Practical Application of a Battery of Brief Tools to Evaluate Geriatric Medical Inpatients for the Three Ds
Publication: The Journal of Neuropsychiatry and Clinical Neurosciences
Abstract
Tweet: Screening elderly inpatients who have delirium to detect comorbid depression and dementia is critical for effective treatment.
Abstract
Objective:
The investigators aimed to identify the clinical characteristics of patients with or without delirium and preexisting depression, dementia, both, or neither by using validated tools easily administered in clinical practice.
Methods:
In this cross-sectional prospective observational study conducted in Medellín, Colombia, 200 geriatric inpatients were evaluated with the Delirium Diagnostic Tool–Provisional (DDT-Pro), Informant Questionnaire on Cognitive Decline in the Elderly, Hachinski Ischemic Scale, Cornell Scale for Depression in Dementia, and Charlson Comorbidity Index–short form. Delirium motor subtype, mortality, and length of hospital stay were assessed.
Results:
The study included 134 patients without delirium (67%), 14 with delirium only (7%), 16 with delirium and dementia (8%), 13 with delirium and depression (7%), and 23 with delirium, dementia, and depression (the three Ds) (12%). Prevalence rates of dementia (59%) and depression (55%) among 66 patients with delirium were higher than prevalence rates among patients without delirium (13% and 28%, respectively), suggesting that both conditions are risk factors. Main medical diagnoses, mortality, and dementia type did not differ among groups. Motor subtypes were similar among delirium groups. Patients in the delirium groups, except those in the delirium and depression group, were older than patients without delirium. Medical burden was highest among the patients with delirium and dementia and those with all three conditions. Delirium and dementia were more severe when comorbid with each other. Depression was most severe among patients with delirium and depression. Patients with all three conditions had a longer length of hospital stay than those without delirium.
Conclusions:
Using brief tools to detect dementia and depression in conjunction with the DDT-Pro to assess delirium diagnosis and severity is feasible and enables a more in-depth evaluation of elderly hospitalized patients. Because previous longitudinal research suggests that these comorbid conditions influence prognosis following a delirium episode, better identification of the three Ds offers proactive interventional opportunities. Depression is an underrecognized risk factor for delirium.
Delirium is a disorder of central importance in general hospitals, yet delirium is often comorbid with dementia and depression, which complicates differential diagnosis; co-occurring delirium, dementia, and depression has been nicknamed “the three Ds” (1). The prevalence of dementia in hospital populations was reported to be 13%–63% (2), and that of depression was 12% (3).
Previous studies of the three Ds have focused largely on outcomes (4–8) in different patient settings. All previous studies, except one, diagnosed delirium by using the Confusion Assessment Method (CAM). Functional level was assessed with the Katz Index of Independence in Activities of Daily Living (ADLs) or the Barthel Index, both of which assess basic ADLs such as bathing or eating. The Charlson Comorbidity Index was used in some studies for the measurement of baseline acute medical burden and an analysis of its effect on outcomes. Among the three conditions, depression was least likely to alter longer-term functional status assessed with the Barthel Index, whereas delirium and dementia were associated with reduced functional outcome levels, although the longitudinal trajectory of improvement among patients with depression, delirium, and dementia alone or in combination paralleled that of control subjects without these cognitive disorders (7). Most of these studies (4–6, 8) addressed outcomes associated with more than one comorbid condition. All studies included 6 months of follow-up, with the exception of one study that ended at the time of discharge (4). Notably, the presence of a comorbid condition increased the likelihood of poorer functional outcomes, including greater mortality in long-term care (8), beyond that of a single disorder in acute hospitalization (5) or geriatric rehabilitation for hip fracture (6).
Among patients with hip fracture, there was a 22% prevalence for one of these three conditions, 30% prevalence for any two co-occurring conditions, and 7% prevalence for the presence of all three conditions (5). Because delirium is prevalent among older patients, detailed characterization of patients with delirium and other comorbid conditions compared with patients with delirium only would be helpful; however, studies usually do not report such data. Because of difficulties differentially diagnosing these conditions and the importance of predicting and managing potentially worse longer-term outcomes based on the concurrence of these conditions, we believe a battery of brief tools could assist clinicians with better detection and severity assessment.
Here, we compared patients with dementia and depression as comorbid conditions with patients with or without delirium among consecutively evaluated geriatric medical inpatients. We used a battery of validated brief clinical tools for assessment: the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Hachinski Ischemic Scale (HIS), the Cornell Scale for Depression in Dementia (CSDD), and the Delirium Diagnostic Tool–Provisional (DDT-Pro). These tools are easily administered in routine clinical practice.
