Emergency Department, University of Health Science, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey.
Emergency Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
Am J Emerg Med. 2024 Jan;75:14-21. doi: 10.1016/j.ajem.2023.10.022. Epub 2023 Oct 21.
Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients.
The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients.
The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve.
A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005).
AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.
老年人的精神状态改变（AMS）是急诊科（ED）收治的常见原因，通常由谵妄、昏迷或昏迷引起。熟练识别潜在因素并预测这些患者的临床预后非常重要。
本研究的主要目的是揭示和比较新发神经和认知症状或基线精神状态恶化的老年患者的临床结局和病因因素。次要目的是确定这些患者的 30 天死亡率风险。
该研究采用前瞻性和观察性研究进行。我们纳入了年龄在 65 岁及以上、出现新发神经和认知症状或基线精神状态恶化的患者。排除在 48 小时内无基线精神状态变化且需要紧急干预的患者。使用 RASS 和 4AT 工具对选定的患者进行评估，并将其分为三组：昏迷/昏迷、谵妄和无昏迷/昏迷或谵妄（无 SCD）。应用适当的统计检验比较这 3 组。通过 Cox 生存分析和 Kaplan-Meier 曲线确定 30 天死亡率风险。
共有 236 名患者符合研究条件。根据他们的 RASS 和 4AT 测试评分：56（23.7%）、94（40.6%）和 86（36.4%）名患者分别形成昏迷/昏迷、谵妄和无 SCD 组。三组在性别、平均年龄和合并症方面无统计学差异。神经（34.7%）、感染（19.4%）和呼吸系统（19.0%）疾病是 AMS 的主要原因。事后检验显示，谵妄（6，IQR=3）和昏迷/昏迷（7，IQR=3）组的 CCI 评分无统计学差异。昏迷/昏迷、谵妄和无 SCD 组的 30 天死亡率分别为 42.%、15.9%和 12.8%（p<0.005）。昏迷/昏迷组的危险比为 2.79（CI：95%，1.36-5.47，p=0.005）。
AMS 仍然是急诊科面临的重大临床挑战。使用 RASS 和 4AT 测试可为急诊医师提供益处和优势。神经、感染和呼吸系统疾病可导致危及生命的精神恶化。我们的研究表明，长期死亡率预测因素 CCI 评分在谵妄、昏迷或昏迷患者中相当相似。然而，昏迷/昏迷患者的短期死亡率显著增加，其 30 天死亡率风险比其他患者高 2.8 倍。
