Delirium is Associated with High Mortality in Elderly patients with Acute Decompensated Heart Failure

doi:10.21203/rs.3.rs-53578/v1

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Delirium is Associated with High Mortality in Elderly patients with Acute Decompensated Heart Failure

https://doi.org/10.21203/rs.3.rs-53578/v1

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published 03 Dec, 2020

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Background: Delirium is associated with high mortality after cardiac surgery. However, evidence on the epidemiology of delirium in patients with acute decompensated heart failure (ADHF) is limited. This study aimed to assess the incidence and prognostic impact of delirium in patients with ADHF.

Methods: This single-center prospective observational study enrolled 132 consecutive patients with ADHF. We utilized the Diagnostic and Statistical Manual of Mental Disorders, fifth edition and classified the patients into two groups according to the presence or absence of delirium. The primary endpoint was 90-day all-cause mortality. The prognostic impact and risk factors of delirium were evaluated using multivariable Cox and logistic regression analyses, respectively.

Results: The median patient age was 83 (interquartile range, 75–87) years. Approximately 51.5% were men. Delirium occurred in 36 (27.3%) patients, and hyperactive delirium was the most frequent type (86.1%). The 90-day all-cause mortality was higher in the patients with delirium than in those without (21.6% versus 3.9%, log-rank p=0.002). Delirium was associated with higher mortality with an adjusted hazard ratio of 6.8 (95% confidence interval, 1.1–42.6, p=0.042). The risk factors associated with delirium included advanced age, male sex, higher clinical frailty scale score, and dementia.

Conclusions: Delirium was associated with a higher 90-day all-cause mortality in the elderly patients with ADHF. Hyperactive delirium was the most common subtype.

Geriatrics & Gerontology

Acute decompensated heart failure

hyperactive delirium

clinical frailty scale

dementia

Delirium is one of the most common mental disorders and is characterized by a disturbance in consciousness, which develops in a short period.¹ It is commonly encountered in a variety of clinical settings and conditions, including heart diseases, and advanced age is one of its most known risk factors.² Conversely, the number of patients with acute decompensated heart failure (ADHF) has recently been increasing worldwide owing to the increased prevalence of ischemic and non-ischemic heart diseases with aging and the recent developments in medical and mechanical therapeutic strategies.

It is important for cardiologists and cardiac surgeons to investigate the epidemiology of delirium and further determine appropriate ways to manage it because this condition is associated with a poor prognosis.^3,4 Many studies have reported that postoperative delirium was associated with prolonged hospital stay as well as higher short- and long-term mortalities after cardiac surgery, such as coronary artery bypass grafting and valve surgeries. However, only a few studies have investigated the relationship between delirium and prognosis in patients with ADHF, with majority of the reported evidence derived from retrospective studies.^4–7

The prognosis of patients with delirium depends on its subtype.^1,8 There are three subtypes of delirium: hyperactive, hypoactive, and mixed. The hypoactive subtype is most commonly observed in patients after cardiac surgery, and the prognosis of these patients is worse than that of patients with the hyperactive subtype.^5.9 In addition, the incidence of each subtype of delirium differs among background diseases, and evidence on the prognosis of each subtype has not been fully established in patients with ADHF.¹⁰ On the basis of these backgrounds, the objective of this single-center prospective observational study was to investigate the epidemiology of delirium in patients with ADHF, i.e., incidence, prognostic impact of delirium on mortality, and risk factors for delirium.

Study population

This single-center prospective observational study enrolled 132 consecutive adult patients (age, > 18 years) admitted with ADHF at Shimane University Hospital between January 1 to October 31 in 2018. Herein, we defined ADHF as rapid worsening of heart failure symptoms with a need for hospitalization to manage the signs and symptoms, such as perfusion failure to the main organs or severe dyspnea. The patients received standard treatments for heart failure based on their clinical profiles according to the presence or absence of congestion and hypoperfusion as described in the international guidelines for the management of ADHF.¹¹ The decision for hospitalization or treatment strategies was made at the attending physician’s discretion. The study protocol complied with the Helsinki Declaration standards and was approved by the institutional review board of Shimane University Hospital. Written informed consent was substituted by an opt-out fashion according to the recommendation of the ethical committee because this study employed an observational design, which provided patients with no interventions, and patients with delirium could not voluntarily consent by themselves. This study was registered with the University Hospital Medical Information Network Clinical Trials Registry, as accepted by the International Committee of Medical Journal Editors (UMIN000032646). All authors have read and agreed to the contents of the manuscript.

