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Review  |   January 2017
Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review
Author Notes
  •  *Address correspondence to Martin M. Forsberg, MD, Department of Geriatrics and Gerontology, Rowan University School of Osteopathic Medicine, 42 E Laurel Rd, Ste 1800, Stratford, NJ 08084-1338. E-mail: forsbemm@rowan.edu
     
Article Information
Geriatric Medicine / Neuromusculoskeletal Disorders / Psychiatry
Review   |   January 2017
Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review
The Journal of the American Osteopathic Association, January 2017, Vol. 117, 32-38. doi:10.7556/jaoa.2017.005
The Journal of the American Osteopathic Association, January 2017, Vol. 117, 32-38. doi:10.7556/jaoa.2017.005
Abstract

Advances have been made in our understanding of the neuropathogenesis, recognition, and strategies for reducing the incidence of delirium in acute-care settings. However, relatively little attention has been given to delirium in elderly patients in the postacute care (PAC) and long-term care (LTC) settings. The present article reviews the most relevant current research pertaining to this population. Hospital patients with delirium are often discharged to PAC settings. Delirium that develops in the LTC setting is often more insidious and subtle in presentation. Despite incorporating systematic screening tools for delirium in PAC and LTC settings, delirium prevention strategies have not yet been shown to be beneficial beyond the acute-care setting. The management of delirium combined with dementia and guidance on when it is appropriate to use antipsychotic medications is also discussed.

Keywords: delirium, dementia, elderly, long-term care, postacute care

Delirium continues to be a problem and a cause of morbidity and mortality in all health care settings, especially in postacute care (PAC) and long-term care (LTC) settings.1 Postacute care after acute hospitalization is common.2 Many community physicians are likely to encounter elderly patients who may enter or have recently been in PAC settings.2 Also, PAC outcomes have been increasingly scrutinized because PAC is a major recipient of Medicare spending.3 
Delirium is a syndrome of altered mental status with prominent deficits in attention and a characteristic fluctuating course. Delirium often has a medical cause, but the symptoms can persist even after the medical condition has been resolved. Symptoms can persist for weeks to months after initial recognition.4 
Many causes of delirium exist that can have different characteristics and prognoses.2 Infection is the most common cause of delirium in elderly patients.5 Medication, often as polypharmacy, can cause anticholinergic delirium. Terminal delirium during the dying process is characterized by restlessness, confusion or agitation, and day-night reversal. Other types of delirium may result from hepatic or renal failure, hypoxia, benzodiazepine or alcohol withdrawal, intoxication, metabolic or endocrine disorders, or sleep deprivation. 
Although advances have been made in recognizing, managing, preventing, and understanding the long-term consequences of delirium in the acute care environment,6-8 fewer articles about delirium in PAC and LTC settings have been published. Shorter hospital length of stay has led to more patients discharged with acute medical conditions to PAC and LTC settings as well as a larger proportion of patients with delirium in these settings.9,10 The patients in PAC and LTC settings are arguably the most vulnerable and need to be included in the evidence base. 
The current article reviews the literature on delirium in PAC and LTC settings and provides an update for clinicians working in these facilities, in the community, or in hospitals with patients who may need PAC or LTC placement. This review also addresses the scope of delirium in these settings, predisposing factors, clinical outcomes, difficulties in identification, and methods of preventing and managing delirium. 
The articles in this review were obtained from a search of the Cochrane and PubMed databases for full-text articles in English published within the past 10 years using delirium with PAC or LTC and appropriate synonyms. Reviews and clinical trials were included. The articles selected in this review were chosen based on the relevance to the objective. 
Scope of the Problem
About 22% of hospitalized elderly patients are transferred to inpatient PAC services, such as skilled nursing facilities and LTC placement.3 In 2014, there were 2.4 million PAC stays for 1.7 million Medicare fee-for-service beneficiaries, which cost Medicare $28.6 billion.11 Postacute care facilities admit patients who are often quite ill, and as many as 1 in 7 of these patients has delirium.12 Additionally, PAC facilities with more state survey deficiencies tend to admit a higher proportion of patients with delirium.12 Hospitalized patients with delirium are nearly 3 times more likely to need LTC placement or to die within a year.1 
The 1-year mortality rate for delirium approaches 40%.4 The mortality risk is a factor of how long delirium persists.1 Delirium is a common symptom of medical illness in LTC settings.13 It occurs in nearly 18% of LTC patients with an acute illness and occurs more frequently in women (OR, 2.59).13 Also, LTC patients are 10 times more likely than those who are not in LTC settings to have delirium when evaluated in the emergency department (ED).14 
 
