Delirium has protracted course in elderly care home residents

By Joanna Lyford

Episodes of delirium in elderly care home residents tend to be protracted, typically being preceded and/or followed by subacute symptomatology, a prospective cohort study indicates.

The findings, published in the International Journal of Geriatric Psychiatry, are reported by Martin Cole (McGill University, Montreal, Quebec, Canada) and co-workers, who studied 279 residents of seven long-term care facilities in Montreal and Quebec. The residents' mean age was 87.4 years; 61.0% were female, and 85.4% had a diagnosis of dementia.

During a 24-week observation period, 41 of the residents experienced 61 episodes of delirium (defined using the Confusion Assessment Method [CAM]). Episodes lasted from 7 to 63 days with a mean duration of 11.3 days. The mean episode score on the Delirium Index was 11.5 out of a total of 48, where higher scores indicate greater severity.

In all, 49 (80.3%) of the 61 delirium episodes ended in recovery, three (4.9%) ended in death, and nine (9.9%) were ongoing at the end of observation.

Clinical features of delirium included hyperactivity in 8.2%, hypoactivity in 50%, a mix of hyper- and hypoactivity in 9.8%, and psychosis in 9.8%. Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2%, 77.1%, and 80.3%, respectively.

The vast majority of delirium episodes (91.8%) were preceded or followed by the presence of CAM core symptoms, such as inattention, disorganized thinking, or altered consciousness, the authors note. Sometimes these symptoms were present for many weeks, with a maximum duration of 133 days.

Finally, multivariate survival analysis identified factors that predicted a longer time to recovery, which included greater impairment in activities of daily living, more depressive symptoms, more severe delirium, and hyperactivity.

Cole and team note that the enduring presence of delirium-associated symptoms, arising before and/or after the overt clinical episode, suggests that delirium in elderly care home residents "may be much more frequent and protracted than previously thought."

These and other observations from the study have implications for clinical practice and research, they say.

For instance, the likely consequences of episodes of delirium that occur in the context of protracted symptoms include prolonged cognitive and functional impairment, prolonged behavior problems, increased burden on nursing staff, and increased costs of care.

"It may be useful to prevent or detect and treat symptoms and episodes of delirium in these settings," they write. "As for prevention, interventions effective in preventing delirium in acute care settings may be introduced into long-term care facilities."

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