Diagnosis and treatment of delirium

The presence of delirium was assessed every day by a doctor or nurse for 14 days after the hospitalization using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM–5).¹ The subtypes of delirium were also evaluated using the DSM–5. Hyperactive delirium was defined as loss of control of activity, such as restlessness and hallucination; hypoactive delirium was described as a decreased amount of activity, such as listlessness; and mixed delirium has both features.^1,9 Consultation to a psychiatrist was made as necessary. Some patients took oral sedative–hypnotic drugs, such as ramelteon and benzodiazepines, to achieve a good night’s sleep. Intravenous sedative medications, such as dexmedetomidine and propofol, were administered to patients who received non-invasive positive pressure ventilation (NIPPV) and those who were intubated. When the patients became delirious, we managed delirium as follows. First, non-pharmacological treatments for delirium were provided to all patients. They included reorientation and environmental interventions, such as proper patient care settings with low-level lighting and minimal noise to avoid sleep interruption at night.¹² When non-pharmacological treatments were insufficient, pharmacological treatments, such as oral and intravenous antipsychotic drugs, including risperidone and haloperidol, were additionally considered and provided. When agitation was severe, temporal physical restraints were introduced but held to a minimum.

Statistical analysis

The primary endpoint was set as the 90-day all-cause mortality and the secondary endpoint as the cumulative incidence of delirium from the day of admission. The incidence of each subtype of delirium was also recorded. Continuous variables were expressed as medians (interquartile range [IQR, 25th to 75th percentiles]) and categorical variables as absolute numbers (percentages). The study population was classified into two groups according to the presence or absence of delirium during hospitalization to assess the prognostic impact of delirium. Comparison of data between the two groups was performed using the Wilcoxon rank sum test for continuous variables and chi–square test for categorical variables. Kaplan–Meier analysis was employed to estimate the 90-day all-cause mortality and cumulative incidence of delirium with the corresponding 95% confidence interval (CI). The difference in the 90-day all-cause mortality between the two groups was evaluated using a log–rank test. The prognostic impact of delirium and risk factors associated with delirium were evaluated using univariable and multivariable Cox regression and logistic regression analyses, respectively. Explanatory variables were selected clinically considering previous reports. All statistical analyses were conducted using Microsoft R Open version 3.3.2, and p-values of < 0.05 were considered statistically significant.

Patient characteristics

Table 1 shows the patient characteristics on admission. The median age of the study population was 83 (IQR, 75–87) years, and 51.5% of the patients were men. Approximately 14.4% of the patients had a history of cerebral infarction, and 27.3% had dementia. The median clinical frailty scale score was 4 (3–5) points. In regard to the clinical profiles of heart failure, the warm–wet type was the most frequent at 73.5%. The median brain natriuretic peptide (BNP) level was 601 (331 − 1,264) pg/mL. Echocardiography showed that the median left ventricular ejection fraction in the entire population was 48% (31–60%). As shown in Table 1 and Fig. 1, a total of 36 (27.3%; 95% CI, 19.3–34.5) patients developed delirium within 14 days after hospitalization. There were some significant differences in the baseline characteristics between the patients with and without delirium (Table 1). The patients with delirium were significantly older and had a higher incidence of previous cerebral infarction and dementia, clinical frailty scale score, heart rate, and BNP level than those without delirium.

