Determining Risk Factors for Delirium Among Elderly Patients in The Emergency Care Settings

Öz

Objective: Delirium is reported as a common clinical state among elderly patients seeking care in the emergency departments (ED). However, it is commonly underdiagnosed in the ED. This study aimed to evaluate delirium prevalence and determine the risk factors for developing delirium in elderly patients in ED. Material and Methods: The study included 238 patients who were ≥65 years old and visited the emergency department (ED). The emergency specialist used the ‘Confusion assessment method (CAM)’ to screen for delirium in the patient group. A psychiatrist then evaluated the patients according to DSM-5 criteria for delirium. Demographic data, vital signs, and laboratory findings of the patients were also recorded as part of the study. Results: Delirium was identified in 10.9% of the patients through CAM and 11.8% of the patients according to DSM-5 criteria. No statistically significant difference was found between the groups with and without delirium in terms of age, gender, comorbidities, presence of dementia, and use of polypharmacy. A positive correlation between mean arterial blood pressure (MABP) (r=0.373, p<0.001), pulse rate (r=0.208, p<0.001), and respiratory rate (r=0.284, p<0.001) and a negative correlation between CRP levels (r=-0.139, p=0.032) and the presence of delirium were found. Logistic regression analysis showed that MABP>99 mmHg and respiratory rate>19/min are associated risk factors for delirium. Conclusion: High MABP and respiratory rate could be related to delirium risk. Although the hemodynamic risk factors could contribute to the recognition of delirium, practical clinical screening tools are still the most important and reliable methods to detect delirium.

Anahtar Kelimeler

• Delirium
• emergency department
• elderly
• related factors

Acil Servise Başvuran Yaşlı Hastalarda Deliryum İçin Risk Faktörlerinin Belirlenmesi

Öz

Amaç: Deliryum, acil servislere başvuran yaşlı hastalarda sık görülen bir klinik durum olmakla birlikte, tanısı genellikle atlanmaktadır. Bu çalışmada acil servise başvuran yaşlı hastalarda deliryum prevalansının değerlendirilmesi ve deliryum için risk faktörlerinin belirlenmesi amaçlanmıştır. Gereç ve Yöntemler: Acil servise başvuran 65 yaş üstü 238 hasta çalışmaya dahil edildi. Hasta grubu acil servis uzmanı tarafından ‘Konfüzyon Değerlendirme Yöntemi (KDY)’ kullanılarak deliryum açısından tarandı. Hastalar daha sonra bir psikiyatrist tarafından DSM-5 kriterlerine göre deliryum açısından değerlendirildi. Hastaların demografik verileri, vital bulguları ve laboratuvar bulguları kaydedildi. Bulgular: KDY ile hastaların %10,9’unda, DSM-5 kriterlerine göre hastaların %11,8’inde deliryum tanısı saptandı. Deliryum olan ve olmayan gruplar arasında yaş, cinsiyet, ek hastalık, demans ve polifarmasi varlığı açısından istatistiksel olarak anlamlı bir fark saptanmadı. Ortalama arteriyel kan basıncı (OAKB) (r=0,373, p<0,001), nabız (r=0,208, p<0,001) ve solunum sayısı (r=0,284, p<0,001) ve deliryum arasında pozitif, CRP düzeyleri (r=-0,139, p=0,032) ve deliryum varlığı arasında ise negatif korelasyon saptandı. Lojistik regresyon analizi sonuçları, OAKB> 99 mmHg ve solunum hızı> 19/dk’nın üzerinde olmasının deliryum için risk faktörü olabileceğini gösterdi. Sonuç: Yüksek OAKB ve solunum hızı deliryum riski ile ilişkili olabilir. Hemodinamik risk faktörleri deliryumun tanınmasına katkıda bulunabilse de, pratik klinik tarama araçları deliryumu saptamak için hala en önemli ve güvenilir yöntemlerdir.