Methods
Study Design and Participants
We conducted a cross-sectional prospective observational study of consecutive patients ages ≥60 years with or without delirium admitted during the previous 24–72 hours to the internal medicine ward of the Bolivarian University Clinic (Medellín, Colombia) until a completer sample comprising 200 patients was reached (37 weeks, from March to November 2022). Exclusion criteria were refusal to participate, absence of a relative or caregiver, stupor, coma, or severe communicative difficulties. The study was approved by the Pontifical Bolivarian University Ethics Committee. On the basis of clinical judgment of the patient’s cognitive status, either patients or proxies provided written informed consent to participate.
Clinical Assessment
Demographic and clinical data were collected in a standardized fashion. Spanish translations of the tools were used.
The Charlson Comorbidity Index–short form (CCI-SF) provides an indication of baseline medical burden; eight medical conditions are rated, the score range is 0–10, and a score ≥3 indicates worse prognosis (9).
A relative or caregiver was interviewed for information regarding cognitive and functional status during the past 5 years with the IQCODE. The score can range from 26 to 130 points, and a score ≥86 indicates dementia (10). Degenerative dementia, mixed degenerative-vascular dementia, and vascular dementia were diagnosed according to the HIS score (0–4 points indicates degenerative dementia; 5–6 points indicates mixed dementia; and 7–18 points indicates vascular dementia) (11).
The CSDD (score range is 0–38 points) was used to assess present depression status by means of interview of a patient’s relative or caregiver (12). The highest score on this scale is 38, and scores ≥8 indicate depression. The CSDD is used to assess the severity of five features of depression. Although proposed cutoff scores range from ≥5 to ≥13 for major depression (13), we selected ≥8 as the cutoff because it has the highest positive likelihood ratio of 2.8 with ICD-10 criteria and 2.6 with DSM-IV-TR criteria and the lowest negative likelihood ratio of 0.5 with ICD-10 criteria and 0.4 with DSM-IV-TR criteria (14).
Delirium status was assessed with the DDT-Pro; the score range is 0–9 points, and a score ≤6 indicates delirium (15). The DDT-Pro is used to assess each of the three core symptom domains of delirium (cognitive domain, higher-order thinking domain, and circadian domain). Motor subtypes were determined by using the two motor activity items of the Delirium Rating Scale–Revised-98 (DRS-R98) (16).
Procedures
A psychiatrist reviewed the electronic register for patients meeting entry criteria for the study each weekday, and up to two patients per day were selected. If more than two patients were eligible, a randomizer app (random.org) was used to select patients before assessment of exclusion criteria. A senior research psychiatrist collected patients’ demographic and clinical data and administered the CCI-SF, IQCODE, HIS, and CSDD to the patients meeting entry criteria. One of the other six trained psychiatrists or psychiatry residents took turns administering the DDT-Pro and the motor activity items from the DRS-R98. All raters were blind to other raters’ assessments. Both length of hospital stay and mortality status were registered at the end of the study.
Statistical Analysis
We created a database in SPSS (version 22.0) and categorized patients into the following five groups: no delirium; delirium only; delirium and dementia; delirium and depression; and delirium, dementia, and depression. The prevalence rates of dementia and depression among patients in the no-delirium group are reported.
Although the data were nonnormally distributed in at least one group, continuous variables are reported with means±SD to facilitate interpretation, and their mean ranks were compared with Kruskal-Wallis one-way analysis of variance and post hoc Mann-Whitney U tests. Discrete variables are presented as frequencies and percentage values rounded to the nearest whole number and were compared with chi-square or Fisher’s exact test. Statistical significance was set at p<0.05.
Medians and quartiles for DDT-Pro, IQCODE, and CSDD scores among the study groups are graphed as box plots.
Results
Fourteen patients were excluded (no consent or no relative or caregiver, N=7; stupor or coma, N=4; and communicative difficulties, N=3), and four patients were classified as noncompleters, before reaching the final sample of 200 patients.
