Hostname: page-component-8448b6f56d-sxzjt Total loading time: 0 Render date: 2024-04-24T02:46:49.865Z Has data issue: false hasContentIssue false
  • English
  • Français

Delirium in elderly patients: association with educational attainment

Published online by Cambridge University Press:  09 August 2016

Sónia Martins Open the ORCID record for Sónia Martins [Opens in a new window] ,
José Artur Paiva ,
Mário R. Simões Open the ORCID record for Mário R. Simões [Opens in a new window]  and
Lia Fernandes Open the ORCID record for Lia Fernandes [Opens in a new window]
Sónia Martins
Affiliation:
Center for Health Technology and Services Research/CINTESIS. Faculty of Medicine, University of Porto, Portugal
José Artur Paiva
Affiliation:
Intensive Care and Emergency Autonomous Management Unit, CHSJ. Faculty of Medicine, University of Porto, Portugal
Mário R. Simões
Affiliation:
PsyAssessmentLab. Cognitive and Behavioural Center for Research and Intervention/CINEICC. Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal
Lia Fernandes*
Affiliation:
Center for Health Technology and Services Research/CINTESIS. Faculty of Medicine, University of Porto. Clinic of Psychiatry and Mental Health, CHSJ, Porto, Portugal
*
Lia Fernandes, Faculty of Medicine, University of Porto, Al. Hernâni Monteiro, 4200-319 Porto, Portugal. Tel: +00 351 22 205 2525; Fax: +00 351 22 551 3623; E-mail: lfernandes@med.up.pt
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium.

Methods

The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment.

Results

The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12–0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62–0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20–9.33; p=0.020), after controlling for age and medication.

Conclusion

Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.

