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Psychosomatics 45:235-242, June 2004
© 2004 The Academy of Psychosomatic Medicine

How Do Delirium and Dementia Increase Length of Stay of Elderly General Medical Inpatients?

Stephen M. Saravay, M.D., Michael Kaplowitz, M.D., John Kurek, D.O., David Zeman, M.D., Simcha Pollack, Ph.D., Sonia Novik, B.Sc., Scott Knowlton, B.A., Michael Brendel, B.Sc., and Lillian Hoffman, B.A.

Received Feb. 18, 2003; revision received Aug. 20, 2003; accepted Aug. 28, 2003. From Flushing Hospital Medical Center, Flushing, N.Y.; North Shore Long Island Health System, Southside Hospital, Bayshore, N.Y.; Clara Maass Medical Center, Belleville, N.J.; St. Johns’s University, Jamaica, N.Y.; Royal College of Surgeons, Dublin, Ireland; Long Beach Medical Center, Long Beach, N.Y.; University of Pennsylvania Sleep Disorders Clinic, Philadelphia; and Long Island Jewish Medical Center. Address reprint requests to Dr. Saravay, Long Island Jewish Medical Center, 400 Lakeville Rd., New Hyde Park, NY 11040; saravay{at}lij.edu (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The purpose of this study was to identify the proximate causes through which dementia and delirium extend length of stay (LOS) in elderly general hospital patients. Among 93 patients age >=65 years admitted to a tertiary-care teaching hospital through the emergency department, admission ratings of cognitive impairment, delirium, and dementia predicted the emergence of mental and behavioral manifestations of delirium and dementia in the hospital and greater LOS. Mental and behavioral manifestations also predicted greater LOS. On average, mental manifestations appeared first and were followed by behavioral manifestations, and the appearance of both types of manifestations occurred before the mean LOS. The results suggest that elderly patients with dementia and/or delirium who become symptomatic after admission to a general hospital first show mental signs and symptoms, then show behavioral disturbances, which appear to be the proximate causes of greater LOS.

Key Words: Delirium • Dementia • Length of Stay

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Delirium and dementia and the cognitive impairments to which they give rise are frequently found in elderly patients at the time of admission to a general hospital. Delirium and dementia are seen together in approximately 30%–60% of elderly general hospital patients.1–3

Dimensional and categorical measures of delirium and dementia have shown associations with prolonged length of stay (LOS) and greater use of medical services. Cognitive impairment, measured early in a hospital admission, predicts extended stays even in analyses that control for severity of medical illness, functional impairment, and other potentially confounding variables.1,4–8 Elderly patients with dementia have longer general hospital stays, require more intensive nursing care, and incur higher costs, compared to elderly patients without dementia.9,10 Delirium in elderly general hospital patients has been associated with longer hospital stays, even in analyses that control for severity of medical illness.4,6,11–13 Delirium is also associated with higher hospital costs and greater likelihood of placement in a nursing home at discharge.4,6,11,14,15

Despite an extensive literature reporting the association of delirium and dementia with longer LOS, the causal relationship between these cognitive impairments and longer LOS has not been universally accepted.11 Although dementia is a chronic condition that is not likely to be a result of prolonged hospital stays, that is not true for delirium, a more acute condition. Could delirium be a consequence rather than a cause of prolonged stay? Do delirium and dementia contribute to extended stays by virtue of the severity of illness and frailty with which they are associated, or are other factors involved?11,12

Marcantonio et al.11 and Fulop et al.8 have called for additional research to demonstrate the causal nature of the relationship and in particular to examine the potential role of "aberrant patient behaviors,"8 such as noncompliance and delay in obtaining diagnostic tests, which may extend LOS in cognitively impaired patients.

We predicted that higher scores for cognitive impairment, delirium, and dementia on admission would correlate with their known clinical manifestations and complications during hospitalization and that both delirium and dementia would be associated with longer LOS. We also predicted that, during the patient's hospital stay, the psychiatric manifestations of delirium and dementia would precede the behavioral and procedural complications. We looked for evidence that could help to resolve the question of causality: Do cognitive impairment, delirium, and dementia contribute to extended LOS, or are they merely a consequence of longer, medically complicated hospital stays that provide a longer time period within which delirium or other cognitive disturbances might emerge or be documented in the patient's hospital chart?