Table 1

Patient characteristics on admission
		Overall n = 132	Delirium (–) n = 96	Delirium (+) n = 36	p-value
Age (years)		83 (75 − 87)	82 (75 − 86)	85 (83 − 91)	< 0.001
Men		68 (51.5)	49 (51.0)	19 (52.8)	0.859
Body mass index (kg/m²)		22.3 (19.7 − 24.7)	22.3 (19.9 − 25.0)	22.0 (18.8 − 24.1)	0.284
Hypertension		101 (76.5)	71 (74.0)	30 (83.3)	0.258
Diabetes mellitus		49 (37.4)	36 (37.5)	13 (37.1)	0.970
Dyslipidemia			51 (53.1)	17 (47.2)	0.546
Smoking		50 (37.9)	38 (39.6)	12 (33.3)	0.510
Previous cerebral infarction		19 (14.4)	9 (9.4)	10 (27.8)	0.007
Dementia		36 (27.3)	16 (16.7)	20 (55.6)	< 0.001
Clinical frailty scale score		4 (3 − 5)	3 (3 − 4)	5 (4 − 6)	< 0.001
Underlying heart disease
Ischemic heart disease		24 (18.2)	17 (17.7)	7 (19.4)	0.818
Severe valvular disease Dilated cardiomyopathy		37 (28.0) 18 (13.6)	29 (30.2) 13 (13.5)	8 (22.2) 5 (13.9)	0.363 0.959
Hemodynamic data
Systolic BP (mmHg)		138 (120 − 154)	138 (119 − 157)	139 (126 − 153)	0.986
HR (beats per minute)		78 (60 − 94)	74 (60 − 90)	90 (74 − 100)	0.036
Clinical profile of heart failure
Warm–dry		24 (18.2)	20 (20.8)	4 (11.1)	0.197
Warm–wet		97 (73.5)	68 (70.8)	29 (80.6)	0.260
Cold–dry		1 (0.8)	0 (0.0)	1 (2.8)	0.273
Cold–wet		10 (7.6)	8 (8.3)	2 (5.6)	0.727
Medication
Beta–blocker		50 (37.9)	38 (39.6)	12 (33.3)	0.510
ACEI or ARB		71 (53.8)	55 (57.3)	16 (44.4)	0.187
Diuretics		78 (59.1)	57 (59.4)	21 (58.3)	0.914
Laboratory data
eGFR (mL/min/1.73 m²)	48.3 (27.8–64.3)		47.4 (28.6–66.9)	49.9 (25.3–57.0)	0.409
BNP level (pg/mL)		601 (331 − 1,264)	513 (274 − 1,105)	896 (560 − 1,788)	0.002
Echocardiography
LVEF (%)		48 (31 − 60)	50 (33 − 61)	41 (30 − 58)	0.395
Continuous variables are given as medians and interquartile ranges, whereas categorical variables are summarized as exact numbers and percentages.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BNP, brain natriuretic peptide; BP, blood pressure; eGFR, estimated glomerular filtration rate; HR, heart rate; LVEF, left ventricular ejection fraction

Clinical course during hospitalization

Figure 1 and Table 2 show the clinical and treatment information during hospitalization. The median number of day from admission to the onset of delirium was 2 (1–4), and majority of the delirium cases occurred within a week after hospitalization. Most patients developed hyperactive delirium (86.1%), followed by mixed delirium (8.3%), and hypoactive delirium (5.6%). Among the total study population, the percentage of patients who needed intubation and NIPPV was 4.6% and 26.5%, respectively. Most (78.8%) patients were treated with diuretics, whereas only approximately 20% of the patients were treated with inotropes or vasodilators for the management of ADHF. As sedative–hypnotic or antipsychotic drugs, benzodiazepines, ramelteon, risperidone, propofol, dexmedetomidine, and haloperidol were administered to 12.2%, 28.0%, 6.8%, 3.8%, 15.2%, and 12.9% of the patients, respectively. The median time from admission to discharge was 20 (14–30) days. In the comparisons between the patients with and without delirium, there were significant differences in the treatment strategies; the patients with delirium more frequently received NIPPV, inotropes, and oral and intravenous sedative–hypnotic and antipsychotic drugs, except for benzodiazepines, than did those without delirium. There was no significant difference between the two groups in regard to the duration of hospitalization.

