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Delirium is a global cognitive disorder of rapid and acute onset with transient duration. It is usually characterized by global disturbances of the cognitive sphere concerning attention, memory, disorientation, language, thought, or perception and by alterations in the state of consciousness, agitation, psychomotor retardation, and altered sleep-wake rhythms.1 Delirium is a clinical syndrome that is frequently found in those older than 65 years. This cognitive disorder is of growing health importance in the light of the demographic forecasts, which estimate that the global population of individuals 65 years or older is expected to more than double, increasing from 761 million in 2021 to 1.6 billion by the year 2050.2
Elderly patients form the population group most frequently encountered in emergency departments (EDs), making up approximately 50% of all care activities within these facilities. This prevalence may stem from the higher comorbidity and prevalence of chronic diseases among the elderly, placing them at a greater risk of suffering events compared with younger adults.3
The greatest prevalence of delirium is found in the elderly who remain on EDs for more than 8 hours.4 The prevalence of this disorder in EDs in elderly subjects is between 12% and 42%.5,6 When delirium occurs, it causes an increase in the length of hospitalization,4,7-9 readmissions within 30 days,9 and mortality.4,9
In EDs, the environmental factors favoring the onset of delirium include the high level of background noise, the crowding of “common spaces,” the application of aids and devices to patients by the health care personnel, the stress caused by hospitalization, and waiting times. Instead, the individual factors recognized as favoring delirium include advanced age, male sex, dementia, disability, comorbidity, multidrug therapy with particular reference to psychotropic drugs, malnutrition, sensory deficit, alcoholism, and a body temperature ≥37.5°C (99.5°F).6,10-13
The recognition of delirium in EDs is underestimated by health care professionals5,14 who do not consider it a priority, preferring to treat the pathology that led to admission to hospital. It is estimated that in EDs, between 57% and 83% of cases of delirium go undetected.4,14
In EDs, the application of tools useful for the early identification of the risk of delirium is still limited. This can be attributed to the difficulty of applying the diagnostic criteria, the characteristics of the screening tools, and/or the lack of training among nursing staff.5,15,16 In the literature, there are numerous and varied tools suitable for identifying delirium. However, the number is considerably reduced if we consider only instruments used specifically in EDs. These include the 4 A's test (4AT) scale, which has a high rate of specificity and sensitivity.16-21 The administration of the 4AT does not require specific training and can be performed by nurses in a few minutes.16,17
In Italy, the last nationwide point prevalence study of delirium in older hospitalized patients was carried out in 2016 and detected delirium in 22.6% of the sample.22
To the best of our knowledge, there are no studies in the literature on the prevalence of delirium in elderly patients in EDs in Italy. Thus, the primary goal of the present study was to evaluate prevalence of the risk of delirium in people 65 years and older hospitalized in EDs for a minimum of 8 hours and within 24 hours of attendance. The study's secondary goal was to identify the variables that influenced the risk of delirium.
METHODS Study DesignA multicenter cross-sectional study was conducted at Cardiologico Monzino Hospital and Bergamo Ovest Hospital. The 2 hospitals have 210 and 840 beds, respectively, and are located in Northern Italy.
Data collection was performed by nurses working in the facilities where the study was conducted. The research team explained to the nurses the objectives of the study and the data collection tool. To be included in the sample, patients had to be in the ED for at least 8 hours and within 24 hours of attending (time calculated from the moment the patient is admitted following triage) and be at least 65 years of age. The latter inclusion criterion was defined on the basis of the World Health Organization indications, which defines people 65 years or older as “elderly.”23 Data were collected once for each patient. We used G*Power (Heinrich Heine University, Dusseldorf, Germany) analysis to determine the necessary sample size under the following conditions: a medium effect size of 0.15, an α of .05, and a statistical power of .8. According to power analysis, the sufficient sample size for this study was 98, with a confidence level of 95%. Data collection took place from June 28 to August 31, 2022.
The InstrumentThe risk of delirium was assessed using the Italian version of the 4AT.17 The 4AT comprises 4 items. Item 1 assesses state of alertness. The next 2 items are brief cognitive screening tests: the Abbreviated Mental Test 4 and attention testing with Months Backwards. Item 4 assesses acute change or fluctuation in the patient's mental status. The range of scores for the 4AT is between 0 and 12. A score of 4 or more suggests delirium, but it is not confirmatory. The diagnosis ultimately relies on clinical judgment. A score ranging from 1 to 3 indicates potential cognitive impairment, suggesting the need for more comprehensive cognitive testing. A score of 0 does not definitively exclude delirium or cognitive impairment: more detailed testing may be needed depending on the clinical context.24 The characteristics that make this scale a valid and reliable tool for screening delirium in EDs are the following: (a) good internal consistency (Cronbach α = .80), (b) sensitivity of 91.2%, specificity of 82.7%, (c) the speed of application, (d) the possibility of using the test even on noncompliant persons, and (e) the possibility of use by nursing staff.16,17 The original instrument is available at https://www.the4at.com/4atguide, and its use is free.