Some authors have suggested potential pathways by which cognitive disturbances give rise to behavioral and medical complications that might contribute to longer LOS.11 Delirium has been associated with impairments in motivation and compliance.16–18 Agitation caused by postoperative delirium has anecdotally been linked to early dislocation of hip prostheses and trochanteric separation, as well as wound separation and wound hematomas.19 Cognitive disturbances and delirium in medical settings have been associated with falls4,17,20 and urinary incontinence, the latter of which might contribute to bedsores or result in urinary tract infections related to the introduction of indwelling catheters.4,12,16,17,20,21

Dehydration,10,22 aspiration,14 pneumonia secondary to immobility,14 congestive heart failure, and myocardial infarction secondary to psychomotor agitation13,23 have been cited as possible consequences of delirium and dementia in medical settings. These items have also been cited as possible contributors to delirium.13,19 Similarly, confinement to bed, restraints, urinary catheters, and sedative medications have been cited as both causes and consequences of delirium.24–26 Clinical experience shows that cognitive impairment delays diagnostic evaluation and other procedures, gives rise to time-consuming informed-consent issues, and results in poor compliance with rehabilitation regimens and other medical care recommendations.11

This paper describes how measurements of cognitive impairment, dementia, and delirium in elderly patients on admission to a general hospital medical service predicted the appearance of mental signs and symptoms, which were then followed by behavioral problems that were associated with extended hospital stays. The chronology of events is consistent with a causal relationship between behavioral manifestations and extended LOS.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
The study was approved by the Human Subjects Review Committee of the Long Island Jewish Medical Center, the Long Island Campus for the Albert Einstein College of Medicine, and was declared a "no-risk" study. Medical patients age >=65 years who were admitted through the hospital emergency department were enrolled in the study. Patients were excluded before testing if they were transferred from the Hillside Division psychiatric inpatient service, were transferred from a nursing home, had been admitted for an elective procedure or elective surgery, or were expected to be hospitalized for less than 48 hours. Patients were approached for participation in the study in the chronological order of admission to the emergency department. Informed consent was requested from the patient or from the next of kin if the patient was determined to lack capacity. Patients were then screened with the Mini-Mental State Examination (MMSE). A MMSE score <=23 indicated cognitive impairment. We attempted to recruit equal numbers of patients with and without cognitive impairment, and patients with a MMSE score >23 were bypassed when the number of cognitively impaired subjects exceeded half of the number of patients enrolled in the study. Patients who were recruited for the study were then evaluated with the Delirium Rating Scale,27 the Blessed Dementia Rating Scale,28 the Hachinski Ischemic Scale,29 and the Hamilton Rating Scale for Depression. When possible, caregivers were asked to fill out the relevant portion of the Delirium Rating Scale and the Caregiver Strain Index.30 Admission medical diagnoses, the type of medications the patient received, and demographic data were recorded. A The Karnofsky Performance Status Scale,31 a rating scale for functional impairment, was completed by a nurse who provided care for the patient.

The patients' charts were reviewed after their discharge, and the dates of any of the following events were recorded: use of restraints, use of sedation, occurrence of falls, use of one-to-one observation, problems with compliance, uncooperativeness, incontinence, pulled intravenous lines, problems obtaining informed consent, urinary tract infections, and other mental or behavioral symptoms, such as confusion, disorientation, agitation, memory problems, and hallucinations. A ceiling of six instances of each of the events was used in the analysis. The researchers who reviewed the charts were not aware of the patients' rating scale scores on admission.

We examined the relationship of a factor derived from analysis of the admission measures with a factor derived from analysis of data on clinical manifestations of cognitive impairment recorded in the chart notes during the subsequent hospital stay. We also analyzed the relationship of each factor with LOS. The analyses controlled for the potentially confounding variables of age and functional impairment. We also looked at whether mental or behavioral manifestations appeared first in patients whose charts included records of both types of manifestations.