Keywords

agedcognitive reservedeliriumeducational status
Type
Original Articles
Information
Acta Neuropsychiatrica , Volume 29 , Issue 2 , April 2017 , pp. 95 - 101
Check for updates
Copyright
© Scandinavian College of Neuropsychopharmacology 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Inouye, SK, Westendorp, RG, Saczynski, JS. Delirium in elderly people. Lancet 2014;383:911–922.CrossRefGoogle ScholarPubMed
2. Siddiqi, N, House, AO, Holmes, JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006;35:350–364.CrossRefGoogle ScholarPubMed
3. Witlox, J, Eurelings, LS, De Jonghe, JF, Kalisvaart, KJ, Eikelenboom, P, Van Gool, WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010;304:443–451.CrossRefGoogle ScholarPubMed
4. Leentjens, AF, Rundell, J, Rummans, T et al. Delirium: an evidence-based medicine (EBM) monograph for psychosomatic medicine practice, commissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP). J Psychosom Res 2012;73:149–152.CrossRefGoogle Scholar
5. Inouye, SK, Charpentier, PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852–857.CrossRefGoogle ScholarPubMed
6. Jones, RN, Yang, FM, Zhang, Y, Kiely, DK, Marcantonio, ER, Inouye, SK. Does educational attainment contribute to risk for delirium? A potential role for cognitive reserve. J Gerontol A Biol Sci Med Sci 2006;61:1307–1311.CrossRefGoogle ScholarPubMed
7. Jones, RN, Manly, J, Glymour, MM, Rentz, DM, Jefferson, AL, Stern, Y. Conceptual and measurement challenges in research on cognitive reserve. J Int Neuropsychol Soc 2011;17:593–601.CrossRefGoogle ScholarPubMed
8. Katzman, R, Terry, R, Deteresa, R et al. Clinical, pathological, and neurochemical changes in dementia: a subgroup with preserved mental status and numerous neocortical plaques. Ann Neurol 1988;23:138–144.CrossRefGoogle ScholarPubMed
9. Stern, Y. What is cognitive reserve? Theory and research application of the reserve concept. J Int Neuropsychol Soc 2002;8:448–460.CrossRefGoogle ScholarPubMed
10. Stern, Y. The concept of cognitive reserve: a catalyst for research. J Clin Exp Neuropsychol 2003;25:589–593.CrossRefGoogle ScholarPubMed
11. Stern, Y. Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol 2012;11:1006–1012.CrossRefGoogle ScholarPubMed
12. Fratiglioni, L, Wang, HX. Brain reserve hypothesis in dementia. J Alzheimer’s Dis 2007;12:11–22.CrossRefGoogle ScholarPubMed
13. Dekhtyar, S, Wang, HX, Scott, K, Goodman, A, Koupil, I, Herlitz, A. A life-course study of cognitive reserve in dementia-from childhood to old age. Am J Geriatr Psychiatry 2015;23:885–896.CrossRefGoogle ScholarPubMed
14. Saczynski, JS, Inouye, SK, Kosar, C et al. Brain reserve capacity on symptom onset after brain injury: a formulation and review of evidence for threshold theory. Neuropsychology 1993;7:273–295.Google Scholar
15. Fay, TB, Yeates, KO, Taylor, HG et al. Cognitive reserve as a moderator of postconcussive symptoms in children with complicated and uncomplicated mild traumatic brain injury. J Int Neuropsychol Soc 2010;16:94–105.CrossRefGoogle ScholarPubMed
16. Bigler, ED, Stern, Y. Traumatic brain injury and reserve. Handb Clin Neurol 2015;128:691–710.CrossRefGoogle ScholarPubMed
17. Staff, RT, Murray, AD, Deary, IJ, Whalley, LJ. What provides cerebral reserve? Brain 2004;127:1191–1199.CrossRefGoogle ScholarPubMed
18. Stern, Y. Cognitive reserve. Neuropsychologia 2009;47:2015–2028.CrossRefGoogle ScholarPubMed
19. Valenzuela, MJ, Sachdev, P. Brain reserve and cognitive decline: a non-parametric systematic review. Psychol Med 2006;36:1065–1073.CrossRefGoogle ScholarPubMed
20. Valenzuela, MJ, Sachdev, P. Brain reserve and dementia: a systematic review. Psychol Med 2006;36:441–454.CrossRefGoogle ScholarPubMed
21. Valenzuela, MJ, Sachdev, P. Assessment of complex mental activity across the lifespan: development of the Lifetime of Experiences Questionnaire (LEQ). Psychol Med 2007;37:1015–1026.CrossRefGoogle ScholarPubMed
22. Schmand, B, Smit, JH, Geerlings, MI, Lindeboom, J. The effects of intelligence and education on the development of dementia. A test of the brain reserve hypothesis. Psychol Med 1997;27:1337–1344.CrossRefGoogle ScholarPubMed
23. Nelson, HE. National Adult Reading Test (NART): for the assessment of premorbid intelligence in patients with dementia: test manual. Windsor, UK: NFER-Nelson, 1982.Google Scholar
24. Mortimer, JA, Graves, AB. Education and other socioeconomic determinants of dementia and Alzheimer’s disease. Neurology 1993;43(Suppl. 4):S39–S40.Google Scholar
25. Meng, X, D’Arcy, C. Education and dementia in the context of the cognitive reserve hypothesis: a systematic review with meta-analyses and qualitative analyses. PLoS One 2012;7:e38268.CrossRefGoogle ScholarPubMed
