Risk factors for incident delirium in acute medical in-patients. A systematic review

Review question/objective
What risk factors are associated with incident delirium in adult patients during an acute medical hospitalisation?
More specifically, the objectives are to:
Identify and synthesise the best available evidence on the factors which are associated with delirium in adult patients admitted to acute medical facilities.

Types of participants
This review will consider studies that include adults (defined as 18 years and above) who were admitted to an acute medical setting (e.g. general medical units, stroke units, short stay units and neuromedical units) who were not delirious on admission (in order to differentiate incident delirium) but who developed incident delirium during hospitalisation

The review will exclude patients who were:
- critically ill and admitted to specialist unit e.g. ICU or CCU
- admitted for any type of surgery
- admitted for alcohol related reasons
- admitted to psychiatric facility
These patients will be excluded in order to determine factors that may be exclusive to the medical in patient setting.

Types of intervention(s)/phenomena of interest
This review will consider studies that evaluate any risk factors that may contribute to the development of delirium during in-patient hospitalisation. The review will look at factors present on admission (predisposing) and also factors that may occur during hospitalisation (precipitating) that contribute to incident delirium.

Types of outcomes
This review will consider studies that include the following outcome measures: the incidence of delirium as related to individual risk factors.

Risk factors for incident delirium in acute medical in-patients: a systematic review

Delirium is a serious problem that can occur in many older people admitted to hospital. Delirium has the potential to dramatically complicate the hospitalisation of a patient, and often results in functional decline, an increased likelihood of complications associated with longer hospital stays, increasing the risk of admission to a care facility post discharge, a greater incidence of falls and is associated with high mortality and morbidity rates. Understanding the factors that contribute to delirium can provide insights into the mechanisms that underlie the syndrome.

Incident delirium in the acute general medical setting

 Delirium is a serious neuro‐cognitive disorder that affects many people admitted to hospital. Results of this research have contributed valuable knowledge regarding the risk factors, health outcomes and management of medical patients with who developed incident delirium during hospitalisation.

Risk factors for incident delirium in an acute general medical setting: a retrospective case – control study

Aims and ObjectivesTo determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission.BackgroundIncident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients that are most susceptible to incident delirium.DesignRetrospective case-control study with two controls per case.MethodsAn audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data was collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1st January 2012 and 31st December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation.ResultsIdentified using logistic regression modelling, predisposing risk factors for incident delirium were: dementia, cognitive impairment, functional impairment, previous delirium, and fracture on admission. Precipitating risk factors for incident delirium were: use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission.ConclusionsMultiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation.Relevance to clinical practiceNurses and other health care professionals should be aware of patients that have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

Prospective observational study of dementia and delirium in the acute hospital setting

Background: Dementia and delirium appear to be common among older patients admitted to acute hospitals, although there are few Australian data regarding these important conditions. Aim: The aim of this study was to determine the prevalence and incidence of dementia and delirium among older patients admitted to acute hospitals in Queensland and to profile these patients. Method: Prospective observational cohort study (n = 493) of patients aged 70 years and older admitted to general medical, general surgical and orthopaedic wards of four acute hospitals in Queensland between 2008 and 2010. Trained research nurses completed comprehensive geriatric assessments and obtained detailed information about each patient’s physical, cognitive and psychosocial functioning using the interRAI Acute Care and other standardised instruments. Nurses also visited patients daily to identify incident delirium. Two physicians independently reviewed patients’ medical records and assessments to establish the diagnosis of dementia and/or delirium. Results: Overall, 29.4% of patients (n = 145) were considered to have cognitive impairment, including 102 (20.7% of the total) who were considered to have dementia. This rate increased to 47.4% in the oldest patients (aged 90 years). The overall prevalence of delirium at admission was 9.7% (23.5% in patients with dementia), and the rate of incident delirium was 7.6% (14.7% in patients with dementia). Conclusion: The prevalence of dementia and delirium among older patients admitted to acute hospitals is high and is likely to increase with population aging. It is suggested that hospital design, staffing and processes should be attuned better to meet these patients’ needs.

Prevalencia de delirium en población adulta en cuidado intensivo.

Introducción: El delirium es un trastorno de conciencia de inicio agudo asociado a confusión o disfunción cognitiva, se puede presentar hasta en 42% de pacientes, de los cuales hasta el 80% ocurren en UCI. El delirium aumenta la estancia hospitalaria, el tiempo de ventilación mecánica y la morbimortalidad. Se pretendió evaluar la prevalencia de periodo de delirium en adultos que ingresaron a la UCI en un hospital de cuarto nivel durante 2012 y los factores asociados a su desarrollo. Metodología Se realizó un estudio transversal con corte analítico, se incluyeron pacientes hospitalizados en UCI médica y UCI quirúrgica. Se aplicó la escala de CAM-ICU y el Examen Mínimo del Estado Mental para evaluar el estado mental. Las asociaciones significativas se ajustaron con análisis multivariado. Resultados: Se incluyeron 110 pacientes, el promedio de estancia fue 5 días; la prevalencia de periodo de delirium fue de 19.9%, la mediana de edad fue 64.5 años. Se encontró una asociación estadísticamente significativa entre el delirium y la alteración cognitiva de base, depresión, administración de anticolinérgicos y sepsis (p< 0,05). Discusión Hasta la fecha este es el primer estudio en la institución. La asociación entre delirium en la UCI y sepsis, uso de anticolinérgicos, y alteración cognitiva de base son consistentes y comparables con factores de riesgo descritos en la literatura mundial.