Table 2

Clinical and treatment information during hospitalization
	Overall n = 132	Delirium (–) n = 96	Delirium (+) n = 36	p-value
Delirium
Time from admission to delirium (day)	–	–	2 (1–4)	–
Delirium within a week (%)	–	–	32 (88.9)	–
Subtype of delirium
Hyperactive Hypoactive Mixed	– – –	– – –	31 (86.1) 2 (5.6) 3 (8.3)	– – –
Respirator
Intubation	6 (4.6)	4 (4.2)	2 (5.6)	0.664
NIPPV	35 (26.5)	21 (21.9)	14 (38.9)	0.049
Drug for heart failure
Diuretics Inotrope Vasodilator	104 (78.8) 24 (18.2) 26 (19.7)	73 (76.0) 13 (13.5) 17 (18.5)	31 (86.1) 11 (30.6) 9 (26.5)	0.208 0.024
Diuretics Inotrope Vasodilator	104 (78.8) 24 (18.2) 26 (19.7)	73 (76.0) 13 (13.5) 17 (18.5)	31 (86.1) 11 (30.6) 9 (26.5)	0.325
Sedative–hypnotic and antipsychotic drugs
Oral drugs Benzodiazepines	16 (12.2)	12 (12.6)	4 (11.1)	1.000
Ramelteon	37 (28.0)	15 (15.6)	22 (61.1)	< 0.001
Risperidone	9 (6.8)	1 (1.0)	8 (22.2)	< 0.001
Intravenous drugs
Propofol	5 (3.8)	1 (1.1)	4 (11.1)	0.020
Dexmedetomidine	20 (15.2)	6 (6.2)	14 (38.9)	< 0.001
Haloperidol	17 (12.9)	1 (1.0)	16 (44.4)	< 0.001
Hospitalization
Time from admission to discharge (day)	20 (14 − 30)	20 (15 − 30)	20 (13 − 31)	0.651
Continuous variables are given as medians and interquartile ranges, whereas categorical variables are summarized as percentages. NIPPV, non-invasive positive pressure ventilation

Impact on mortality and risk factors of delirium

Figure 2 shows the 90-day survival estimates. The 90-day mortality was significantly higher in the patients with delirium (21.6%; 95% CI, 3.4–36.4) than in those without (3.9%, 95% CI 0.0–8.3), at a log–rank p-value of 0.002; that in the total study population was 8.3% (95% CI, 2.8–13.4). In addition, the multivariable Cox regression analysis revealed that delirium was independently associated with the 90-day all-cause mortality, with a hazard ratio (HR) of 6.8 (95% CI, 1.1–42.6; p = 0.042) after adjustments of patient backgrounds (Table 3). In contrast, the multivariable logistic regression analysis demonstrated that older age (adjusted odds ratio [OR], 1.1; 95% CI, 1.0–1.2; p = 0.040), male sex (adjusted OR, 3.2; 95% CI, 1.2–10.1; p = 0.031), higher clinical frailty scale score (adjusted OR, 2.1; 95% CI, 1.4–3.4; p < 0.001), and presence of dementia on admission (adjusted OR, 3.3; 95% CI, 1.1–10.4; p = 0.040) were associated with the development of delirium after hospitalization owing to ADHF.

Table 3

Impact of delirium and other clinical indices on the primary and secondary endpoints
Primary endpoint (90-day mortality)		Univariable			Multivariable
Primary endpoint (90-day mortality)		HR	95% CI	p-value	Adjusted HR	95% CI		p-value
Age		1.0	0.9–1.1	0.989	0.9	0.8–1.0	0.081
Male sex		0.4	0.1–1.7	0.240	0.5	0.1–2.2	0.334
Clinical frailty scale score		2.0	1.3–3.0	0.002	1.5	0.9–2.5	0.181
Dementia		6.4	1.6–25.7	0.009	3.0	0.5–20.2	0.251
BNP level		1.0 6.8	1.0–1.1 1.7–27.3	0.673 0.007	1.0 6.8	0.9–1.0 1.1–42.6	0.372 0.042
Delirium		1.0 6.8	1.0–1.1 1.7–27.3	0.673 0.007	1.0 6.8	0.9–1.0 1.1–42.6	0.372 0.042
Risk factors for delirium	Univariable			Multivariable
Risk factors for delirium	OR	95% CI	p-value	Adjusted OR	95% CI	p-value
Age	1.1	1.0–1.2	0.001	1.1	1.0–1.2	0.040
Male sex	1.1	0.5–2.3	0.859	3.2	1.2–10.1	0.031
Clinical frailty scale score	2.5	1.7–3.8	< 0.001	2.1	1.4–3.4	< 0.001
Dementia	6.3	2.7–14.9	< 0.001	3.3	1.1–10.4	0.040
BNP level	1.0	1.0–1.1	0.040	1.0	1.0–1.1	0.339
BNP, brain natriuretic peptide; CI, confidence interval; HR, hazard ratio; OR, odds ratio

