Dharmarajan Kumar, Swami Sunil, Gou Ray Y, Jones Richard N, Inouye Sharon K
Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
J Am Geriatr Soc. 2017 May;65(5):1026-1033. doi: 10.1111/jgs.14743. Epub 2016 Dec 30.
(1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality.
Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000.
Large academic hospital.
Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only.
(1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission.
Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8-6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation.
Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults.
（1）确定住院期间发生的谵妄与90天死亡率之间的关系；（2）识别谵妄增加90天死亡率的潜在院内中介因素。
对“康复计划”的数据进行分析，该计划是1995年至1998年一项谵妄预防干预的对照临床试验，并随访至2000年。
大型学术医院。
入院时无谵妄、发生谵妄风险为中到高且仅接受常规护理的70岁及以上患者。
（1）新发谵妄；（2）谵妄对死亡的潜在中介因素，包括使用约束装置（身体约束、导尿管）、发生医院获得性状况（HACs）（跌倒、压疮）以及遭受其他有害刺激（睡眠剥夺、急性营养不良、脱水、吸入性肺炎）；（3）入院后90天内死亡。
在469例患者中，70例（15%）发生了新发谵妄。这些患者更有可能使用约束装置（37%对16%，P <.001）、发生HACs（37%对12%，P <.001）、遭受其他有害刺激（63%对49%，P =.03）以及90天死亡率更高（24%对6%，P <.001）。在双变量分析中，因谵妄导致死亡的逆概率加权风险为4.2（95%CI = 2.8 - 6.3），随着更多地暴露于约束装置、HACs和其他有害刺激而呈分级增加，在加入这些潜在中介因素类别后下降了10.9%，提供了中介作用证据。
谵妄患者中约束装置、HACs和其他有害刺激更常见，呈分级增加死亡率，且谵妄与死亡之间的关联中有很大比例是由它们导致的。通过额外努力预防谵妄增加死亡率的潜在下游中介因素，可能有助于改善住院老年人的预后。