Early detection of delirium in older medical inpatients: prodrome, predictors and motor subtyping

Background Delirium is highly prevalent, especially in older patients. It independently leads to adverse outcomes, but remains under-detected, particularly hypoactive forms. Although early identification and intervention is important, delirium prevention is key to improving outcomes. The delirium prodrome concept has been mooted for decades, but remains poorly characterised. Greater understanding of this prodrome would promote prompt identification of delirium-prone patients, and facilitate improved strategies for delirium prevention and management. Methods Medical inpatients of ≥70 years were screened for prevalent delirium using the Revised Delirium Rating Scale (DRS--‐R98). Those without prevalent delirium were assessed daily for delirium development, prodromal features and motor subtype. Survival analysis models identified which prodromal features predicted the emergence of incident delirium in the cohort in the first week of admission. The Delirium Motor Subtype Scale-4 was used to ascertain motor subtype. Results Of 555 patients approached, 191 patients were included in the prospective study. The median age was 80 (IQR 10) and 101 (52.9%) were male. Sixty-one patients developed incident delirium within a week of admission. Several prodromal features predicted delirium emergence in the cohort. Firstly, using a novel Prodromal Checklist based on the existing literature, and controlling for confounders, seven predictive behavioural features were identified in the prodromal period (for example, increasing confusion; and being easily distractible). Additionally, using serial cognitive tests and the DRS-R98 daily, multiple cognitive and other core delirium features were detected in the prodrome (for example inattention; and sleep-wake cycle disturbance). Examining longitudinal motor subtypes in delirium cases, subtypes were found to be predominantly stable over time, the most prevalent being hypoactive subtype (62.3%). Discussion This thesis explored multiple aspects of delirium in older medical inpatients, with particular focus on the characterisation of the delirium prodrome. These findings should help to inform future delirium educational programmes, and detection and prevention strategies.

Business Process Redesign in Information Technology Incident Management: A teaching case

This paper consists of a detailed case narrative on how a leading Australian Finance organisation has utilised contemporary Business Process Management (BPM) concepts for improving the IT incident management processes within the whole organisation. The target audience includes practitioners who are interested in BPM case studies and Academics who may be seeking case studies for innovative teaching practices.

Study on the method of freeway incident detection using wireless positioning terminal

Improving the performance of a incident detection system was essential to minimize the effect of incidents. A new method of incident detection was brought forward in this paper based on an in-car terminal which consisted of GPS module, GSM module and control module as well as some optional parts such as airbag sensors, mobile phone positioning system (MPPS) module, etc. When a driver or vehicle discovered the freeway incident and initiated an alarm report the incident location information located by GPS, MPPS or both would be automatically send to a transport management center (TMC), then the TMC would confirm the accident with a closed-circuit television (CCTV) or other approaches. In this method, detection rate (DR), time to detect (TTD) and false alarm rate (FAR) were more important performance targets. Finally, some feasible means such as management mode, education mode and suitable accident confirming approaches had been put forward to improve these targets.

Delirium in early-stage Alzheimer's disease : enhancing cognitive reserve as a possible preventive measure

Delirium is a disorder of acute onset with fluctuating symptoms and is characterized by inattention, disorganized thinking, and altered levels of consciousness. The risk for delirium is greatest in individuals with dementia, and the incidence of both is increasing worldwide because of the aging of our population. Although several clinical trials have tested interventions for delirium prevention in individuals without dementia, little is known about the mechanisms for the prevention of delirium in early-stage Alzheimer’s disease (AD). The purpose of this article is to explore ways of preventing delirium and slowing the rate of cognitive decline in early-stage AD by enhancing cognitive reserve. An agenda for future research on interventions to prevent delirium in individuals with early-stage AD is also presented.

Tracking rail safety : incident and accident investigation in Australia

Scoping Project: Currently no national or structured learning framework available in Aus or NZ Current Project: Develop a national training program & capability framework for rail incident investigators - Establish the potential market demand - Define the curricula for a multi-level national training program - Explore training providers & delivery options

Airports of the future : incident response planning in Australian airports

Airports are typical examples of large and complex infrastructure systems. They serve a purpose of not only transporting people around the globe but are central to trade and commerce and, in a nation as large as Australia, an important means to connect people and regions. Reducing uncertainty and managing risk in such systems are not only critical tasks integral to effective management practice but equally important for border protection and national security outcomes. This latter issue has been emphasised on a national level in Australia with a number of recent enquiries taking place, most notably the Wheeler Review1 into aviation security in 2005 and the 2009 National Aviation Policy White Paper2 on the future of aviation in Australia.

Adventure as the metaphoric basis for constructing a narrative to defuse a collective critical incident

This article describes an exercise in collective narrative practice, built around the metaphor of adventure. This metaphor helped to scaffold the development of stories of personal agency for a group of Australian primary school children whose teachers were afraid they might be traumatised by events which occurred during a school excursion. During the excursion, the group of 110 Year 5 and 6 school children had their accommodation broken into on two separate occasions and various belongings stolen. The very brief period made available for ‘debriefing’ was used to introduce the metaphor of adventure, and open up space for the children to begin constructing a story in which they were ‘powerful’, as an alternative to the story of powerlessness and victimhood in which they were initially caught up.

Drivers of satisfaction and dissatisfaction for overseas service consumers : a critical incident technique approach

This is one of the few studies in the academic literature that directly addresses inward exporting of customer services, which is a topic that has gained less attention from an international services marketing point of view. The objective of this study is to explore the drivers of satisfaction and dissatisfaction for overseas service customers of higher education in Australia. Critical incident technique (CIT) method was used to collect and analyse the data and a total of 107 critical incidents were collected. Findings from this study show that service satisfaction and dissatisfaction for international students derive from: elements of the core service (educational service performance), personal sources (international student performance), and the external environment (socialization and host environment performance). Additionally, results show that the drivers of satisfaction and dissatisfaction for international students are not necessarily the same. Limitations relating to the specific sector of higher education and the cross sectional natures of the data are addressed.