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Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality.

ABSTRACT: (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.

SUBMITTER: Dharmarajan K

PROVIDER: S-EPMC5435507 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality.

Dharmarajan Kumar K Swami Sunil S Gou Ray Y RY Jones Richard N RN Inouye Sharon K SK

Journal of the American Geriatrics Society 20161230 5

<h4>Objectives</h4>(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.<h4>Design</h4>Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000.<h4>Setting</h4>Large academic hospital.<h4>Participants</h4>Patients ≥70 years old without delirium at hospital ad ...[more]

PMID: 28039852

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Project description:Background During the coronavirus diseases 2019 (COVID-19) pandemic, population’s mortality has been affected not only by the risk of infection itself, but also through deferred care for other causes and changes in lifestyle. This study aims to investigate excess mortality by cause of death and socio-demographic context during the COVID-19 pandemic in South Korea. Methods Mortality data within the period 2015–2020 were obtained from Statistics Korea, and deaths from COVID-19 were excluded. We estimated 2020 daily excess deaths for all causes, the eight leading causes of death, and according to individual characteristics, using a two-stage interrupted time series design accounting for temporal trends and variations in other risk factors. Results During the pandemic period (February 18 to December 31, 2020), an estimated 663 (95% empirical confidence interval [eCI]: -2356–3584) excess deaths occurred in South Korea. Mortality related to respiratory diseases decreased by 4371 (3452–5480), whereas deaths due to metabolic diseases and ill-defined causes increased by 808 (456–1080) and 2756 (2021–3378), respectively. The increase in all-cause deaths was prominent in those aged 65–79 years (941, 88–1795), with an elementary school education or below (1757, 371–3030), or who were single (785, 384–1174), while a decrease in deaths was pronounced in those with a college-level or higher educational attainment (1471, 589–2328). Conclusion No evidence of a substantial increase in all-cause mortality was found during the 2020 pandemic period in South Korea, as a result of a large decrease in deaths related to respiratory diseases that offset increased mortality from metabolic disease and diseases of ill-defined cause. The COVID-19 pandemic has disproportionately affected those of lower socioeconomic status and has exacerbated inequalities in mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14785-3.

Project description:ObjectivesCause-of-death discrepancies are common in respiratory illness-related mortality. A standard epidemiological metric, excess all-cause death, is unaffected by these discrepancies but provides no actionable policy information when increased all-cause mortality is unexplained by reported specific causes. To assess the contribution of unexplained mortality to the excess death metric, we parsed excess deaths in the COVID-19 pandemic into changes in explained versus unexplained (unreported or unspecified) causes.DesignRetrospective repeated cross-sectional analysis, US death certificate data for six influenza seasons beginning October 2014, comparing population-adjusted historical benchmarks from the previous two, three and five seasons with 2019-2020.Setting48 of 50 states with complete data.Participants16.3 million deaths in 312 weeks, reported in categories-all causes, top eight natural causes and respiratory causes including COVID-19.Outcome measuresChange in population-adjusted counts of deaths from seasonal benchmarks to 2019-2020, from all causes (ie, total excess deaths) and from explained versus unexplained causes, reported for the season overall and for time periods defined a priori: pandemic awareness (19 January through 28 March); initial pandemic peak (29 March through 30 May) and pandemic post-peak (31 May through 26 September).ResultsDepending on seasonal benchmark, 287 957-306 267 excess deaths occurred through September 2020: 179 903 (58.7%-62.5%) attributed to COVID-19; 44 022-49 311 (15.2%-16.1%) to other reported causes; 64 032-77 054 (22.2%-25.2%) unexplained (unspecified or unreported cause). Unexplained deaths constituted 65.2%-72.5% of excess deaths from 19 January to 28 March and 14.1%-16.1% from 29 March through 30 May.ConclusionsUnexplained mortality contributed substantially to US pandemic period excess deaths. Onset of unexplained mortality in February 2020 coincided with previously reported increases in psychotropic use, suggesting possible psychiatric or injurious causes. Because underlying causes of unexplained deaths may vary by group or region, results suggest excess death calculations provide limited actionable information, supporting previous calls for improved cause-of-death data to support evidence-based policy.

Dataset Information

Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality.

Publications

Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality.

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