Inouye Sharon K, Zhang Ying, Jones Richard N, Kiely Dan K, Yang Frances, Marcantonio Edward R
Aging Brain Center, Hebrew SeniorLife, 1200 Centre St, Boston, MA 02131, USA.
Arch Intern Med. 2007 Jul 9;167(13):1406-13. doi: 10.1001/archinte.167.13.1406.
Persistent delirium at the time of hospital discharge is associated with poor outcomes. The objectives of this study were to develop and validate a predictive model for persistent delirium at hospital discharge.
This study followed a prospective validation design. For the development cohort, 491 consecutive patients 70 years or older admitted to the hospital without delirium and surviving to discharge were enrolled from the general medical units of an academic teaching hospital. For the validation cohort, 461 comparable subjects were enrolled. Twenty-two candidate risk factors were examined, including 12 baseline factors (present on admission) and 10 precipitating factors (hospital related). The primary outcome was delirium at hospital discharge, measured by the Confusion Assessment Method.
Delirium at discharge was present in 58 patients (11.8%) in the development cohort. Five independent risk factors for delirium at discharge were identified: dementia (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.7); vision impairment (OR, 2.1; 95% CI, 1.3-3.2); functional impairment (OR, 1.7; 95% CI, 1.2-3.0); high comorbidity (OR, 1.7; 95% CI, 1.1-2.6); and use of physical restraints during delirium (OR, 3.2; 95% CI, 1.9-5.2). A risk stratification system was created by adding 1 point for each factor present. Rates of delirium for the low-risk (0-1 factors), intermediate-risk (2-3 factors), and high-risk (4-5 factors) groups were 4%, 18%, and 63%, respectively (P < .001). The corresponding rates in the validation cohort, where 28 patients (6.1%) had delirium at discharge, were 3%, 14%, and 27% (P < .001).
A predictive model based on 5 risk factors has been successfully validated for prediction of delirium at discharge in hospitalized older patients. At least 4 of these risk factors are amenable to intervention strategies.
出院时持续性谵妄与不良预后相关。本研究的目的是开发并验证一种出院时持续性谵妄的预测模型。
本研究采用前瞻性验证设计。在一个学术教学医院的普通内科病房，纳入了491例70岁及以上无谵妄入院且存活至出院的连续患者作为开发队列。在验证队列中，纳入了461例可比对象。研究了22个候选危险因素，包括12个基线因素（入院时存在）和10个促发因素（与医院相关）。主要结局是出院时的谵妄，采用意识模糊评估法进行测量。
开发队列中有58例患者（11.8%）出院时存在谵妄。确定了出院时谵妄的5个独立危险因素：痴呆（比值比[OR]，2.3；95%置信区间[CI]，1.4 - 3.7）；视力障碍（OR，2.1；95% CI，1.3 - 3.2）；功能障碍（OR，1.7；95% CI，1.2 - 3.0）；高共病率（OR，1.7；95% CI，1.1 - 2.6）；以及谵妄期间使用身体约束（OR，3.2；95% CI，1.9 - 5.2）。通过为每个存在的因素加1分创建了一个风险分层系统。低风险（0 - 1个因素）、中风险（2 - 3个因素）和高风险（4 - 5个因素）组的谵妄发生率分别为4%、18%和63%（P <.001）。在验证队列中，有28例患者（6.1%）出院时存在谵妄，相应的发生率分别为3%、14%和27%（P <.001）。
基于5个危险因素的预测模型已成功验证，可用于预测住院老年患者出院时的谵妄。这些危险因素中至少有4个适合采用干预策略。
