2014; 25(4):350–5. https://doi.org/10.1016/j.ejim.2014.02.008.

25. Choi SJ, Cho YA. Prevalence and related risk factors of delirium in intensive care units as detected by the CAM-ICU. Journal of Korean Clinical Nursing Research. 2014; 20(3):406–16. https://doi.org/10.22650/JKCNR.2014.20.3.406.

26. Van Rompaey B, Elseviers MM, Schuurmans MJ, ShortridgeBaggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Critical Care. 2009; 13(3):R77. https://doi.org/10.1186/cc7892.

27. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine. 2007; 33(1):66–73. https://doi.org/10.1007/s00134-006-0399-8.

28. Krzych LJ, Wybraniec MT, Krupka-Matuszczyk I, Skrzypek M, Bochenek AA. Delirium screening in cardiac surgery (DESCA RD): a useful tool for nonpsychiatrists. Canadian Journal of Cardiology. 2014; 30(8):932–9. https://doi.org/10.1016/j.cjca.2014.04.020.

29. Beresin EV. Delirium in the elderly. Journal of Geriatric Psychiatry and Neurology. 1988; 1(3):127–43. https://doi.org/10.1177/089198878800100302.

Figure 1.

Flow diagram of the subject selection.

Table 1.

Demographics Characteristics of the Participants (N=382)

Characteristics	Categories	n (%) or M± SD	Range
Age (year)		72.81±5.87	64~98
Gender	Men	231 (60.5)
Gender	Women	151 (39.5)
Education	None	20 (5.2)
	Elementary school	84 (22.1)
	Middle school	81 (21.3)
	High school	98 (25.7)
	≥ College	98 (25.7)
Job	Yes	102 (26.7)
Job	No or housewife	280 (73.3)
Marriage	Married	347 (90.8)
	Single	6 (1.6)
	Divorced	2 (0.5)
	Widowed	27 (7.1)
Religion	Yes	216 (56.6)
Religion	No	166 (43.4)
Admitted route	Emergency room	204 (53.4)
	Outpatient unit	158 (41.4)
	Intensive care unit	9 (2.3)
	Other clinics	11 (2.9)
Diagnosis	Cerebrovascular disease	227 (59.4)
	Movement disorders	104 (27.2)
	Demyelinating disease	4 (1.1)
	Neuro muscular disease	22 (5.8)
	Seizure disorders	2 (0.5)
	CNS infectious disease	3 (0.8)
	Others (dizziness, LOC, diplopia, SIH, spinal stenosis)	20 (5.2)
Operation/intervention^†	Stent insertion	17 (4.5)
	Deep brain stimulation	7 (1.8)
	Carotid endarterectomy	5 (1.3)
	Coil embolization	4 (1.0)
	Others (thymectomy, PTGBD, PEG, ERCP, trachostomy, EBP)	7 (1.8)
	No	343 (89.8)
SD=standard deviation; CNS=central nervous system; LOC=loss of consciousness; SIH=spontaneous intracranial hypotension;

PTGBD=percutaneous transhepatic gallbladder drainage; ERCP=endoscopic retrograde cholangiopancreatography; PEG=percutaneous endoscopic gastrostomy; EBP=epidural blood patch;

^† Multiple responses.

Table 2.

Characteristics and Pattern in Patients with Delirium (N=23)

Characteristics	Categories	n (%)
Occurrence of delirium from admission (days)	1~3	15 (65.2)
	4~6	3 (13.0)
	7~9	4 (17.4)
	≥10	1 (4.4)
Delirium pattern^†	Disorientation	21 (91.3)
	Inappropriate behavior	17 (73.9)
	Inappropriate communication	13 (56.5)
	Illusions/Hallucinations	4 (17.4)
	Psychomotor retardation	1 (4.3)
Time of occurrence (hour)	6:30~14:30	2 (8.7)
	14:30~22:30	8 (34.8)
	22:30~6:30	13 (56.5)
Medication treatment^†	Quetiapine	16 (69.6)
	Lorazepam	6 (26.1)
	Haloperidol	3 (13.0)
Nursing care^†	Notify to doctor	16 (69.6)
	Administer oral medication	16 (69.6)
	Administer intramuscular or intravenous injection	3 (13.0)
Use the physical	Yes	11 (47.8)
restraints	No	12 (52.2)

^† Multiple responses.

Table 3.