As well as personal information, data on the presence of any the following pathologies were also collected from the patient's clinical documentation: heart disease, diabetes mellitus, and active cancer. The presence of the main risk factors of delirium in acute hospital medical units was also investigated, such as hearing/visual impairments, bed confinement, dehydration, use of psychotropic drugs (ie, opioids, benzodiazepines, anticholinergics, antipsychotics, psychostimulants, antidepressants), and body temperature ≥37.5°C. Dehydration was assessed through tongue dryness identified as a potentially practical tool to identify dehydration risk among older people in the clinical care setting.25 The other potential risk factors were collected through health records.
Statistical AnalysisThe mean and SD were used to describe the continuous variables. Categorical variables were analyzed using frequencies and percentages. The Kolmogorov-Smirnov test was used to assess distribution normality. The distribution of the scores was normal, so a multivariate stepwise linear regression analysis was conducted using the 4AT as the dependent variable to explore the factors connected with high risk of the onset of delirium. To identify predictors of delirium, the 4AT score was also analyzed as a categorical output (≥4 = yes, <4 = no). Thus, a binary logistic regression analysis was performed. The levels of significance were set at P = .05. Statistical analyses were conducted using SPSS version 22 (IBM Corp, Armonk, New York).
Ethical AspectsThe survey was conducted in compliance with Italian privacy laws and the Declaration of Helsinki. The purpose of the study and the confidentiality of the data provided were explained to each participant. All respondents gave their written informed consent. The institutional review boards of Cardiologico Monzino Hospital and Bergamo Ovest Hospital approved the survey.
RESULTSOne hundred patients were enrolled. As highlighted in Table 1, the sample is equally distributed between men and women, with an average age of 80.19 (SD, 8.41) years (65-98 years) and an average hospitalization in the ED of 14.53 (SD, 4.92) hours (8-26 hours). The priority codes assigned to triage are of medium-low severity in 97% of cases. The pathologies found from the analysis of the clinical documentation of the patients are mainly heart-related (66%) and metabolic (diabetes 24%). Forty-one percent of the sample was bedridden, and 23% was dehydrated. The majority of the sample did not use psychotropic drugs (88%) and was afebrile (89%). Table 2 shows the 4AT scores for the sample involved. The risk of delirium was detected in 29% of the sample, whereas the risk of cognitive impairment was 13% (Figure).
TABLE 1 - Sociodemographic Characteristics and Profile of the Sample Characteristics Mean Ds Age 80.63 8.41 Hours of attendance 14.35 4.92 n % Sex Male 50 50 Female 50 50 Heart disease Yes 66 66 No 34 33 Use of psychotropic drugs Yes 12 12 No 88 88 Sensitivity deficit Yes 22 22 No 78 78 Stroke Yes 5 5 No 95 95 Active cancer Yes 14 14 No 86 86 Diabetes Yes 76 76 No 24 24 Bedridden Yes 41 41 No 59 59 Dehydration Yes 23 23 No 77 77 Dementia Yes 82 82 No 18 18 Axillary temperature ≥37.5°C Yes 11 11 No 89 89 Color code Green 42 42 Yellow 55 55 Red 3 3Abbreviation: AMT4, Abbreviated Mental Test 4.
Figure: Risk of delirium and cognitive impairment.
As shown in Table 3, linear regression analysis showed that the highest scores occurred among patients taking psychotropic drugs and suffering from dementia, bedridden, and with signs of dehydration.
TABLE 3 - Multivariate Stepwise Linear Regression Analysis of Factors Influencing the 4AT Scores Unstandardized B CoefficientAbbreviation: VIF, variance inflation factor.
The coefficient of determination R2 was 0.37, indicating that these 4 factors may explain 37.4% of all 4AT variations. The analysis of variance test that verifies the validity of the model was statistically significant: F4,95 = 14.18; P < .001.
As for binary logistic regression analysis, the backward technique was used to select the optimal model. The Omnibus test of the model's coefficients revealed statistical significance (χ25 = 39.85; P < .001), confirming the model's suitability. Nagelkerke R2 showed that the model explained 43.1% of the variance. The final model had a correct classification rate of 81% (specificity, 88.7%; sensitivity, 62.1%). As shown in Table 4, the use of psychotropic drugs increased the risk of delirium by 11.8 times (odds ratio [OR], 11.80; P = .003). Bed confinement increased the risk by 4.3 times (OR, 4.31; P = .009). Being dehydrated increased the risk of onset by 4.6 times (OR, 4.62; P = .010). Having dementia increased the risk of the onset of delirium by 4.4 times (OR, 4.35; P = .021).