KEY POINTS

Delirium is a syndrome of altered mental status with prominent deficits in attention and a characteristic fluctuating course.

In all health care settings, especially in postacute care and long-term care, delirium is a cause of morbidity and mortality.

Although delirium often has a medical cause, symptoms can persist even after the medical condition has been resolved.

Delirium occurs in nearly 18% of long-term care patients who develop an acute illness and occurs more frequently in women.

Risk factors for delirium in long-term care include dementia, polypharmacy, restraint use, multiple illnesses, frailty, advanced age, and alcohol use.

New-onset perceptual disturbance, disorganized thinking, and worsening 3-object registration test results each predict delirium independently; patients with changes in all 3 symptoms were 3 times more likely to have delirium.

Unless delirium detection occurs early, the chance of a complete recovery is low. Delirium detection should ideally occur early and be communicated at the transition of care.

Instruments used to identify delirium include Confusion Assessment Method and Delirium Rating Scale Revised-98.

Infection is the most common cause of delirium in elderly patients.

Low-dose antipsychotic medication is commonly used in patients with delirium.

Although acute delirium should be seen as a medical emergency, the potential risks of transporting patients with delirium to the emergency department where their baseline is not known should be considered.

Predisposing Risk Factors
Risk factors for delirium in LTC settings include dementia, polypharmacy, restraint use, multiple medical illnesses, frailty, advanced age, and alcohol use. Patients who have had to be physically restrained are 5 times more likely to have delirium.15 Substantial overlap in symptoms of delirium and dementia exist. Overall, 68% of new LTC patients have dementia and many have several of the other risk factors as well.16 The combination of delirium and dementia in PAC settings increases the odds of walking dependence (OR, 15.5), institutionalization (OR, 5.0), and 1-year mortality (OR, 1.8).17 Voyer et al18 have studied antecedent symptoms of delirium and found a pattern of 3 symptoms: new-onset perceptual disturbance, disorganized thinking, and worsening results of the 3-object registration test (part of the Mini-Mental State Examination). Each of these symptoms predicted delirium independently, and delirium was 3 times more likely to develop in patients with changes in all of these symptoms.18 Kolanowski et al19 reported that PAC patients’ daily pain ratings correlated with more delirium symptoms. However, Yoo et al20 found that delirium was associated with LTC placement, but pain was not. Delirium was reported to occur in 27% of patients after stroke and was associated with an increased risk of LTC placement of these patients within 12 months (hazard ratio, 3.54).21 In patients who have had cardiac procedures, delirium has been associated with increased mortality (13.5% vs 2.0% in patients without delirium) and hospital readmissions (45.7% vs 26.5%), as well as reduced quality of life.22 
Outcomes
Marcantonio et al23 found that patients admitted to PAC settings with delirium had a 6-month mortality rate of 25.0% compared with 5.7% in patients admitted without delirium. Kiely et al24 added that the 1-year mortality rate was mostly elevated in the hypoactive subtype of delirium. In one study, PAC patients whose delirium resolved by 2 weeks without recurrence regained all of their prehospital functional level, whereas patients whose delirium had not resolved regained less than 50% of their prehospital functional level.25 Patients in PAC settings with delirium exhibit a pattern of fluctuating motor performance that is chronologically related to the onset and the end of delirium.26 
Incident delirium (ie, delirium that occurs during the course of admission) in LTC settings may be somewhat different in that it is not associated with decline in activities of daily living or falls, but it is a risk factor for cognitive function decline (OR, 4.59).13 Delirium has tripled the risk of PAC placement leading to LTC placement.20 The presence of residual subsyndromal delirium at the time of hospital discharge also predicts adverse outcomes.27 von Gunten et al28 found that delirium and depression during the first year of LTC placement were associated with more complicated trajectories of recurrent delirium until death. 
Identification