To determine LOS, we used the date of discharge. In the few instances in which the patient was converted to an alternate level of care (e.g., medically cleared for discharge while awaiting disposition arrangements), we used the date the patient was medically cleared for discharge in order to minimize the influence of social disposition problems on our results. Disposition designations were also recorded.

Correlations and t tests (both independent and paired) were used for the analysis of continuous variables. Factor analysis was used for data reduction. (We attempted a structural equation model by using path analysis of the factors, but the number of subjects was too small to produce stable results.) All analyses were done by using a two-tailed significance of <0.05. When parametric distributional assumptions were not met, nonparametric analyses, such as the sign test, were used. Potentially confounding variables were controlled for in an analysis of covariance.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
From October 1993 through June 1994, 448 patients age >=65 years were identified as eligible for participation in the study and were approached for consent. A total of 339 patients were excluded for various reasons, and 109 entered the study. The study participants included 56 cognitively impaired subjects and 53 subjects who were not cognitively impaired. Sixteen patients were excluded after study entry because of incomplete data or other factors, leaving a total of 93 patients. Of the 339 patients who were approached but who did not enter the study, 89 were excess patients without cognitive impairment, 85 had problems with communication, 79 were unavailable for testing, 31 refused participation, 24 were too physically ill to participate, 14 had levels of consciousness too impaired to participate, and 17 did not enter the study for other miscellaneous reasons. Excluding the excess patients without cognitive impairment, whose data were not further analyzed, the group of patients who were approached but who did not enter the study did not differ in age or sex from the study participants but had a significantly longer hospital stay than the study participants (t=2.5, p<0.02).

Data reduction by means of factor analysis of the five variables representing admission ratings of cognition, delirium, and dementia produced factor 1. Three of the five admission rating scales of mental functioning were included in factor 1 (MMSE, Delirium Rating Scale, and Blessed Dementia Rating Scale), and together these items accounted for 78.2% of the variance in the data. Factor 1 demonstrated a high correlation with the individual components of the factor (factor 1 loadings were 0.93 for the Delirium Rating Scale, –0.86 for the MMSE, and 0.86 for the Blessed Dementia Rating Scale). Table 1 reports the characteristics and admission scores of the patients with and without cognitive impairment.


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TABLE 1. Characteristics of Elderly General Hospital Patients Admitted Through the Emergency Department, by Presence or Absence of Cognitive Impairment at Admissiona



A second, separate factor analysis of the eight variables taken from the hospital chart notes of mental and behavioral manifestations and complications produced factor 2. The eight components in factor 2 each correlated strongly with the factor and together explained 48.9% of the variance in the data (Table 2). Attempts to extract additional factors did not improve the model.


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TABLE 2. Factor Loadings for Mental and Behavioral Manifestations of Delirium and Dementia Among 93 Elderly General Hospital Patients Admitted Through the Emergency Department



As expected, factor 1, which included cognitive impairment, delirium, and dementia measured on admission, was highly correlated with factor 2, which included clinical and behavioral complications recorded in hospital chart notes (r=0.65, p=0.001, N=75), and each factor was separately correlated with increasing LOS (factor 1: r=0.25, p=0.02, N=85; factor 2: r=0.37, p=0.001, N=83) (Figure 1).



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FIGURE 1.  Relationship of Factors Encompassing Admission Ratings of Cognitive Impairment and Complications During Hospital Stay With Length of Stay Among Elderly General Hospital Patients Admitted Through the Emergency Department


We expressed these results in a way that might be more clinically meaningful by comparing the LOS of subjects with high values for factor 1 to that of subjects with low values for factor 1. (Subject groups were identified by using a median split of factor 1 scores.) We similarly dichotomized the subject group with respect to their factor 2 scores. Independent t tests indicated that subjects with high factor scores had a significantly longer mean LOS than those with low factor scores. The difference in mean LOS was 14 days for subjects differentiated by high and low factor 1 scores (p<0.05) and 10 days for subjects differentiated by high and low factor 2 scores (p<0.01).