In the present study, we revealed several important epidemiological findings on delirium in patients with ADHF in a prospective fashion. The major findings included the following: 1) The incidence of delirium in this study population was 27.3%, and the median time from admission to delirium was 2 days; 2) hyperactive delirium was the most common subtype; 3) the 90-day all-cause mortality was significantly higher in the patients with delirium, and delirium was associated with poor survival; and 4) the independent risk factors for delirium in the patients with ADHF were older age, male sex, high clinical frailty scale score, and dementia. Considering the lack of evidence concerning delirium in patients with ADHF, we believe that our prospective observational data bridge the evidence gap in this field and contribute to the advancements in the management of delirium in patients with ADHF.

Incidence of delirium in patients with ADHF

The incidence of delirium in this study was slightly higher than that in previous retrospective studies of patients with ADHF; the incidence was reported to be 17–23% during hospitalization.^4,6 This can be attributed to the advanced age of our study population compared with that in previous studies because older age is one of the common risk factors of delirium. The retrospective study design and use of brief screening tools, such as the Intensive Care Delirium Screening Checklist or the Confusion Assessment Method of delirium, in previous studies may also cause this difference; the incidence of clinical events can be underestimated in these situations. Herein, we employed the DSM–5 in a prospective fashion. Delirium occurred at the early phase after the onset of ADHF in this study. This is consistent with several previous reports demonstrating that delirium occurred most frequently on the day and the next day of surgery and tended to occur until 5 days of surgery.^13–15 However, it is also important to know the possibility of relatively later-phase occurrence of delirium because 4 (11.1%) of 36 patients started to develop delirium after ≥ 10 days (Fig. 1).

In addition, it is notable that hyperactive delirium was the most common subtype (86.1%) in the present study, whereas hypoactive delirium was the most common subtype after cardiac surgery in some previous studies.^5,16 Because the mechanism and pathophysiology of delirium are poorly understood with several disparate etiologies indicated in previous reports, including hypoxemia, decreased blood supply to the brain, or electrolyte disturbances associated with heart failure, it is difficult to discuss the reason why hyperactive delirium was the most common subtype in this study.^7,17−19 However, we should note that the evaluation of the subtype is recommended by the DSM–5 because the mortality of patients with hypoactive delirium is higher than that of patients with hyperactive delirium owing to its resistance to drug therapy.^1,8,10 In these viewpoints, our data may paradoxically suggest that patients with ADHF are expected to benefit from aggressive treatment for delirium because hyperactive delirium is susceptible to drug therapy, and its prognosis is better than hypoactive delirium.^10.20

Prognosis and risk factors for delirium in patients with ADHF

As the 30-day mortality of ADHF was reported to be 6–11%, the 90-day mortality in our study population of 8.4% could be common.^21,22 We showed that the prognosis of the patients with ADHF who developed delirium was worse than that of those without delirium. Delirium was independently associated with the 90-day all-cause mortality, with an adjusted HR of 6.8 (95% CI, 1.1–42.6, p = 0.042) in the present study. To the best of our knowledge, there were only two retrospective reports available concerning this topic; Uthamalingam et al. and Honda et al. reported that the adjusted HRs for the presence of delirium in relation to the all-cause mortality were 2.10 (95% CI, 1.53–2.88, p < 0.0001) at 90 days and 2.38 (95% CI, 1.30–4.35, p = 0.005) at a median of 335 days in patients with ADHF, respectively.^4,6 Our results are consistent with these reports in view of the high risk of delirium in association with mortality; however, the HR was estimated to be higher than that in these two reports. This difference may be attributed to an underestimation of the incidence of delirium associated with the retrospective study design, which then resulted in a lower estimation of the HR.