Without structured evaluation, recognition of delirium can be unreliable. Voyer et al29 found that detection rates ranged from 25% to 67%. Morandi et al30 found that in patients with delirium, the word delirium was used in 9% of medical records. Instead, confusion was more commonly used and led to less management actions than when delirium was used in communication with physicians.30 Unless delirium detection occurs early, the chance of a complete recovery is low.31 Delirium detection should ideally occur at admission and be communicated at the transition of care. 
Several instruments for identifying delirium have been used with good results. With appropriate training, nonclinicians can detect delirium with high interrater reliability using a structured delirium assessment process.32 Two popular instruments are the Confusion Assessment Method (CAM) and the Delirium Rating Scale Revised-98 (DRS-98). The CAM was developed in 1990 and has several modified forms. In 2014, Inouye et al33 validated a new delirium severity measure based on the CAM that correlated with outcomes such as length of stay, mortality, and care dependence. The DRS-98 can be used to track severity. 
The Minimum Data Set (MDS) screens elderly patients’ functional capabilities and can identify health problems. This tool is completed within 2 weeks of admission to a nursing home, then quarterly or after notable changes. The MDS aims to increase delirium awareness and recognition in PAC and LTC settings16 and was updated in 2010 to include the CAM questionnaire. Another variation of the CAM was developed for nursing home patients and uses MDS data to predict delirium. However, this instrument needs clinical validation.34 
Incident delirium in LTC settings often presents differently from delirium in the acute-care setting.35 The onset can be insidious and patients may have many prodromal symptoms of subclinical delirium.18 In patients with delirium and behavioral and psychological symptoms of dementia, sleep changes were found to be the only reliable distinction between those with and those without delirium.36 More than half of patients with delirium and dementia in PAC settings remembered being confused, and many reported a moderate level of distress related to the delirium episode.37 
Prevention
A 2014 Cochrane review38 found limited evidence for the efficacy of delirium prevention methods. The review did support medication review by consultation pharmacists and a computerized system to identify medications that may contribute to delirium risk. Using automated medication reviews can reduce the rate of delirium, though a clear reduction in hospitalization, falls, or mortality has yet to be reported.39 When LTC staff are educated about delirium, the total number of documented episodes increases because of greater awareness and recognition of delirium. In one study, educating home care staff led to more delirium cases being recognized but fewer total prescriptions being written over 6 months.40 Delirium abatement programs do show changes in staff attitude.41-43 Although these programs have had modest to no benefit in PAC settings, they may have some benefit in hospital geriatric units.44 The cost savings of preventing delirium in hospitalized LTC patients have been estimated to be 15%, mostly owing to shorter length of stay. Long-term care room characteristics can have an impact on patients’ behavior. When a clock or calendar (OR, 1.93) or telephone (OR, 2.79) were absent from a patient’s room, he or she was more likely to have disruptive behavior and receive antipsychotic medication.45 Foltyn46 reported a case series in which oral pain and oral hygiene underlie some presentations of delirium and urged the inclusion of oral health and dentistry in LTC settings. 
Osteopathic manipulative treatment (OMT) optimizes structure and function and enhances the body’s homeostatic mechanisms. Snider et al47 studied various outcomes, including delirium, in nursing home patients after preventive OMT vs a light-touch sham treatment was applied. No patients in either group developed delirium during the study, so the results were inconclusive.47 
Treatment
The causes of delirium are diverse, and no standard treatment exists. Therefore, the osteopathic philosophy of understanding and addressing the cause of individual cases is especially important. Infection is the most common cause of delirium in elderly patients.5 Physicians may want to rule out and manage urinary tract infections (UTIs) in patients with delirium. Because asymptomatic bacteriuria is common in LTC patients, Nace et al48 recommended against performing urinalysis in LTC patients with isolated nonspecific signs or noninfectious symptoms such as fatigue, foul-smelling or cloudy urine, or delirium. Evidence supports dysuria, high frequency, and lower abdominal pain as symptoms of a UTI.48 Observation and monitoring is recommended instead of antibiotics for patients who may have bacteriuria but do not clearly meet strict UTI criteria.48 