It is interesting to note that while the admission ratings included in factor 1 did not predict values for the chart notes about disposition problems (r=0.20, p=0.17, N=70), factor 2 did show a significant correlation with disposition problems (r=0.39, p=0.008, N=45).

We also found that despite creating a ceiling of six for the number of times we scored chart notes about each of the components of factor 2, the total number of chart notes was also associated with increasing LOS (r=0.41, p=0.001, N=61). We also controlled statistically for the potentially confounding factors of age and functional impairment on admission, each of which was associated with increasing LOS, and found no substantial changes in the results.

Factor 2 contained both mental and behavioral elements (Table 1). For the 32 patients for whom the occurrence of both mental and behavioral signs and symptoms was noted in the chart, we examined the order in which the signs and symptoms appeared. We found that, as a group, the mental symptoms and signs appeared first in time and were followed by the behavioral problems (p<0.03, parametric t test; p<0.04, nonparametric sign test).

Since factor 2 did not include all of the mental and behavioral manifestations recorded in the chart notes, we performed another analysis after adding data for the chart notations of delirium, dementia, delusions, hallucinations, depression, agitation, and confusion to the analysis of mental symptoms and signs and adding data for the notations of one-to-one observation, uncooperativeness, and problems obtaining consent to the analysis of behavioral manifestations. We did not include data from chart notes about sedation, since sedation could be a sign of delirium or a consequence of treatment for delirium or dementia. We also did not include urinary tract infection because it has frequently been cited as both a cause and consequence of delirium and since the number of notations of this event was small.

We again found that the mental manifestations noted in the chart more frequently preceded the behavioral manifestations (p<0.02, independent t test; p=0.007, nonparametric sign test). The median day of the first appearance of mental manifestations was day 1 of hospitalization. The median day of the first appearance of behavioral manifestations was day 2.

Excluding one patient whose behavioral manifestations first appeared on day 26, the remaining 31 patients with both mental and behavioral manifestations had their first appearance of mental manifestations at a mean of 2.0 days. The first appearance of mental manifestations occurred on day 1 for 16 patients, day 2 for five patients, day 3 for six patients, day 4 for two patients, and day 5 for two patients. The first appearance of behavioral manifestations occurred at a mean of 2.7 days. Behavioral manifestations first occurred on day 1 for eight patients, day 2 for nine patients, day 3 for eight patients, day 4 for two patients, day 5 for one patient, day 6 for one patient, and day 7 for two patients. The difference between the mean first appearance of mental manifestations and the mean first appearance of behavioral manifestations was significant (p<0.02) (Figure 2).



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FIGURE 2.  First Appearance of Mental and Behavioral Manifestations of Delirium and Dementia Among Elderly General Hospital Patients Admitted Through the Emergency Department


In all 37 of the patients with mental or behavioral manifestations, the first appearance of either occurred before the mean LOS for the group of all study participants (7.2 days).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study attempted to elucidate how cognitive impairment, delirium, and dementia measured on admission may contribute to extended hospital stays. We found that cognitive impairment associated with delirium and dementia measured on admission first manifests with mental signs and symptoms, which are then followed on average a day later by behavioral manifestations, which are associated with extended hospital stays. The early appearance of these mental and behavioral manifestations relative to the mean or median LOS in all study participants further suggests that these factors are the cause, not the result, of increased LOS.

Our findings that mental and behavioral problems appeared before day 7 of the hospital stay are consistent with earlier work reporting that new-onset delirium contributing to prolonged LOS became evident by day 7 in 90% of elderly hospitalized patients.1 These findings are important because they suggest that timely identification of and interventions for mental symptoms and signs may have the potential to prevent the subsequent behavioral problems that give rise to extended LOS.

