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15 September 1993 | Volume 119 Issue 6 | Pages 474-481
Objective: To prospectively develop and validate a predictive model for the occurrence of new delirium in hospitalized elderly medical patients based on characteristics present at admission.
Design: Two prospective cohort studies done in tandem.
Setting: University teaching hospital.
Patients: The development cohort included 107 hospitalized general medical patients 70 years or older who did not have dementia or delirium at admission. The validation cohort included 174 comparable patients.
Measurements: Patients were assessed daily for delirium using a standardized, validated instrument. The predictive model developed in the initial cohort was then validated in a separate cohort of patients.
Results: Delirium developed in 27 of 107 patients (25%) in the development cohort. Four independent baseline risk factors for delirium were identified using proportional hazards analysis: These included vision impairment (adjusted relative risk, 3.5; 95% CI, 1.2 to 10.7); severe illness (relative risk, 3.5; CI, 1.5 to 8.2); cognitive impairment (relative risk, 2.8; CI, 1.2 to 6.7); and a high blood urea nitrogen/creatinine ratio (relative risk, 2.0; CI, 0.9 to 4.6). A risk stratification system was developed by assigning 1 point for each risk factor present. Rates of delirium for low- (0 points), intermediate- (1 to 2 points), and high-risk (3 to 4 points) groups were 9%, 23%, and 83% (P < 0.0001), respectively. The corresponding rates in the validation cohort, in which 29 of 174 patients (17%) developed delirium, were 3%, 16%, and 32% (P < 0.002). The rates of death or nursing home placement, outcomes potentially related to delirium, were 9%, 16%, and 42% (P = 0.02) in the development cohort and 3%, 14%, and 26% (P = 0.007) in the validation cohort.
Conclusions: Delirium among elderly hospitalized patients is common, and a simple predictive model based on four risk factors can be used at admission to identify elderly persons at the greatest risk.
Author and Article Information
From Yale University School of Medicine, New Haven Connecticut.
ARTICLE
A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics
Requests for Reprints: Sharon K. Inouye, MD, MPH, Yale-New Haven Hospital, 20 York Street, Tompkins 15, New Haven, CT 06504.
Acknowledgments: The authors thank the patients, families, and physicians from Yale-New Haven Hospital who participated in their study; the nursing staffs and head nurses Cynthia Johnson, Coy Smith, Marg Meglin, Gail Wojtyna, Noreen Fitzmartin, and Dorothy Moniz-Narracci on the medical floors, who participated in daily interviews despite a critical nursing shortage; Mary Lockett and the Yale Emergency Room staff for assistance in screening our patients; Dr. Lisa Berkman for advice on methods; Sandra Ginter, Anne Fasanella, and Mr. William Sharpe for research assistance; Denise Acampora for research and data coordination; Christine Brady for data management and analysis; Wanda Carr for data entry; Geraldine Hawthorne for clerical assistance; and Drs. Leo Cooney and Alvan Feinstein for helpful review of the manuscript.
Grant Support: In part by grant 90-44, 91-66 from the Retirement Research Foundation, grant 11 from the Sandoz Foundation for Gerontological Research, a grant from the American Federation for Aging Research, and grant RR05443 from the Biomedical Research Support Grant Program, Division of Research Resources, National Institutes of Health. Dr. Inouye is a Dana Foundation Faculty Scholar and recipient of Academic Award 1K08AG00524-01 from the National Institute on Aging.
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