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Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia A Meta-analysis

Joost Witlox, MSc; Lisa S. M. Eurelings, MSc; Jos F. M. de Jonghe, PhD; Kees J. Kalisvaart, MD, PhD; Piet Eikelenboom, MD, PhD; Willem A. van Gool, MD, PhD
JAMA. 2010;304(4):443-451. doi:10.1001/jama.2010.1013.
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Context Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease.

Objective To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders.

Data Sources A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL.

Study Selection Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language. Titles, abstracts, and articles were reviewed independently by 2 of the authors. Of 2939 references in the original search, 51 relevant articles were identified.

Data Extraction Information on study design, characteristics of the study population, and outcome were extracted. Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies.

Data Synthesis The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia. Pooled-effect estimates were calculated with random-effects models. The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 22.7 months (7 studies; 271/714 patients [38.0%] with delirium, 616/2243 controls [27.5%]; HR, 1.95 [95% confidence interval {CI}, 1.51-2.52]; I2, 44.0%). Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 14.6 months; 176/527 patients [33.4%] with delirium and 219/2052 controls [10.7%]; odds ratio [OR], 2.41 [95% CI, 1.77-3.29]; I2, 0%) and dementia (2 studies; average follow-up, 4.1 years; 35/56 patients [62.5%] with delirium and 15/185 controls [8.1%]; OR, 12.52 [95% CI, 1.86-84.21]; I2, 52.4%). The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results.

Conclusion This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia.

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Figure 1. Identification, Review, and Selection of Articles Included in the Meta-analysis
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Figure 2. Primary Analyses
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Analyses of the association between delirium and mortality, institutionalization, and dementia adjusted for age, sex, comorbid illness or illness severity, and baseline dementia. CI indicates confidence interval. Weighting was assigned according to the inverse of the variance. Hazard ratios and odds ratios larger than 1 indicate increased risk of mortality, institutionalization, or dementia among participants who experienced delirium.

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Figure 3. Meta-analytic Survival Curve
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Based on mortality rates among patients that experienced delirium during hospitalization from studies listed in the eFigure. Circles are proportional to study size and depict the proportion of surviving individuals. For specified periods, aggregated weighted estimates for survival are depicted by a horizontal line with corresponding 95% confidence intervals (gray area). For example, 2 to 4 years after delirium, 45% of individuals are still alive.

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