26. Hugo, J, Ganguli, M. Dementia and cognitive impairment: epidemiology, diagnosis, and treatment. Clin Geriatr Med 2014;30:421–442.CrossRefGoogle ScholarPubMed
27. Pompei, P, Foreman, M, Rudberg, MA, Inouye, SK, Braund, V, Cassel, CK. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–815.CrossRefGoogle Scholar
28. Galanakis, P, Bickel, H, Gradinger, R, Von Gumppenberg, S, Förstl, H. Acute confusional state in the elderly following hip surgery: incidence, risk factors and complications. Int J Geriatr Psychiatry 2001;16:349–355.CrossRefGoogle ScholarPubMed
29. Yang, FM, Inouye, SK, Fearing, MA, Kiely, DK, Marcantonio, ER, Jones, RN. Participation in activity and risk for incident delirium. J Am Geriatr Soc 2008;56:1479–1484.CrossRefGoogle ScholarPubMed
30. Fisher, BW, Flowerdew, G. A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc 1995;43:175–178.CrossRefGoogle ScholarPubMed
31. Lerner, AJ, Hedera, P, Koss, E, Stuckey, J, Friedland, RP. Delirium in Alzheimer disease. Alzheimer Dis Assoc Disord 1997;11:16–20.CrossRefGoogle ScholarPubMed
32. Mccusker, J, Cole, M, Dendukuri, N, Belzile, É, Primeau, F. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 2001;165:575–583.Google ScholarPubMed
33. Leung, JM, Sands, LP, Mullen, EA, Wang, Y, Vaurio, L. Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients? J Gerontol A Biol Sci Med Sci 2005;60:1563–1568.CrossRefGoogle ScholarPubMed
34. Saczynski, JS, Inouye, SK, Kosar, CM. Cognitive and brain reserve and the risk of postoperative delirium in older patients: analysis of data from a prospective observational study. Lancet Psychiatry 2014;1:437–443.CrossRefGoogle ScholarPubMed
35. Teasdale, G, Jennett, B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81–84.CrossRefGoogle ScholarPubMed
36. Inouye, SK, Van Dyck, CH, Alessi, CA, Balkin, S, Siegal, AP, Horwitz, RI. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med 1990;113:941–948.CrossRefGoogle Scholar
37. Martins, S, Lourenço, C, Pinto-De-Sousa, J et al. Validation study of the European Portuguese version of the Confusion Assessment Method (CAM). Int Psychogeriatr 2015;27:777–784.CrossRefGoogle ScholarPubMed
38. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR, 4th edn. (Text Review). Washington, DC: APA, 2000.Google Scholar
39. Folstein, MF, Folstein, SE, Mchugh, PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.CrossRefGoogle Scholar
40. Wechsler, D. Wechsler Adult Intelligence Scale-III. San Antonio, TX: The Psychological Corporation, 1997.Google Scholar
41. Saxena, S, Lawley, D. Delirium in the elderly: a clinical review. Postgrad Med J 2009;85:405–413.CrossRefGoogle ScholarPubMed
42. National Institute for Health and Clinical Excellence. Delirium: diagnosis, prevention and management (Clinical guideline 103) NICE. 2010. Available at www.nice.org.uk/CG103 Accessed June 2015.Google Scholar
43. Elie, M, Cole, MG, Primeau, FJ, Bellavance, F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998;13:204–212.CrossRefGoogle ScholarPubMed
44. Noimark, D. Predicting the onset of delirium in the post-operative patient. Age Ageing 2009;38:368–373.CrossRefGoogle ScholarPubMed
45. Aldemir, M, Özen, S, Kara, IH, Sir, A, Baç, B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5:265.CrossRefGoogle ScholarPubMed
46. Takeuchi, T, Matsushima, E, Moriya, H, Shintani, M, Nakamura, S. Delirium in inpatients with respiratory diseases. Psychiatry Clin Neurosci 2005;59:253–258.CrossRefGoogle ScholarPubMed
47. Cavallazzi, R, Saad, M, Marik, PE. Delirium in the ICU: an overview. Ann Intensive Care 2012;2:49.CrossRefGoogle ScholarPubMed
48. Manly, JJ, Byrd, D, Touradji, P, Sanchez, D, Stern, Y. Literacy and cognitive change among ethnically diverse elders. Int J Psychol 2004;39:47–60.CrossRefGoogle Scholar
49. Katzman, R. Education and the prevalence of dementia and Alzheimer’s disease. Neurology 1993;43:13–20.CrossRefGoogle ScholarPubMed
50. Jones, RN, Fong, TG, Metzger, E et al. Aging, brain disease, and reserve: implications for delirium. Am J Geriatr Psychiatry 2010;18:117–127.CrossRefGoogle ScholarPubMed
51. Kolanowski, AM, Fick, DM, Clare, L, Therrien, B, Gill, DJ. An intervention for delirium superimposed on dementia based on cognitive reserve theory. Aging Ment Health 2010;14:232–242.CrossRefGoogle ScholarPubMed
52. Kolanowski, AM, Fick, DM, Litaker, MS, Clare, L, Leslie, D, Boustani, M. Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial. Trials 2011;12:119.CrossRefGoogle ScholarPubMed
53. Kramer, AF, Bherer, L, Colcombe, SJ, Dong, W, Greenough, WT. Environmental influences on cognitive and brain plasticity during aging. J Gerontol A Biol Sci Med Sci 2004;59:M940–M957.CrossRefGoogle ScholarPubMed