Aging Medicine and Healthcare 2019;10(4):122-127. doi:10.33879/AMH.2019.122-1811.033 Aging Medicine and Healthcare https://www.agingmedhealthc.com Original Article Cognitive and Functional Outcomes in Elderly Patients with Post-Stroke Delirium *Efraim Aizen1,2, Igor Yalonnitsky3, Eduard Zalyesov1, Inna Shugaev1 1Fliman Geriatric Rehabilitation Hospital, Haifa, Israel 2Bruce Rappaport Faculty of Medicine, Technion- Institute of Technology, Haifa, Israel 3Department of Geriatrics, Carmel Medical Center, Haifa, Israel ABSTRACT Background/Purpose: Delirium is common after stroke in elderly patients and may be associated with short and long-term changes in cognitive function. We aimed to assess disease trajectories and functional outcome in post stroke delirium. Methods: A prospective study of elderly patients admitted to geriatric rehabilitation after an acute stroke. Patients with delirium were identified with the use of the Confusion Assessment Method (CAM) criteria for delirium. Patients with delirium were assessed daily during hospitalization using the Delirium Rating Scale (DRS-R-98) and the MOTYB test. Functional outcome was assessed in all stroke patients by FIM scores at admission and on discharge and by FIM change and efficiency. Results: The majority of the 30 participants in whom delirium developed after a stroke continue to be delirious during the hospitalization. Twenty days after admission 19 patients (66.3%) were still delirious. Cognitive performance had *Correspondence a steady improvement until discharge. FIM scores on admission and discharge Dr. Efraim Aizen were significantly lower in stroke patients with delirium. Being a post-stroke Fliman Geriatric delirium patient was independently associated with lower FIM at admission Rehabilitation Hospital, (38.4±9.7 vs. 50.7±18.1; P <0.01), lower FIM at discharge (45.8±14.0 vs. Haifa, Israel 72.5±23.8; P <0.001), lower FIM change (7.5±3.0 vs. 22.9±17.6; P <0.001), and E-mail: lower FIM Efficiency (0.42±0.16 vs. 0.95±0.1; P <0.01). [email protected] The majority of post-stroke delirium patients were still Received 22 November 2018 Conclusion: delirious during the first month of rehabilitation and there was an ongoing Accepted 8 May 2019 improvement in delirium severity until discharge. Post-stroke delirium adversely affects rehabilitation outcome of stroke patients and is associated Keywords with substantial loss of functional independence. Cognitive outcome, delirium, elderly, functional outcome, 2663-8851/Copyright © 2019, Asian Association for Frailty and Sarcopenia and Taiwan storke. Association for Integrated Care. Published by Full Universe Integrated Marketing Limited. 1. INTRODUCTION a high mortality, longer in-patient stay, and higher complication rate, increased risk of institutionalization Delirium is one of the most common complications and increased risk of dementia.1,2 Stroke is a known that elderly patients develop when they are admitted risk factor for the development of delirium.3,4 The to hospital.1 Patients who develop delirium have incidence of delirium in stroke patients varied from 122 Aging Medicine and Healthcare2019;10(4):122-127. doi:10.33879/AMH.2019.122-1811.033 13% to 48%5 compared to 10% to 25% in patients for inclusion. Patients were excluded if they refused admitted to general internal medicine wards.6 participation, or were severely aphasic; comatose; or were considered too unwell for interview by staff. There have been only a small number of studies that have assessed post-stroke delirium. Usual 2.2. Assessments predisposing conditions are advanced age, an underlying urinary or respiratory infection, and Stroke type (ICH and CI) and location15 was defined preexisting cognitive impairment.4,7 In addition to based on clinical data and on acute computed the usual precipitating factors, the onset of post- tomography/magnetic resonance (CT/MR). If CT/MR stroke delirium is likely to be dependent on several failed to show an acute lesion location was derived factors unique to this clinical setting: the area of brain from clinical data and grouped as: i). brainstem/ affected by the stroke, extent of the stroke, type of cerebellum, hemispherical or both (cortical stroke are stroke, extent of cerebral hypo perfusion and cerebral those affected cortical regions of the cerebral cortex, edema post-stroke, in addition to the development and subcortical strokes affected structures below the of medical complications post-stroke. Specific stroke cortex, including the internal capsule, thalamus, basal types, such as left-sided stroke,8 hemispherical strokes ganglia, brainstem and cerebellum); and ii). left or and intra cerebral hemorrhages,9 cardio embolic right hemispherical or both. Patients were examined stroke and anterior circulation