Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-4700, USA.
Ann Emerg Med. 2010 Sep;56(3):244-252.e1. doi: 10.1016/j.annemergmed.2010.03.003. Epub 2010 Apr 3.
Delirium's adverse effect on long-term mortality in older hospitalized patients is well documented, whereas its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients treated in the ED are also unknown. As a result, we seek to determine whether delirium in the ED is independently associated with 6-month mortality in older patients and whether this relationship is modified by nursing home status.
Our prospective cohort study was conducted at a tertiary care, academic ED, using convenience sampling, and included English-speaking patients who were aged 65 years and older and were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or had incomplete data. The Confusion Assessment Method for the Intensive Care Unit was used to determine delirium and was administered by trained research assistants. Cox proportional hazard regression was performed to determine whether delirium in the ED was independently associated with 6-month mortality after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. To test whether the effect of delirium in the ED on 6-month mortality was modified by nursing home residence, an interaction term (delirium*nursing home) was incorporated into the multivariable model. Hazard ratios with their 95% confidence intervals were reported.
Of the 628 patients enrolled, 108 (17.2%) were delirious in the ED and 58 (9.2%) were from the nursing home. For the entire cohort, the 6-month mortality rate was higher in the delirious group compared with the nondelirious group (37.0% versus 14.3%). Delirium was an independent predictor of increased 6-month mortality (hazard ratio=1.72; 95% confidence interval 1.04 to 2.86) after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. The "delirium*nursing home" interaction was nonsignificant (P=.86), indicating that place of residence had no effect on the relationship between delirium in the ED and 6-month mortality.
Delirium in older ED patients is an independent predictor of increased 6-month mortality, and this relationship appears to be present regardless of nursing home status.
谵妄对老年住院患者的长期死亡率的不良影响已得到充分证实,而其对老年急诊科(ED)患者的影响尚不清楚。同样,ED 治疗的养老院患者谵妄的后果也未知。因此,我们旨在确定 ED 中的谵妄是否与老年患者的 6 个月死亡率独立相关,以及这种关系是否受养老院状况的影响。
我们的前瞻性队列研究在一家三级护理、学术 ED 中进行,采用便利抽样,并纳入了年龄在 65 岁及以上、入组时在 ED 中停留时间少于 12 小时且能讲英语的患者。如果患者拒绝同意、之前已入组、在基线时无法遵循简单指令、昏迷或数据不完整,则将其排除在外。使用经培训的研究助理使用 ICU 意识混乱评估法来确定谵妄,并进行评估。采用 Cox 比例风险回归来确定 ED 中的谵妄是否在调整年龄、合并症负担、疾病严重程度、痴呆、功能依赖和养老院居住情况后与 6 个月死亡率独立相关。为了检验 ED 中谵妄对 6 个月死亡率的影响是否受养老院居住情况的影响,将交互项(谵妄*养老院)纳入多变量模型。报告风险比及其 95%置信区间。
在纳入的 628 名患者中,108 名(17.2%)在 ED 中出现谵妄,58 名(9.2%)来自养老院。对于整个队列,谵妄组的 6 个月死亡率高于非谵妄组(37.0%比 14.3%)。在调整年龄、合并症负担、疾病严重程度、痴呆、功能依赖和养老院居住情况后,谵妄是 6 个月死亡率增加的独立预测因子(风险比=1.72;95%置信区间 1.04 至 2.86)。“谵妄*养老院”交互项无统计学意义(P=.86),表明养老院的居住情况对 ED 中谵妄与 6 个月死亡率之间的关系没有影响。
老年 ED 患者的谵妄是增加 6 个月死亡率的独立预测因子,且这种关系似乎与养老院状况无关。