Disease and Environment-related Characteristics (N=382)

Characteristics	Categories	Delirium (n=23)	Non-delirium (n=359)	x² or t	p
Characteristics	Categories	n (%) or M± SD	n (%) or M± SD	x² or t	p
Age (year)		78.91±8.64	72.42±5.43	3.56	.002
Gender	Men	12 (52.2)	219 (61.0)	0.70	.510
Gender	Women	11 (47.8)	140 (39.0)
Smoking	Smoker	5 (21.8)	44 (12.3)	2.67	.263
	Non-smoker	15 (65.2)	228 (63.5)	0.01
	Ex-smoker	3 (13.0)	87 (24.2)
Alcohol drinking	Drinker	7 (30.4)	109 (30.4)	0.01	.997
	Non-drinker	14 (60.9)	217 (60.4)
	Ex-drinker	2 (8.7)	33 (9.2)
Body temperature (° C)		37.2±0.6	37.2±1.7	-0.04	.965
Hemoglobin (g/dL)		12.2±2.2	13.0±1.7	-2.45	.015
Na+ (mmol/L)		138.2±3.8	139.3±3.2	-1.58	.116
Glucose (mg/dL)		161.8±74.9	131.2±54.0	1.92	.066
BUN (mg/dL)		18.3±8.2	18.0±9.0	0.12	.906
Creatinine (mg/dL)		1.09±0.47	1.00±0.83	0.54	.591
Hearing difficulty	Yes	3 (13.0)	43 (12.0)	0.02	.540
Visual difficulty	Yes	7 (30.4)	152 (42.3)	1.26	.184
Pain score (NRS)	Yes	10 (43.5)	206 (57.4)	1.70	.201
Hypertension	Yes	19 (82.6)	205 (57.1)	5.80	.012
Diabetes mellitus	Yes	11 (47.8)	94 (26.2)	5.08	.026
Both DM and HTN	Yes	11 (47.8)	70 (19.5)	10.81	.004
History of stroke	Yes	7 (30.4)	62 (17.3)	2.53	.112
Use of antibiotics	Yes	8 (34.8)	42 (11.7)	10.12	.005
Number of multidrug		12.1±5.1	9.01±4.2	3.41	.001
Mobility status	Walk alone Minimum assist	2 (8.7)11 (47.8)	87 (24.2)164 (45.7)	3.53	.317
	Much assistant	8 (34.8)	85 (23.7)
	Unable to walk with aids	2 (8.7)	23 (6.4)
Diagnosis at admission	Cerebrovascular disease	18 (78.4)	209 (58.2)	7.50	.277
	Movement disorders	3 (13.0)	101 (28.1)
	Demyelinating disease	1 (4.3)	3 (0.8)
	Neuro muscular disease	1 (4.3)	21 (5.9)
	Seizure disorders	0 (0.0)	20 (5.6)
	CNS infectious disease	0 (0.0)	2 (0.6)
	Other chronic disease	0 (0.0)	3 (0.8)
Hospital stay (days)		10.8±7.2	7.2±5.7	2.87	.004
Sleep deprivation	Yes	14 (60.9)	62 (17.3)	25.78	.001
Sleep deprivation	No	9 (39.1)	297 (82.7)
Route of admission	Emergency room/ ICU	20 (87.0)	193 (53.8)	9.66	.002
	Outpatient unit/ Other clinics	3 (13.0)	166 (46.2)
Number of catheter		2.0±1.4	1.1±0.8	3.20	.004
Number of mechanical monitoring		1.5±0.8	0.9±1.0	3.47	.002
Use of sub-intensive care unit	Yes	16 (69.6)	155 (43.3)	6.03	.017
Operation/intervention	Yes	2 (8.7)	37 (10.3)	0.06	1.000

SD=standard deviation; BUN=blood urea nitrogen; NRS=the numeric rating scale; DM=diabetes mellitus; HTN=hypertension; CNS=central nervous system; ICU=Intensive care unit.

Table 4.

Predictive Risk Factors of Delirium among Older Inpatients (N=382)

Predictors	B	SE	Wald	OR	95% CI	p
Age (year)	0.15	0.04	14.57	1.16	1.07~1.25	.001
Sleep deprivation^†	2.03	0.51	15.77	7.64	2.80~20.85	.001
Number of catheters	0.82	0.22	14.30	2.27	1.48~3.46	.001
Comorbidity of diabetes mellitus^†	1.08	0.52	4.37	2.95	1.07~8.14	.037
	Nagelkerke R²=.375, Hosmer and Lameshow's Goodness of fit p=.138

SE=standard error; OR=odds ratio; CI=confidence interval;

^† Sleep deprivation: Non-sleep deprivation; Comorbidity of diabetes mellitus: Non- diabetes mellitus; Reference.

TOOLS

Similar articles