infarction10 may be whenever possible until the second hospitalization more likely to precipitate delirium. In addition, day. The study involved three stages of assessment: delirium may be associated with specific lesions, for Confusion Assessment Method (CAM);16 the Delirium example, in the thalamus and caudate nucleus.11 In Rating Scale (DRS-R-98)17 and formal inattention using essence, large strokes may be more likely to cause MOTYB test (months of the years backwards).18 delirium, but they also are more likely to cause medical complications, which by themselves could CAM is the most widely used screening, which has cause delirium. been validated in several languages and settings.19 We used two kinds of delirium assessment tools that To the best of our knowledge, there is no evidence involved two stages of assessment: Patients who had in the literature about outcomes in acute stroke subjective or objective reports of confusion were patients presenting with delirium. Post-stroke delirium assessed using the sensitive, short form of the CAM, was found to be associated with increased length and deemed either CAM-positive or CAM-negative. of stay, increased in-patient mortality, increased risk We than rated the presence and the severity of the of institutionalization, increased need for geriatric symptoms of delirium according to the DRS-R-98.17 rehabilitation, increased dependence on discharge Patients were diagnosed as having delirium if they and at 6 months, lower MMSE at 6 months and at 12 were CAM-positive and scored ≥10 on DRS-R-98.13 months, and higher 6 and 12 month mortality rate.10-14 Scoring items 2, 3 and 4 of DRS require verbal Patients with post stroke delirium were found to die responses and an awaken patient. Patients with a 4.7-times more likely in the hospital and within 12 moderate or severe communication disturbance months after discharge.14 were excluded from the study. Moderate or severe communication disturbance was defined as a score This study therefore aimed to examine the ≥2 in the Neurological Institute Health Stroke Scale disease trajectories of post stroke delirium after (NIHSS)20 items: severe dysarthria or speech that a rehabilitation-care hospital admission and to cannot be understood and not fully alert patients, determine characteristics, length and factors defined as a GCS score between 5 and 9, scored associated with subsequent resolution of post stroke zero on these items, unless perceptual disturbance, delirium. We also aimed to compare these patient’s hallucinations or delusions were detected by clinical functional outcomes with those who suffered a stroke history or observation. We than rated the presence without developing delirium. and the severity of inattention by the MOTYB test. MOTYB is a simple attention test very useful in 2. METHODS delirium screening. MOTYB used alone is a most accurate screening test in older people.18 For the 2.1. Participants MOTYB, patients were requested to say the months of the year forward from January to December. They Data was prospectively collected over a 6-month were then asked to recite the months in reverse order period (between January 2016 and July 2016) at the from December back to January. Fliman Rehabilitation Geriatric Hospital (an 175-bed public geriatric facility affiliated with the Technion- Pre-existing cognitive decline was considered by University Medical School and located in Haifa, the following pre-stroke predisposing conditions for Israel). All patients over 65 years of age admitted delirium:12 previous medical diagnosis of dementia or consecutively to the five geriatric rehabilitation of mild cognitive impairment or a history of memory wards, with a diagnosis of acute stroke were eligible and another cognitive impairment with functional 123 Aging Medicine and Healthcare2019;10(4):122-127. doi:10.33879/AMH.2019.122-1811.033 impairment in daily living activities, confirmed by used to characterize the trajectory of delirium scores a proxy. Katz Index of independence in activities over time. We examined the rate of post stroke of daily living (ADL) was used to evaluate the pre- cognitive change over five intervals from baseline (post existing functional ability.21 We utilized the CDR to hospitalization cognitive function): post hospitalization describe the presumed cognitive impairment.22 The day 2, day 3 to 5, 6 to 10, 11 to 15, and 16 to 20 or CDR was obtained through semi structured interviews more. Estimated scores were used for all five intervals of patients and informants, done by well-trained (the estimated score is for the last day of the interval). geriatricians. The CDR utilizes clinical scoring rules In estimating DRS scores, we adjusted for all covariates where CDR 0=no dementia and CDR 0.5, 1, 2, or 3 found