Pathway from Delirium to Death: Potential In‐Hospital Mediators of Excess Mortality

Abstract

OBJECTIVES (1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality. DESIGN Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000. SETTING Large academic hospital. PARTICIPANTS Patients ≥70 years-old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only. MEASUREMENTS (1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission. RESULTS Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs. 16%, p<.001), HACs (37% vs. 12%, p<.001), other noxious insults (63% vs. 49%, p=.03), and 90-day mortality (24% vs. 6%, p<.001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI=2.8–6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation. CONCLUSION Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults.

Is Posthospital Syndrome a Result of Hospitalization-Induced Allostatic Overload?

“…13,[94][95][96] There are also hospital occurrences, outside of allostatic load, that can lead to complications that lengthen the stay, weaken the patient, and directly contribute to subsequent vulnerability. 94,97 Our contention is that the allostatic load of hospitalization, which may also vary by patient depending on the circumstances of hospitalization, is just one contributor, albeit potentially an important one, to vulnerability to medical problems after discharge.…”

Impending Low Intake Dehydration at Admission to A Geriatric Ward- Prevalence and Correlates in a Cross-Sectional Study

“…Inadequate hydration can contribute to increased morbidity in older adults. Unfavorable consequences of dehydration include, among others, the increased risk of delirium [7,8], aspiration pneumonia [9], acute kidney failure or urinary tract infections [10], falls and fractures [11], and result in greater odds of death [12]. Despite the general awareness of the importance of this problem among medical staff, very often, older patients who are dehydrated are not being identified, or their hydration status is misdiagnosed [13,14].…”

An advanced practice nurse‐led delirium consultation service reduces delirium severity and length of stay in orthopedic patients: A nonrandomized posttest only evaluation study

“…1,2 It is associated with poor outcomes, including higher mortality, in hospital complications, such as falls, functional decline, increased hospital length of stay (LOS), and subsequent institutionalization. 3,4 Delirium can be prevented in up to 53% of at risk patients. 5 Various studies have described consultation services as part of a multicomponent intervention program, although with conflicting results.…”