Anahtar Kelimeler

• deliryum
• acil servis
• yaşlı
• ilişkili faktörler

Kaynakça

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Press Inc; 2013.
2. Inouye S, Westendorp R, Saczynski J. Delirium in elderly people. Lancet. 2014; 383(9920):911–22. DOI: 10.1016/S0140-6736(13)60688-1
3. Hshieh T, Inouye S, Oh E. Delirium in the Elderly. Clin Geriatr Med. 2020;36(2):183–99. DOI: 10.1016/j.cger.2019.11.001
4. Mattar I, Chan M, Childs C. Risk factors for acute delirium in critically ill adult patients: A systematic review. Int Sch Res Not. 2013;2013:1–10. DOI: 10.5402/2013/910125
5. Barron E, Holmes J. Delirium within the emergency care setting, occurrence and detection: a systematic review. Emerg Med J. 2013;30(4):263–8. DOI: 10.1136/emermed-2011-200586
6. Nguyen P, Pelletier L, Payot I, Latour J. The Delirium Drug Scale is associated to delirium incidence in the emergency department. Int Psychogeriatr. 2018;30(4):503–10. DOI: 10.1017/S1041610217002538
7. Reynish E, Hapca S, De Souza N, Cvoro V, Donnan P, Guthrie B. Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions. BMC Med. 2017;15(1):1–2. DOI: 10.1186/s12916-017-0899-0
8. Boucher V, Lamontagne M, Nadeau A, Carmichael P, Yadav K, Voyer P, et al. Unrecognized incident delirium in older emergency department patients. J Emerg Med. 2019;57(4):535–42. DOI: 10.1016/j.jemermed.2019.05.024

9. Kakuma R, Du Fort G, Arsenault L, Perrault A, Platt R, Monette J, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4):443–50. DOI: 10.1046/j.1532-5415.2003.51151.x
10. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433–41.
11. Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.
12. Chen F, Liu L, Wang Y, Liu Y, Fan L, Chi J. Delirium prevalence in geriatric emergency department patients: A systematic review and meta-analysis. Am J Emerg Med. 2022;59:121–8. DOI: 10.1016/j.ajem.2022.05.058
13. Han J, Zimmerman E, Cutler N, Schnelle J, Morandi A, Dittus R, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200. DOI: 10.1111/j.1553-2712.2008.00339.x
14. LaMantia M, Messina F, Hobgood C, Miller D. Screening for delirium in the emergency department: a systematic review. Ann Emerg Med. 2014;63(5):551–60. DOI: 10.1016/j.annemergmed.2013.11.010
15. Silva L, Berning M, Stanich J, Gerberi D, Murad M, Han J, et al. Risk factors for delirium in older adults in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2021;78(4):549–65. DOI: 10.1016/j.annemergmed.2021.03.005
16. Rosen T, Connors S, Clark S, Halpern A, Stern M, DeWald J, et al. Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol. Adv Emerg Nurs J. 2015;37(3):183–96. DOI: 10.1097/TME.0000000000000066
17. Duran L, Aygun D. Evaluation of patients with delirium in the emergency department. Balk Med J. 2012;2012(4):381–5. DOI: 10.5152/balkanmedj.2012.023
18. Oliveira J. e Silva L, Stanich J, Jeffery M, Mullan A, Bower S, Campbell R, et al. REcognizing DElirium in geriatric Emergency Medicine: The REDEEM risk stratification score. Acad Emerg Med. 2022;29(4):476–85. DOI: 10.1111/acem.14423
19. Kennedy M, Enander R, Tadiri S, Wolfe R, Shapiro N, Marcantonio E. Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. J Am Geriatr Soc. 2014;62(3):462–9. DOI: 10.1111/jgs.12692
20. Tilley E, Psaltis P, Loetscher T, Davis D, Harrison S, Kim S, et al. Meta-analysis of prevalence and risk factors for delirium after transcatheter aortic valve implantation. Am J Cardiol. 2018;122(11):1917–23. DOI: 10.1016/j.amjcard.2018.08.037
21. Ng K, Lee Z, Ang E, Teoh W, Wang C. Association of obstructive sleep apnea and postoperative cardiac complications: A systematic review and meta-analysis with trial sequential analysis. J Clini Anesth. 2020;62:109731.DOI: 10.1016/j.jclinane.2020.109731
22. Sri-on J, Tirrell G, Vanichkulbodee A, Niruntarai S, Liu S. The prevalence, risk factors and short-term outcomes of delirium in Thai elderly emergency department patients. Emerg Med J. 2016;33(1):17–22. DOI: 10.1136/emermed-2014-204379
23. Pérez-Ros P, Martínez-Arnau F. Delirium assessment in older people in emergency departments. A literature review. Diseases. 2019;7(1):14. DOI: 10.3390/diseases7010014