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Delirium numa enfermaria de medicina interna : impacto do seu reconhecimento para a prática clínica
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O delirium é frequente nos doentes idosos internados. Define-se pela alteração aguda e flutuante da cognição, atenção e consciência, geralmente reversível e de etiologia multifactorial. Apesar do seu marcado impacto socioeconómico e elevada morbimortalidade, permanece uma entidade sub-diagnosticada.
Este trabalho pretende caracterizar o impacto do delirium numa enfermaria de Medicina Interna antes e após a utilização de instrumentos para o seu diagnóstico. Prospectivamente, em 297 doentes, 26% apresentaram delirium, revelando um aumento do seu reconhecimento entre ambos os estudos (12% para 26%). Foi mais frequente à admissão (73%) e metade apresentou-se na forma hiperactiva, mas com maior identificação do delirium hipoactivo no trabalho prospectivo (2 para 41%). Na análise multivariada, a contenção física (p<0.0001) foi o factor independente comum para a ocorrência de todas as formas de delirium, excepto a hipoactiva. Globalmente, também apresentaram associação significativa com o delirium as alterações dos níveis de potássio (p=0.032) e o índice de Barthel (p<0.0001). Estes doentes necessitaram de mais avaliações médicas (Urgência Interna e Psiquiatria de Ligação, p<0.0001), maior contenção farmacológica (p<0.001), com mortalidade superior (Log Rank: Mantel-Cox p<0.0001), principalmente nas formas hipoactivas. O tempo de internamento foi maior, mas sem significado estatístico (p=0.055), tal como o destino de alta ou as readmissões. Metade dos doentes paliativos desenvolveram delirium, na maioria hipoactivo, contudo com elevada contenção física; e menor sobrevida (p<0.0001). Verificou-se também a associação entre o óbito e o delirium (p<0.001), considerado terminal em 8 casos.
Houve uma elevada aplicação e concordância entre as escalas, e apesar de 25% dos doentes não serem testáveis pelo CAM, este teve elevada especificidade.
Assim, o delirium é frequente, principalmente nos doentes idosos e em fim de vida, sendo necessário melhorar o seu reconhecimento e prevenção para melhorar o prognóstico e cuidados prestados aos doentes no internamento.
Delirium is common in hospitalized elderly patients and is defined by the acute and fluctuating, usually reversible, alteration of cognition level, attention and consciousness, with a multifactorial etiology. Despite the marked socioeconomic impact and high morbidity and mortality, it remains under-diagnosed. This study aims to characterize the impact of delirium in an Internal Medicine ward, before and after the use of specific instruments for its diagnosis. Prospectively, in 297 patients, delirium occurred in 26%, showing an increase in its recognition between both studies (12% to 26%). It was more frequent at admission (73%) and half presented a hyperactive form, but with a greater identification of hypoactive delirium (2 to 41%). In the multivariate analysis, physical restraint (p<0.0001) was the common independent factor for the occurrence of all forms of delirium, except hypoactive type. Overall, potassium levels (p=0.032) and Barthel's index (p<0.0001) were also significantly associated with delirium. These patients required more medical evaluations (Internal Urgency and Liaison Psychiatry, both p<0.0001), higher pharmacological restraint (p<0.001), and higher in-hospital and 3 months after discharge mortality (Log Rank: Mantel-Cox p<0.0001), mainly in the hypoactive forms. The admission length was higher, but without statistical significance (p=0.055), such as discharge destination or readmissions. Half of the palliative patients developed delirium, mostly hypoactive forms, but with higher physical restraint use; and had lower survival rates (p<0.0001). There was also an association between death and delirium (p<0.001), considered terminal in 8 cases, most of which occurred early during admission. There was good application and agreement between the scales, and, although 25% of patients were not testable by CAM, it had high specificity. Delirium is frequent, mostly in the elderly and end-of-life patients. Its recognition and prevention need to be improved for a better prognosis and care of the hospitalized patients.
Delirium is common in hospitalized elderly patients and is defined by the acute and fluctuating, usually reversible, alteration of cognition level, attention and consciousness, with a multifactorial etiology. Despite the marked socioeconomic impact and high morbidity and mortality, it remains under-diagnosed. This study aims to characterize the impact of delirium in an Internal Medicine ward, before and after the use of specific instruments for its diagnosis. Prospectively, in 297 patients, delirium occurred in 26%, showing an increase in its recognition between both studies (12% to 26%). It was more frequent at admission (73%) and half presented a hyperactive form, but with a greater identification of hypoactive delirium (2 to 41%). In the multivariate analysis, physical restraint (p<0.0001) was the common independent factor for the occurrence of all forms of delirium, except hypoactive type. Overall, potassium levels (p=0.032) and Barthel's index (p<0.0001) were also significantly associated with delirium. These patients required more medical evaluations (Internal Urgency and Liaison Psychiatry, both p<0.0001), higher pharmacological restraint (p<0.001), and higher in-hospital and 3 months after discharge mortality (Log Rank: Mantel-Cox p<0.0001), mainly in the hypoactive forms. The admission length was higher, but without statistical significance (p=0.055), such as discharge destination or readmissions. Half of the palliative patients developed delirium, mostly hypoactive forms, but with higher physical restraint use; and had lower survival rates (p<0.0001). There was also an association between death and delirium (p<0.001), considered terminal in 8 cases, most of which occurred early during admission. There was good application and agreement between the scales, and, although 25% of patients were not testable by CAM, it had high specificity. Delirium is frequent, mostly in the elderly and end-of-life patients. Its recognition and prevention need to be improved for a better prognosis and care of the hospitalized patients.
Descrição
Tese de mestrado, Cuidados Paliativos, Universidade de Lisboa, Faculdade de Medicina, 2019
Palavras-chave
Delirium Avaliação geriátrica Medicina interna Cuidados paliativos Contenção fisica Teses de mestrado - 2019