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Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study

RA Diwell, View ORCID ProfileD Davis, V Vickerstaff, View ORCID ProfileEL Sampson
doi: https://doi.org/10.1101/251272
RA Diwell
1Division of Psychiatry, Faculty of Brain Sciences, UCL, Gower Street, London, WC1E 6BT
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  • For correspondence: uctvrad@ucl.ac.uk
D Davis
2Senior Clinical Researcher, MRC Unit for Lifelong Health and Ageing at UCL, 33 Bedford Place, London, WC1B 5JU
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  • For correspondence: daniel.davis@ucl.ac.uk
V Vickerstaff
3Research Associate, Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, UCL, Gower Street, London, WC1E 6BT and The Research Department of Primary Care and Population Health, UCL, Rowland Hill Street, London, NW3 2PF
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  • For correspondence: v.vickerstaff@ucl.ac.uk
EL Sampson
4Reader, Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Gower Street, London, WC1E 6BT and Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, N18 1QX
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  • For correspondence: e.sampson@ucl.ac.uk
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ABSTRACT

Background Delirium increases the risk of mortality during an acute hospital admission. Full syndromal delirium (FSD) is associated with greatest risk and subsyndromal delirium (SSD) is associated with intermediate risk, compared to patients with no delirium - suggesting a dose-response relationship. It is not clear how individual diagnostic symptoms of delirium influence the association with mortality. Our objectives were to measure the prevalence of FSD and SSD, and assess the effect that FSD, SSD and individual symptoms of delirium (from the Confusion Assessment Method-short version (s-CAM)) have on mortality rates.

Methods Exploratory analysis of a prospective cohort (aged ≥ 70 years) with acute (unplanned) medical admission (4/6/2007-4/11/2007). The outcome was mortality (data censored 6/10/2011). The principal exposures were FSD and SSD compared to no delirium (as measured by the CAM), along with individual delirium symptoms on the CAM. Cox regression was used to estimate the impact FSD and SSD and individual CAM items had on mortality.

Results The cohort (n=610) mean age was 83 (SD 7); 59% were female. On admission, 11% had FSD and 33% had SSD. Of the key diagnostic symptoms for delirium, 17% acute onset, 19% inattention, 17% disorganised thinking and 17% altered level of consciousness. Unadjusted analysis found FSD had an increased hazard ratio (HR) of 2.31 (95%CI 1.71, 3.12), for SSD the HR was 1.26 (1.00, 1.59). Adjusted analysis remained significant for FSD (1.55 95%CI 1.10, 2.18) but nonsignificant for SSD (HR=0.92 95% CI 0.70, 1.19). Two CAM items were significantly associated with mortality following adjustment: acute onset and disorganised thinking.

Conclusion We observed a dose-response relationship between mortality and delirium, FSD had the greatest risk and SSD having intermediate risk. The CAM items “acute onset” and “disorganised thinking” drove the associations observed. Clinically, this highlights the necessity of identifying individual symptoms of delirium.

  • LIST OF ABBREVIATIONS

    ANOVA
    analysis of variance
    APACHE-11
    Acute Physiology and Chronic Health Evaluation
    CAM
    Confusion Assessment Method
    S-CAM
    Short Confusion Assessment Method
    CCI
    Charlson Comorbidity Index
    DSM
    Diagnostic and Statistical Manual of Mental Disorders
    FAST
    Functional Assessment staging
    FSD
    full syndromal delirium
    HR
    hazard ratio
    IQR
    interquartile range
    sd
    standard deviation
    ONS
    Office for National Statistics
    SSD
    subsyndromal delirium
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    Posted January 22, 2018.
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    Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study
    RA Diwell, D Davis, V Vickerstaff, EL Sampson
    bioRxiv 251272; doi: https://doi.org/10.1101/251272
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    Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study
    RA Diwell, D Davis, V Vickerstaff, EL Sampson
    bioRxiv 251272; doi: https://doi.org/10.1101/251272

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