Table 1 shows the frequency of diagnoses for each group in the study sample (N=200), which included 134 patients without delirium (67%) and 66 with delirium (33%). Among patients with delirium, there were 21% with delirium only, 24% with delirium and dementia, 20% with delirium and depression, and 35% with all three conditions. Motor subtypes of delirium were categorized as hypoactive in 58% of the patients, hyperactive in 33%, and mixed in 9%. In relation to the entire study sample, the prevalence of delirium only was 7%, delirium and dementia was 8%, delirium and depression was 7%, and delirium, dementia, and depression was 12% (for additional details, see the Venn diagram in Figure S1 in the online supplement ).
| Variable | No delirium (N=134) | Delirium only (N=14) | Delirium and dementia (N=16) | Delirium and depression (N=13) | Delirium, dementia, and depression (N=23) | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Demographic and clinical characteristics | ||||||||||
| | Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD |
| Age (years) | 73.0 | 9.0 | 83.1b,c | 9.2 | 85.4b,c | 7.7 | 76.6 | 8.3 | 82.8b | 6.2 |
| Length of stay (days)d | 8.9 | 7.7 | 10.9 | 6.0 | 10.1 | 7.6 | 12.5 | 14.3 | 12.6b | 6.5 |
| CCI-SF score | 1.6 | 1.3 | 1.6 | 1.4 | 3.6b,c,e | 1.6 | 2.3 | 1.4 | 3.8b,c,e | 1.7 |
| | N | % | N | % | N | % | N | % | N | % |
| Female | 69 | 52 | 8 | 57 | 13 | 81b | 8 | 62 | 14 | 61 |
| >1 active medical diagnosis | 78 | 58 | 12 | 86b | 9 | 56 | 8 | 62 | 22 | 96b,c,f |
| Most common diagnoses | | | | | | | | | | |
| Systemic infection | 51 | 38 | 4 | 29 | 6 | 38 | 6 | 46 | 12 | 52 |
| Organ insufficiency or failure | 33 | 25 | 4 | 29 | 5 | 31 | 4 | 31 | 9 | 39 |
| Metabolic or endocrine | 13 | 10 | 2 | 14 | 0 | 0 | 0 | 0 | 2 | 9 |
| Systemic neoplasm | 10 | 8 | 1 | 7 | 2 | 13 | 1 | 8 | 0 | 0 |
| Cerebrovascular | 9 | 7 | 2 | 14 | 0 | 0 | 0 | 0 | 0 | 0 |
| Deathg | 3 | 2 | 1 | 7 | 2 | 13 | 0 | 0 | 1 | 4 |
| Delirium severity and characteristics | ||||||||||
| | Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD |
| DDT-Pro total score | – | – | 5.1 | 1.1 | 3.3e | 2.2 | 4.2 | 1.9 | 3.7 | 2.0 |
| Comprehension | – | – | 2.1 | 0.5 | 1.1e | 1.0 | 1.6 | 1.0 | 1.5 | 0.9 |
| Vigilance | – | – | 1.2 | 1.2 | 0.6 | 1.0 | 1.2 | 1.3 | 0.7 | 1.1 |
| Sleep-wake cycle | – | – | 1.8 | 0.8 | 1.6 | 1.1 | 1.2 | 0.8 | 1.6 | 0.9 |
| | N | % | N | % | N | % | N | % | N | % |
| Delirium motor subtype (per DRS-R98 score) | | | | | | | | | | |
| Hyperactive | – | – | 4 | 29 | 4 | 25 | 4 | 31 | 10 | 44 |
| Hypoactive | – | – | 8 | 57 | 10 | 63 | 9 | 69 | 11 | 48 |
| Mixed | – | – | 2 | 14 | 2 | 13 | 0 | 0 | 2 | 9 |
| Dementia severity and characteristicsh | ||||||||||
| | Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD |
| IQCODE score | 93.1 | 10.0 | – | – | 108.4b | 14.2 | – | – | 108.0b | 14.3 |
| | N | % | N | % | N | % | N | % | N | % |
| Dementia type (per Hachinski Ischemic Scale score) | | | | | | | | | | |
| Degenerative | 12 | 67 | – | – | 11 | 69 | – | – | 11 | 48 |
| Vascular | 5 | 28 | – | – | 4 | 25 | – | – | 5 | 22 |
| Mixed | 1 | 6 | – | – | 1 | 6 | – | – | 7 | 30 |
| Depression severity and characteristicsi | ||||||||||
| | Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD |
| CSDD total score | 15.3 | 4.6 | – | – | – | – | 18.8j | 7.0 | 13.6 | 5.4 |
| Mood-related signs | 4.1 | 1.5 | – | – | – | – | 4.6 | 2.2 | 3.7 | 1.7 |
| Behavioral disturbances | 2.2 | 1.5 | – | – | – | – | 3.2 | 2.2 | 2.8 | 1.2 |
| Physical signs | 3.3 | 2.1 | – | – | – | – | 4.2j | 1.5 | 2.5 | 1.8 |
| Circadian mood and sleep | 3.7j | 2.0 | – | – | – | – | 4.5j | 2.3 | 2.2 | 2.0 |
| Thought content alterations | 2.0 | 1.3 | – | – | – | – | 2.2 | 2.1 | 2.6 | 1.9 |
a
Statistical comparisons were made by using Kruskal-Wallis one-way analysis of variance with post hoc pairwise comparisons, Mann-Whitney U test, and pairwise chi-square or Fisher’s exact test, as appropriate. Statistical significance was set at p<0.05; boldfaced values indicate a significant difference from another group. CCI-SF=Charlson Comorbidity Inventory–short form, with higher scores indicating a greater medical burden and worse prognosis; CSDD=Cornell Scale for Depression in Dementia, with higher scores indicating increased symptom severity; DDT-Pro=Delirium Diagnostic Tool–Provisional, with lower scores indicating increased symptom severity; DRS-R98=Delirium Rating Scale–Revised-98, with scores indicative of motor subtype; IQCODE=Informant Questionnaire on Cognitive Decline in the Elderly, with higher scores indicating increased symptom severity.