There are several possible mechanisms underlying the poor prognosis in patients with ADHF complicated with delirium. First, delirium itself implies the presence of poor and severe conditions, such as multiple organ failure due to ADHF.²³ In the present study, the BNP level on admission was higher in the patients with delirium. Although it was adjusted in the multivariable Cox regression analysis, there could be some unmeasured confounders regarding the severity of AHDF. Second, it is possible that treatments for heart failure can be sometimes disturbed by agitated behaviors due to delirium, such as self-extubation, catheter removal, or excessive afterload associated with excessive physical activities, as we showed that hyperactive delirium was the most common subtype in the present study.²⁴ Last, difficulty in controlling heart failure, such as noncompliance in taking medications and disruption of daily weight monitoring after discharge, might also be associated with the poor outcome.²⁵ Regarding the risk factors of delirium, advanced age, male sex, high clinical frailty scale score, and dementia were associated with the occurrence of delirium in this study. These risk factors have been proven with sufficient evidence, except for controversies on sex.^2,26,27 At any rate, it is notable that advanced age remained as a risk factor even in this advanced-aged study population.

Clinical perspectives

With the lack of prospective evidence concerning delirium in patients with ADHF, our data contribute to better understanding of delirium in patients with ADHF, and it is noteworthy that hyperactive delirium was the most common subtype observed in the present study. Because patients with hyperactive delirium are more susceptible to needing drug therapy, and its prognosis is better than that of hypoactive delirium, we believe that our data suggest areas for improvement regarding the outcomes of patients with ADHF. Proper diagnosis of delirium and evaluation of its subtype according to the DSM–5 rather than use of brief evaluation tools may play an important role for improving the prognosis of ADHF with the aging society. Physicians should consider delirium when treating ADHF, and evaluation of early occurrence of and accurate diagnosis of delirium in relation to the prognosis in patients with ADHF are mandatory in future trials.

Limitations

There are several limitations in the present study, which should be considered when interpreting our results. First, the prognosis of the patients with each subtype of delirium could not be clarified in this study because the number of included patients was small. The results of this single-center study should be validated in a multicenter study. Second, we could not assess the long-term prognosis, although one of the final goals of medicine is to improve the long-term outcomes, such as survival as well as patients’ quality of life. Third, the relationship between delirium and sedative–hypnotic drug use could not be assessed because the decision for administration of such drugs for the patients depended on the individual judgment of each attending physician. More specific proposal for the management of delirium in patients with ADHF could be needed. However, our prospective data remain important, considering the lack of evidence to discuss future perspectives in managing delirium occurring in patients with ADHF.

Delirium was associated with a higher 90-day all-cause mortality in the patients with ADHF. Hyperactive delirium was the most common subtype according to the DSM–5.

ADHF

acute decompensated heart failure

BNP

brain natriuretic peptide

confidence interval

DSM–5

Diagnostic and Statistical Manual of Mental Disorders, fifth edition

hazard ratio

IQR

interquartile range

LVEF

left ventricular ejection fraction

NIPPV

non-invasive positive pressure ventilation

odds ratio

The study protocol complied with the Helsinki Declaration standards and was approved by the institutional review board of Shimane University Hospital. Written informed consent was substituted by an opt-out fashion according to the recommendation of the ethical committee because this study employed an observational design, which provided patients with no interventions, and patients with delirium could not voluntarily consent by themselves. This study was registered with the University Hospital Medical Information Network Clinical Trials Registry, as accepted by the International Committee of Medical Journal Editors (UMIN000032646). All authors have read and agreed to the contents of the manuscript.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None.

Authors' contributions

All authors read and approved the final manuscript.

Acknowledgements

We express our heartfelt gratitude to the Japan Society of Clinical Research for its dedicated support.

