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Assessing Delirium in the Elderly

New Research Sheds Light on Delirium’s Impact on Health Care Cost and Patient Outcomes

Sharon K. Inouye, M.D., M.P.H.'s picture
Assessing Delirium in the Elderly
Assessing Delirium in the Elderly

I have devoted my research career to advancing the understanding of a serious condition called delirium and the impact it has on clinical outcomes. As a medical resident, I observed symptoms of confusion and disorientation in many of the seniors I cared for during my hospital rotations. These symptoms were generally shrugged off as just something that sometimes happens to older patients. Little, if anything was done to prevent or treat it despite its devastating effects.

Delirium is characterized by an acute confusion or change in mental status, and is a common occurrence among hospitalized older adults recovering from illness or surgical procedures. Undetected and untreated, delirium in older adults places a significant burden on our health care system with costs of more than $182 billion yearly.  But of even greater concern is the toll it takes on patients. Hospital delirium can cause functional decline leading to the need for nursing home care and in the worst cases, death. I realized early on in my career that the medical community was in dire need of approaches to detect, prevent, and treat delirium. In response, I developed an instrument for identifying delirium – the Confusion Assessment Method (CAM) – that is now the most widely used standard in the field.

Recently, I published a paper with fellow investigators that reported on the culmination of research from Harvard Medical School, Brown, and UMASS, which examined a new scoring system for the CAM that we call CAM-S. We developed and validated the new CAM-S system in two groups of patients, all aged 70 or older. The first group of 300 patients were scheduled for major surgery as part of the Successful Aging after Elective Surgery (SAGES) study. The second group of 919 adults were admitted for medical hospitalizations as part of the Project Recovery study.

Our team of investigators based the new scoring method on the original 4-item short form and 10-item long form versions of the CAM. Then, we examined the impact of the CAM-S scores on hospital and post-hospital clinical outcomes.

We found that length of hospital stay for patients increased with the degree of delirium severity—from seven days for no delirium symptoms to 13 days for severe delirium based on CAM-S short form scores. The CAM-S long form scores showed similar increases in length of stay from six days to 12 days between no symptom and severe symptom groups.

We also found that the mean hospital costs increased along with delirium severity. Measured by the CAM-S short form, costs rose from $5,100 for patients without delirium symptoms to $13,200 for those with severe symptoms. The CAM-S long form scores showed mean costs rising from $4,200 to $11,400 across delirium symptom groups ranging from no delirium to severe.

By allowing us to better measure delirium severity, this tool will help to advance the field. We believe that this measure holds great promise to improve understanding of the effects of delirium on clinical care, prognosis, pathophysiology, and response to treatment. Ultimately, we hope that this measure will help to prevent the effects of this devastating condition and improve quality of life for older adults.

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Director, Aging Brain Center

Sharon Inouye, M.D., M.P.H., is a geriatrician at HRC, senior scientist at the Institute for Aging Research, and director of its Aging Brain Center. She also holds the Milton and Shirley F. Levy Family Chair in Alzheimer's Disease at IFAR. Dr. Inouye received her medical degree from the University of California San Francisco and her master's in public health from Yale University. She completed a residency at the UCSF, an internal medicine fellowship at Stanford University School of Medicine, and a fellowship in geriatrics and clinical epidemiology at Yale. Her research focuses on the...

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