b
Significant difference from the no-delirium group.
c
Significant difference from the delirium and depression group.
d
Days are from hospital admission to medical discharge. Length of stay measure is based on 183 patients (after excluding those who died and the censured observations due to discharge for administrative or nonmedical reasons).
e
Significant difference from the delirium-only group.
f
Significant difference from the delirium and dementia group.
g
Death during admission value is based on 190 patients (after excluding censured patients due to discharge for administrative or nonmedical reasons).
h
The number of patients with dementia in the no-delirium group was 18.
i
The number of patients with depression in the no-delirium group was 37.
j
Significant difference from the delirium, dementia, and depression group.
The study sample, regardless of delirium status, included 73 patients with depression (37%) and 57 with dementia (29%). Among patients with dementia, the dementia type was degenerative for 60% of patients, vascular for 25%, and mixed for 16%. A dementia diagnosis was less common among patients without delirium (N=18, 13%) than among those with delirium (N=39, 59%) (χ2=45.2, df=1, p<0.001). Similarly, a depression diagnosis was less common among patients without delirium (N=37, 28%) than among those with delirium (N=36, 55%) (χ2=13.8, df=1, p<0.001).
The study sample comprised Colombians from Antioquia (the capital is Medellín) who are predominantly Hispanic/Latino mixed with Black or Indigenous ethnic-racial ancestry. Other demographic and clinical characteristics of the study sample are summarized in Table 1. Patients with delirium were older, except for patients with delirium and depression who were more similar in age to those without delirium. Female sex predominated among patients with delirium and dementia compared with those without delirium.
There were no differences among groups regarding main active medical diagnoses. The most common medical diagnoses were systemic infection (40%) and organ insufficiency or failure (28%). However, patients with delirium only and those with all three conditions were more likely to have multiple active medical diagnoses than patients in the other groups. Patients with dementia (including those with delirium or all three conditions) had higher scores on the CCI-SF, an indicator of premorbid medical burden, than those without delirium, whereas patients with delirium only or delirium and depression had scores similar to those without delirium.
Regarding dementia type, most patients with delirium and dementia (69%) and nearly half of those with all three conditions (48%) had degenerative dementia. The next most common dementia type was vascular dementia among 25% of patients with delirium and dementia, and mixed dementia among 30% of patients with all three conditions. The pattern of dementia types among patients without delirium was similar to that among patients with delirium and dementia. Dementia severity, assessed with the IQCODE, was similar among patients with delirium and dementia with and without depression and was higher than that among patients without delirium.
Depression was less severe among patients with all three conditions than among patients with delirium and depression. In addition, patients with all three conditions were reported to have fewer physical signs of depression and less disruption in circadian mood and sleep patterns than patients with delirium and depression.
Delirium severity, as assessed with the DDT-Pro, among patients with delirium only (mean±SD=5.1±1.1) was less severe than that among those with delirium and dementia (mean=3.3±2.2) (higher scores indicate lower severity) but not different from that among those with delirium and depression (mean=4.2±1.9) and among those with all three conditions (mean=3.7±2.0). DDT-Pro item mean scores differed only for comprehension, which was worse for those with delirium and dementia than for those with delirium only. Delirium motor subtype prevalence did not differ among the groups of patients with delirium, where the hypoactive subtype predominated in every group, followed by the hyperactive and mixed subtypes.