American Psychiatric Association. Diagnostic and Statistical Manual. 5th edition. Washington, DC: APA Press, 2013.
Zaal IJ, Devlin JW, Peelen LM, Slooter AJC. A systematic review of risk factors for delirium in the ICU. Crit Care Med. 2015;43:40–7.
Ogawa M, Izawa KP, Kobayashi SS, Tsuboi Y, Komaki K, Gotake Y, et al. Impact of delirium on postoperative frailty and long term cardiovascular events after cardiac surgery. PLOS ONE. 2017;12:1–14.
Uthamalingam S, Gurm GS, Daley M, Flynn J, Capodilupo R. Usefulness of acute delirium as a predictor of adverse outcomes in patients > 65 years of age with acute decompensated heart failure. Am J Cardiol. 2011;108:402–8.
McPherson JA, Wagner CE, Boehm LM, Hall JD, Johnson DC, Miller LR, et al. Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med. 2013;41:405–13.
Honda S, Nagai T, Sugano Y, Okada A, Asaumi Y, Aiba T, et al. Prevalence, determinants, and prognostic significance of delirium in patients with acute heart failure. Int J Cardiol. 2016;222:521–7.
Lee A, Mu JL, Chiu CH, Gin T, Underwood MJ, Joynt GM. Effect of motor subtypes of delirium in the intensive care unit on fast–track failure after cardiac surgery. J Thorac Cardiovasc Surg. 2018;155:268–75.
Stransky M, Schmidt C, Ganslmeier P, Grossmann E, Haneya A, Moritz S, et al. Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation. J Cardiothorac Vasc Anesth. 2011;25:968–74.
Meagher D. Motor subtypes of delirium: past, present and future. Int Rev Psychiatry. 2009;21:59–73.
O’Keeffe ST. Clinical subtypes of delirium in the elderly. Dementia Geriatr Cognit Disord. 1999;10:380–5.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129–200.
Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5:210–520.
Sabol F, Bily B, Artemiou P, Kolesar A, Torok P, Bilecova-Rabajdova M, et al. Incidence and risk factors of delirium in patients after cardiac surgery: modifiable and non–modifiable factors. Cor Vasa. 2015;57:168–75.
Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. Motor subtypes of postoperative delirium in older adults. Arch Surg. 2011;146:295–300.
Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive function after cardiac surgery from phenotypes to mechanisms. Anesthesiology. 2018;129:829–51.
McIntyre JS, Charles SC, Anzia DJ. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156:1–20.
Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry. 2013;21:1190–222.
Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface of delirium and dementia in older persons. Lancet Neurol. 2015;14:823–32.
Kotfis K, Szylinska A, listewnik M, Strzelbicka M, Brykczynski M, Rotter I, et al. Early delirium after cardiac surgery: an analysis of incidence and risk factors in elderly (≥ 65 years) and very elderly (≥ 80 years) patients. Clin Interventions Aging. 2018;13:1061–70.
Rooij SE, Schuurmans MJ, Mast RC, Levi M. Clinical subtypes of delirium and their relevance for daily clinical practice: a systematic review. Int J Geriatr Psychiatry. 2005;20:609–15.
Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KKL, et al. Long–term trends in the incidence of and survival with heart failure. N Engl J Med. 2002;347:1397–402.
Roger VL, Weston SU, Redfield MM, Hellermann-Homan JP, Jill Killian,Yawn BP, et al. Trends in heart failure incidence and survival in a community–based population. JAMA. 2004;292:344–50.
Siew ED, Fissell WH, Tripp CM, Blume JD, Wilson MD, Clark MJ, et al. Acute kidney injury as a risk factor for delirium and coma during critical illness. Am J Respir Crit Care Med. 2017;195:1597–607.
Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med. 2001;27:1297–304.
Noriega FJ, Vidan MT, Sanchez E, Diaz A, Serra–Rexach JA, Fernandez–Aviles F, et al. Incidence and impact of delirium on clinical and functional outcomes in older patients hospitalized for acute cardiac diseases. Am Heart J. 2015;170:938–44.
Watt J, Tricco AC, Talbot–Hamon C, Ba’ Pham, Rios P, Grudniewicz A, et al. Identifying older adults at risk of delirium following elective surgery: a systematic review and meta–analysis. J Gen Intern Med. 2018;33:500–9.
Noimark D. Predicting the onset of delirium in the post–operative patient. Age Ageing. 2009;38:368–73.

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published 03 Dec, 2020

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Delirium is Associated with High Mortality in Elderly patients with Acute Decompensated Heart Failure

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Journal Publication

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Abstract

Figures

Background

Methods

Study population

Diagnosis and treatment of delirium

Statistical analysis

Results

Patient characteristics

Clinical course during hospitalization

Impact on mortality and risk factors of delirium

Discussion

Incidence of delirium in patients with ADHF

Prognosis and risk factors for delirium in patients with ADHF

Clinical perspectives

Limitations

Conclusions

Abbreviations

Declarations

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Status:

Journal Publication

Version 1