Two innovative preventive intervention programs have been shown to reduce the incidence of delirium in patients who have risk factors on admission or who develop risk factors during the course of hospitalization.3,22 However, studies of both programs found that once delirium appeared, the interventions had no effect on the severity, course, or recurrence of the delirium. Strategies to prevent extended hospital stays for demented patients have been described.10 However, preventive programs represent only one component of the comprehensive intervention programs recommended by previous studies. Treatment and follow-up strategies are needed as well.32

Patients who enter the hospital with dementia or develop delirium during their hospital stay will require follow-up after discharge. Between 32% and 96% of elderly delirious patients have been reported to leave the hospital without resolution of the new-onset symptoms.6,12,13,33,34 Severity of the delirious episode may predict its duration and may thus serve as a useful marker for patients in need of follow-up care. Symptom severity measured during the day of delirium onset35 or during the first week after onset36 has been shown to predict duration of the delirious episode.

Patients with dementia may be expected to have a continuing deteriorating course. The severity of cognitive impairment overall may be a useful marker for identifying patients who are more likely to have persistent symptoms and greater decline in function after discharge34,37 and a greater likelihood of rehospitalization and institutionalization within the 2-year period after discharge.7,12,38

Although dementia on admission may predict the subsequent development of delirium,1,4,11,12 delirium is not known to give rise to dementia during a given hospital stay. However, resolution of delirium may unmask a preexisting dementia, or the delirium may be a harbinger of or a contributor to the development of dementia and functional decline over the long term.34,39–42

Our findings and those of others should encourage the development of programs for the prevention, detection, treatment, and follow-up of mental and behavioral manifestations and complications of delirium and dementia in the general hospital.

This study had some limitations that must be considered in interpreting the data. The study had a relatively small number of participants but nevertheless yielded statistically significant findings. Although mental and behavioral function were prospectively assessed on admission, the study relied on a retrospective review of chart notes after discharge. We considered the date of a patient's conversion to an alternative level of care as equivalent to a discharge date, but it is possible that this strategy did not fully capture the degree to which disposition problems were a major factor extending hospital stays in this population. Factor 2 (behavioral manifestations), but not factor 1, was significantly associated with chart notes of "disposition problems," which suggests that the behavioral manifestations of delirium and dementia, rather than the cognitive impairment itself, may give rise to delays in arranging for disposition. However, our data did not distinguish between delays due to lack of available facilities to receive patients and delays due to clinical manifestations, such as uncooperativeness that impeded discharge planning.

In addition, we used dimensional rather than categorical measures of delirium, dementia, and cognitive impairment, and we combined the three concepts together in the analyses. Other studies have productively used categorical diagnoses of delirium and dementia. The use of dimensional scales for cognitive impairment, delirium, and dementia may have identified patients with subsyndromal diagnoses. Levkoff et al.6 showed that patients with subsyndromal delirium still had double the LOS of patients without any signs of delirium even after the analysis controlled for illness severity and preexisting cognitive impairment. Dimensional approaches also provide a measure of severity that categorical measures may not8 and have been used to demonstrate change in degree of impairment over time.40

Because of the common co-occurrence of dementia and delirium, it may be practical to consider the two together for purposes of constructing clinical programs while differentiating them for basic research purposes.43 For example, dementia itself is a well-known risk factor for delirium.12 Dehydration, another risk factor for delirium, is seen three times more frequently in patients hospitalized with dementia than in those without dementia.10 There is also an overlap of the psychiatric and behavioral disturbances seen in delirium and dementia.43 Both are associated with agitation, aggression, and other behavioral disturbances, as well as with hallucinations and delusions.3 Often, it is not easy to determine whether dementia or delirium is responsible for the manifestations that complicate treatment and extend hospital stays. For example, Dorra et al.44 studied cognitive impairment of delirium and dementia in elderly inpatients at a rehabilitation center after hip fracture repair and found results similar to those of our study. Cognitive impairment was associated with agitation, poor safety awareness, bizarre and psychotic behaviors, and aggressive and combative behavior, and these factors as a group predicted poor clinical outcome.

A comprehensive intervention program should include prevention strategies, education and screening methods to enhance detection, in-hospital treatment strategies, and postdischarge follow-up treatment. Only with a comprehensive approach can the overlapping signs and symptoms of delirium and dementia be addressed clinically, while research continues to elucidate the interrelationship between delirium and dementia and their combined, and separate, effects on function, quality of life, and health care utilization.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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