The box plots in Figure 1 show medians and distributions of severity scores on the IQCODE (dementia status), CSDD (depression status), and DDT-Pro (delirium status) for the relevant groups. The findings with these median values paralleled those with the mean scores reported in Table 1. Dementia was worse in both groups with comorbid delirium than in the group without delirium. Depression was worse in the group of patients with delirium and depression than in the group of patients with all three conditions. Delirium was worse when comorbid with dementia compared with delirium only and delirium comorbid with depression.
FIGURE 1. Distribution of severity scores among elderly internal medicine patients in different diagnostic categories (N=200)a
aA: Scores on the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), an indicator of dementia, among patients with dementia but not delirium (N=18), patients with delirium and dementia (N=16), and patients with delirium, dementia, and depression (N=23). B: Scores on the Cornell Scale for Depression in Dementia (CSDD), an indicator of depression, among patients with depression but not delirium (N=37), patients with delirium and depression (N=13), and patients with delirium, dementia, and depression (N=23). C: Scores on the Delirium Diagnostic Tool–Provisional (DDT-Pro), an indicator of delirium, among patients with delirium only (N=14), patients with delirium and dementia (N=16), patients with delirium and depression (N=13), and patients with delirium, dementia, and depression (N=23). Higher scores on the IQCODE and CSDD indicate increased symptom severity, and lower scores on the DDT-Pro indicate increased symptom severity. Solid lines within the boxes represent medians; boxes indicate the middle 50% of the score distribution; and each tail represents a 25th percentile. The two open circles and the asterisk indicate outliers.
Finally, there were no differences in length of hospital stay among groups, except that the patient group with all three conditions had a longer length of stay than the group with no delirium. The mortality rate for the entire study sample during hospitalization was low (4%), with 7 deaths from 190 noncensured observations at follow-up, and this rate did not differ among groups.
Discussion
This is the first prospective study, to our knowledge, characterizing the clinical characteristics of patients with delirium only and those with delirium comorbid with depression, dementia, or both compared with a control group of patients without delirium. Dementia is a well-described comorbid condition and risk factor for delirium among elderly patients, but depression has been studied less frequently. The three Ds—delirium, dementia, and depression—are common among older persons but difficult to differentially diagnose even when using DSM criteria, because delirium symptoms overshadow the other conditions. Furthermore, delirium impairs a patient’s ability to describe preexisting conditions. Therefore, we applied several brief and validated tools that are easily completed with family members and caregivers, and we assessed for symptoms of dementia and depression that preexisted the delirium episode to evaluate the impact of these comorbid conditions during the patient’s hospitalization. Previous work suggested that postdischarge functional status is affected by these comorbid conditions. Our findings have practical implications for clinicians.
In our study, the most common delirium group was the group including patients with delirium, dementia, and depression (12%). A previous study of geriatric patients undergoing hip fracture reported 7% of patients with all three conditions; in that study, the largest subgroup included those with cognitive impairment and delirium (18% of patients), delirium only was reported in 11%, and delirium and depression in 6% (5). Our sample included geriatric inpatients with a diverse array of baseline medical conditions. Although patients in the no-delirium control group were generally younger than those in the delirium groups, they were similar to patients in the delirium groups regarding other variables, such as the number of active medical conditions and mortality rate. The exception was when dementia was comorbid with delirium, because patients in this group carried a greater medical burden at baseline. Additionally, patients without delirium were less frequently affected by depression and dementia than those with delirium. Our patients with delirium and dementia also had more severe dementia per IQCODE scores than those with dementia without delirium. As in the general population, the most common dementia type was degenerative. Patients with delirium, dementia, and depression had a longer length of hospital stay than patients without delirium. CCI-SF scores were the highest among patients in the delirium with dementia groups, suggesting that medical burden was driving the duration of hospitalization. Mortality during hospital admission was low and did not differ among groups, although it is known that large samples are needed to find statistical differences in mortality rates. The mortality rate was numerically but not statistically higher in the delirium-dementia group than the other groups. No patient in the delirium-depression group died.