TABLE 4 - Predictors of a Provisional Diagnosis of Delirium B SE Wald df OR P Dementia: yes 1.47 0.64 5.31 1 4.35 .021 Use of psychotropic drugs: yes 2.47 0.82 9.09 1 11.8 .003 Dehydration: yes 1.53 0.61 6.31 1 4.62 .012 Bedridden: yes 1.46 0.56 6.77 1 4.31 .009Abbreviation: OR, odds ratio.
This study investigated the prevalence of the risk of delirium in EDs in people 65 years and older hospitalized in EDs for a minimum of 8 hours. The study is deemed to be the first to investigate the prevalence of delirium and its associated factors in Italian EDs.
The study involved a sample of 100 people and found a prevalence of delirium in 29% of the sample. Our results are in line with the scientific literature, which reports values between 12% and 42% for the prevalence of delirium in those older than 65 years who are hospitalized in EDs for more than 8 hours.9,14,26
This study highlighted the epidemiological importance of this pathology in EDs. Indeed, in this setting, the high level of background noise added to the stress; the waiting time and the clinical conditions of the patient create a situation very favorable to the development of delirium.27
Our findings reaffirm the need to systematically assess the presence of delirium with a valid and reliable tool. Previous studies emphasized that health care professionals working in EDs tend to consider other life-threatening emergency medical problems to be more important than managing delirium.4 For this reason, it is estimated that, in 80% of cases, delirium goes undiagnosed. However, the ED is the “start” of the hospital journey for many elderly people, and it is the place where we can assess the risk of developing delirium as early as possible leading to a more favorable pathological course.14
Second, our study analyzed the factors associated with the risk of the onset of this pathology. Our results show that patients using psychotropic drugs, who are bedridden, and with a history of dementia and signs of dehydration have a higher risk of developing delirium. The results of previous studies confirm that dementia and the use of psychotropic drugs increase the risk of the onset of delirium.4,14,18 The relationship between the risk of developing delirium and the condition of being bedridden and/or dehydrated has not been analyzed in previous studies. However, If we consider being bedridden as a symptom of patient frailty, our results confirm previous findings. Indeed, the strong association between delirium and frailty defined as “the accumulation of deficits or a decreased reserve due to a cumulative decline that impairs one's ability to compensate for stressors” was widely confirmed.11
LimitationsThe study has several limitations. First, the results may have been influenced by the small sample size. Second, this study did not investigate all the variables indicated by the literature as predisposing factors of delirium (eg, the environmental factors of noise levels, crowding, and stress levels) because of the very rapid action and tight deadlines of the EDs that did not allow for further evaluations. Third, the 4AT detects the risk of developing delirium; diagnostic certainty of this pathological picture requires the application of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria.28 Finally, the study did not collect whether patients identified as at risk actually underwent a proper assessment for the presence of delirium.
CONCLUSIONSSeveral findings highlighted that delirium in EDs often escapes the attention of health care providers.3 This deficiency is further exacerbated by the misconception that delirium is a benign condition and a natural part of the aging process. Our results confirmed that in Italy the risk of developing delirium in the EDs is high. The systematic use of assessment scales would enable the timely detection of the risk of this pathology and the prompt implementation of actions to reduce the onset of this syndrome. This would also mitigate the consequences in terms of both health costs and negative impacts on patient health. Because delirium is most commonly observed among the elderly who spend more than 8 hours in the ED,4 these assessment scales should be utilized upon the patient's entry in the ED and in any case within the first 8 hours. Assessing the prevalence of delirium and its associated factors is essential for identifying areas that may benefit from the organizational-level intervention. In light of these findings, health care organizations might consider creating spaces for individuals at risk of delirium in which it is possible to reduce environmental noise, facilitate sleep and rest, and limit exposure to stressors.27
Giving health professionals the opportunity to be trained on the correct identification of the delirium and the factors that favor or reduce the occurrence of this disorder is extremely important.4 Indeed, being aware of the factors favoring delirium may be useful to implement preventive measures and facilitate decision-making by health care professionals, as well as support clinical judgment and establish priorities of care for patients at risk of developing delirium. Given the underestimation of delirium in EDs, it is imperative to undertake additional studies to gain a comprehensive understanding of the phenomenon. These studies would enable the assessment of the effectiveness of strategies to prevent or reduce delirium in EDs and support nurses in making decisions in favor of patients' health.
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