Antipsychotic medication is a commonly used treatment for patients with delirium. A Cochrane review found evidence for using low-dose antipsychotic medication to decrease severity and duration of delirium in acute care.49 A review of antipsychotic treatment for hospitalized elderly patients with delirium concluded that atypical antipsychotic medications demonstrate similar rates of efficacy as haloperidol, with lower rates of extrapyramidal adverse effects.50 In 2008, the US Food and Drug Administration issued a black box warning of increased mortality from using antipsychotics in elderly patients with dementia.51 Hatta et al52 found that treating elderly hospitalized patients for delirium with antipsychotic medications did not result in increased mortality. Raivio et al53 also found that antipsychotic medications prescribed for delirium- and dementia-related behaviors did not increase mortality in a Finnish nursing home population. They concluded that these results may have been caused by the advanced age and frailty of their population, in which the short-term mortality rate was already rather high.53 A large number of medications and a need for physical restraints predicted a 2-fold higher mortality rate over 2 years.53 Jung et al54 found that patients in PAC settings without objective evidence of delirium who received antipsychotics had worse outcomes and an increased rate of death. No clear benefit exists for managing presumed delirium with antipsychotic medications unless severe behavioral or psychiatric symptoms are present. Terminal delirium is considered irreversible, but management should involve palliative care. Benzodiazepines are often used to provide relief for patients with terminal delirium as well as for patients with delirium due to alcohol or benzodiazepine withdrawal; benzodiazepines should be avoided in other types of delirium. Postacute care and LTC regulations require antipsychotic medication use to be closely monitored and require active efforts to reduce and eliminate these medications. Antipsychotic use for patients with delirium should be temporary, and reduction after severe symptoms have resolved is recommended. Antipsychotic use must be evidence based and well documented. 
Facilities are often understaffed and ill prepared for when a patient becomes acutely agitated. Timely psychiatric consultation is not always available, and the management usually falls on the attending physician or nurse practitioner. Patients who present with an acute change in mental status are often transferred to the ED for evaluation. Arendts et al55 found that decisions to transfer patients from an LTC setting to an ED are often influenced by considerations beyond the expected benefit to the individual patient, such as inadequate facility resourcing and care planning. Although acute delirium should be seen as a medical emergency, the potential risks of transporting a patient with delirium to the ED where their baseline is not known should be considered. In 2006, Inouye56 published a useful algorithm for managing delirium in older persons. The 2008 American Medical Directors Association guidelines57 includes a decisional algorithm on delirium and acute problematic behavior specific to the LTC setting. Postacute care and LTC facilities must be prepared to conduct complete patient evaluations and treat patients with delirium in the facility. Nursing and administration staff must support and cooperate with these efforts because the interventions can be labor intensive. 
Conclusion
Although delirium in PAC and LTC settings may share many properties with delirium in other settings, unique features such as insidious onset and incomplete resolution or long duration should be considered. The literature reviewed in this article contributes to the evidence base for the appropriate use of antipsychotics in PAC and LTC settings and clarifies some of the difficult, yet essential, clinical questions facing physicians. The recently implemented penalties58 on hospitals for rehospitalizations from PAC and LTC settings may generate interest in studying delirium in PAC and LTC settings and whether a decrease in delirium may lead to decreased rehospitalizations. No studies have been published that demonstrate the effect of OMT on delirium incidence or course, to the authors’ knowledge. More research is needed to better understand delirium in the PAC and LTC setting. 
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