DDT-Pro mean scores revealed less severe symptoms among patients with uncomplicated delirium and more severe symptoms among patients with delirium comorbid with dementia, who had the lowest scores for all three core domain symptoms. Dementia lowers the threshold for delirium and has some overlapping cognitive symptoms; however, studies show that when comorbid, the delirium symptoms overshadow dementia (17). In a rare study of delirium that included an assessment of noncognitive symptoms of dementia, Neuropsychiatric Inventory scores did not differ among delirium, dementia, and delirium-dementia groups (18).
Although the relationship between delirium and dementia has been commonly studied, it is rare that depression is considered in delirium research. It is well known that dementia is a risk factor for delirium among elderly patients, whereas the influence of depression is less appreciated. Previous studies showed that depression increased risk of delirium in medicine, postsurgery, and skilled nursing units (19–23). Our delirium-depression group had the highest severity of depression, with a mean±SD score (18.8±7.0) well above the CSDD threshold score for probable depression. This suggests that a serious episode of depression may be a risk factor for delirium.
Although both depression and delirium can alter affect, sleep, motor behavior, and concentration, which results in a challenging differential diagnosis, the particular characteristics of these symptoms are different, and when these conditions are comorbid, the depressive symptoms are overshadowed by delirium symptoms. The core nature of depression and delirium is different, with mood disturbance being a core feature of depression but cognitive and higher-order thought disturbances being a core feature of delirium.
The differential diagnosis of depression and dementia among patients with delirium requires a third party to report recent symptoms prior to the onset of delirium. By using the CSDD, we found a notable incidence of depression where no other clinical variable assessed in the context of delirium would have identified the presence of preexisting depressive symptoms. Higher prehospitalization medical burden (CCI-SF score) was associated with depressive symptoms when delirium was comorbid with dementia (i.e., the groups with delirium and dementia with or without depression). Whether depression causally increases delirium risk through effects on neural substrates or whether the medical burden causally influences both depression and delirium cannot be disentangled. However, screening elderly patients for depression at admission could identify patients at increased risk for delirium.
Previous work found a more negative long-term impact of dementia or delirium than depression on functional levels following discharge from the hospital. In that study, the functional recovery was slow with parallel trajectories of improvements for all three diagnoses over 6 months (7).
The main limitation of this study is that our sample size of 200 was small for the group comparisons; therefore, our findings are exploratory because we could not apply certain statistical analyses that would allow controlling for confounding variables, such as medical morbidity. Although the number of main active medical diagnoses did not differ, we found that CCI-SF scores were worse in the two delirium groups with comorbid dementia. Another limitation is that delirium measures could be affected by multiple research raters. However, all raters in our study were psychiatrists or psychiatry residents trained to administer the DDT-Pro, which was designed for use by non–doctoral-level clinicians, and the scores have very high reliability (0.9) and are highly correlated with DRS-R98 scores (0.7) (15).
Clinicians need to consider the three Ds when assessing elderly inpatients. Simple, brief tools can help detect underlying, preexisting depression and dementia through an interview with a family member or caregiver, because the patient with delirium cannot reliably respond. Using the DDT-Pro to assess delirium is easy in clinical situations, but this tool has a smaller score range than a more comprehensive tool, such as the DRS-R98. Furthermore, the DDT-Pro measures all three core domains of delirium and provides a severity score, unlike the CAM, which has been used in most previous comorbidity studies.
Conclusion
In summary, the most common delirium group was the group including patients with delirium, dementia, and depression, suggesting that these comorbid conditions are worthy of clinical attention after the delirium episode resolves. Depression is a meaningful risk factor for delirium among elderly patients and deserves greater consideration in both clinical and research settings. Unlike dementia, depression is treatable and represents a modifiable risk factor for delirium. Although future studies will require much larger sample sizes for certain analyses, if our results are combined with longer-term outcome studies that find increased likelihood of poor outcomes for elderly patients whose delirium is comorbid with depression or dementia or both (5), then proactively screening for depression on hospitalization could alter that outcome trajectory if an intervention for depression is prescribed.
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Received: 16 February 2023
Revision received: 11 May 2023
Accepted: 31 May 2023
Published online: 5 September 2023
Published in print: Winter 2024
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Competing Interests
Drs. Trzepacz and Franco hold the copyright for the Delirium Diagnostic Tool–Provisional, and Dr. Trzepacz holds the copyright for the Delirium Rating Scale–Revised-98. They do not charge a fee for not-for-profit or governmental use of these instruments. The other authors report no financial relationships with commercial interests.
Funding Information
This work was supported by the Centro de Investigación para El Desarrollo y la Innovación (CIDI) from the Universidad Pontificia Bolivariana, Medellín, Colombia.
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