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Abstract

Background:

Because of progress in cardiovascular management, many critically ill geriatric patients undergo various procedures and intensive cardiovascular care treatments. Although delirium frequently affects geriatric patients post-procedurally and after intensive cardiovascular care, the impact of delirium on acute cardiac patients has not been well understood. The objective of this study was to investigate the impact of delirium on outcomes in acute, non-intubated cardiac patients.

Methods:

This was a prospective cohort study including non-surgical cardiac patients aged 65 years or older admitted to the intensive care unit or intensive cardiac care unit. We excluded mechanically ventilated patients. Delirium was evaluated using the confusion assessment method for the intensive care unit. The primary outcome analysed was 60-day mortality. The secondary outcomes analysed were risk and precipitating factors for delirium development.

Results:

Of 163 patients, 35 (21.5%) developed delirium. Patients with delirium had higher 60-day mortality rates than those without delirium (22.9% versus 3.9%, P<0.001) and spent an average of 10 days longer in the hospital (32±20 versus 22±16 days, P=0.002). On the multivariable Cox analysis, delirium was independently associated with 60-day mortality (adjusted hazard ratio 3.91; 95% confidence interval 1.06−17.36; P=0.04), which was also confirmed by the propensity score-matched analysis. Dementia, history of cerebrovascular disease, and higher sequential organ failure assessment score were significantly associated with delirium development.

Conclusions:

Acute delirium is common and predicts mortality in non-intubated cardiac patients. Cardiac critical care providers should be aware of this neurological condition.

Keywords

Aging cardiovascular disease delirium mortality cerebrovascular disorder

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References

Afilalo

Alexander

Mack

et al . Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol 2014; 63: 747–762.

Chaudhry

Wang

Gill

et al . Geriatric conditions and subsequent mortality in older patients with heart failure. J Am Coll Cardiol 2010; 55: 309–316.

Ely

Shintani

Truman

et al . Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291: 1753–1762.

Koster

Oosterveld

Hensens

et al . Delirium after cardiac surgery and predictive validity of a risk checklist. Ann Thorac Surg 2008; 86: 1883–1887.

Koster

Hensens

van der Palen

. The long-term cognitive and functional outcomes of postoperative delirium after cardiac surgery. Ann Thorac Surg 2009; 87: 1469–1474.

Katz

Shah

Volz

et al . Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit Care Med 2010; 38: 375–381.

Jessup

Abraham

Casey

et al . 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119: 1977–2016.

Ferreira

Bota

Bross

et al . Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286: 1754–1758.

Charlson

Pompei

Ales

et al . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383.

10.

Ely

Inouye

Bernard

et al . Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286: 2703–2710.

11.

Barr

Pandharipande

. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion. Crit Care Med 2013; 41: S99–115.

12.

O’Regan

Fitzgerald

Timmons

et al . Delirium: a key challenge for perioperative care. Int J Surg 2013; 11: 136–144.

13.

Pandharipande

Girard

Jackson

et al . Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369: 1306–1316.

14.

van den Boogaard

Schoonhoven

Evers

et al . Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med 2012; 40: 112–118.

15.

Vasilevskis

Ely

Speroff

et al . Reducing iatrogenic risks: ICU-acquired delirium and weakness – crossing the quality chasm. Chest 2010; 138: 1224–1233.

16.

Witlox

Eurelings

de Jonghe

et al . Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010; 304: 443–451.

17.

Gure

Blaum

Giordani

et al . Prevalence of cognitive impairment in older adults with heart failure. J Am Geriatr Soc 2012; 60: 1724–1729.

18.

Uthamalingam

Gurm

Daley

et al . Usefulness of acute delirium as a predictor of adverse outcomes in patients >65 years of age with acute decompensated heart failure. Am J Cardiol 2011; 108: 402–408.

19.

Barr

Fraser

Puntillo

et al . Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263–306.

20.

Lin

Chen

Wang

. Meta-analysis of factors which influence delirium following cardiac surgery. J Card Surg 2012; 27: 481–492.

21.

Gunther

Morandi

Krauskopf

et al . The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Crit Care Med 2012; 40: 2022–2032.

22.

Morandi

Rogers

Gunther

et al . The relationship between delirium duration, white matter integrity, and cognitive impairment in intensive care unit survivors as determined by diffusion tensor imaging: the VISIONS prospective cohort magnetic resonance imaging study*. Crit Care Med 2012; 40: 2182–2189.

23.

Roman

Kalaria

. Vascular determinants of cholinergic deficits in Alzheimer disease and vascular dementia. Neurobiol Aging 2006; 27: 1769–1785.

24.

Backman

Nyberg

Lindenberger

et al . The correlative triad among aging, dopamine, and cognition: current status and future prospects. Neurosci Biobehav Rev 2006; 30: 791–807.

25.

Fong

Bogardus

Jr Daftary

et al . Cerebral perfusion changes in older delirious patients using 99mTc HMPAO SPECT. J Gerontol A Biol Sci Med Sci 2006; 61: 1294–1299.

26.

McPherson

Wagner

Boehm

et al . Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med 2013; 41: 405–413.

27.

Reade

Finfer

. Sedation and delirium in the intensive care unit. N Engl J Med 2014; 370: 444–454.

28.

Le Maguet

Roquilly

Lasocki

et al . Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study. Intensive Care Med 2014; 40: 674–682.

The impact of delirium on outcomes in acute,non-intubated cardiac patients