Skip Navigation


Age and Ageing Advance Access originally published online on July 28, 2007
Age and Ageing 2007 36(6):644-649; doi:10.1093/ageing/afm094
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
36/6/644    most recent
afm094v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Adamis, D.
Right arrow Articles by Martin, F. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Adamis, D.
Right arrow Articles by Martin, F. C.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Associations of delirium with in-hospital and in 6-months mortality in elderly medical inpatients

DImitrios Adamis1,2,3, Adrian Treloar2,3, Fai-Zaza Darwiche1, Norman Gregson4, Alastair J. D. Macdonald2 and Finbarr C. Martin1

1 Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
2 Institute of Psychiatry, King's College, London, UK
3 Department of Old Age Psychiatry, Oxleas NHS Trust, London, UK
4 Department of Clinical Neurosciences, King's College, London, UK

Address correspondence to: Dimitrios Adamis. Tel: 020 8836 8520; Fax: 020 8856 5359. Email: dimaadamis{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Key points
 Conflict of interest declaration
 References
 
Background: studies on the association between mortality and delirium in older hospital inpatients have produced conflicting results. This insconsistency might be explained by case-mix differences in terms of clinical or underlying patho-physiological processes. For example, both albumin and C-reactive protein (CRP) have been reported as predictors of in-hospital mortality and interleukin-6 of longer-term mortality.

Methods: we used data from a longitudinal study of delirium to investigate the delirium–mortality relationship. A cohort of 164 patients, 70+ years were assessed within 3 days of acute hospital admission and hence twice weekly until hospital discharge, for the presence and severity of delirium and a range of clinical and laboratory measures, including initial albumin (n = 149), CRP (n = 76) and cytokine (n = 60) levels. In-hospital and 6-months mortality were determined from clinical records and telephone contact.

Results: during hospitalisation 14 (8.5%) patients died, 6 with delirium: mortality was not associated with delirium. At 6 months, 119 of 150 (77.3%) discharged patients were still alive, 21 (14.0%) dead, and 13 (8.7%) uncontactable. In bivariate analysis, 6-months mortality was associated with older age (P = 0.013), lower albumin (P = 0.001), higher CRP (P = 0.014) and higher interleukin-6 levels (P = 0.007), but not with presence or severity of in-hospital delirium. After controlling for other variables significant predictors (P < 0.05) for six-month mortality were initial MMSE, albumin, interferon-{lambda} and interleukin-6.

Conclusions: the lack of demonstrable association between delirium and mortality may reflect inadequate statistical power in this study due to low numbers. These findings, however, highlight specific patho-physiological factors which may be important in the prognosis after delirium.

Keywords: delirium, elderly, cytokines, albumin, CRP, mortality, outcome, frailty


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Key points
 Conflict of interest declaration
 References
 
It is well recognised that delirium during acute illness of hospital inpatients is associated with a range of adverse outcomes [1, 2], even after statistically adjusting for predisposing factors such as disability and cognitive impairment and severity of illness [2]. But studies investigating the relationship of delirium to short- or long-term mortality have reported inconsistent results. Some have reported higher inpatient mortality [1, 3], others not [4]. Some have reported higher subsequent mortality risk after delirium with various periods of follow-up [5–7], but others not [4, 8].

A meta-analysis[9] of eight studies estimated a mortality rate of 14.2% for delirious patients at 1 month and 22.2% at 6 months and concluded that the presence of dementia or the severity of illness, or both, may have influenced this high rate. For example, Francis and Kapoor's study finding[8] of hospitalised delirious patients reported that mortality risk was largely explained by pre-existing cognitive and functional impairment. In contrast, one recent study reported a higher 12-month mortality rate among persons with delirium without pre-existing dementia[7]. Thus the contribution of delirium and dementia to mortality is complex and unclear. Perhaps inconsistent findings might be explained by case-mix differences in terms of clinical or underlying pathophysiological processes.

A systematic review of published studies of clinical outcomes of older hospitalised patients reported that physical function and cognition at the time of admission were the more consistent, though not, invariable predictors of death in hospital[10]. Low serum albumin and high C-reactive protein (CRP) levels soon after hospital admission have also been reported to be associated with in-hospital mortality[11]. In healthy, older people however, higher levels of the inflammatory cytokine interleukin 6 (IL-6) was more important than albumin in predicting 4-year mortality[12]. Admission CRP levels are also associated with subsequent development of delirium in hospitalised older patients,[13] while recovery from delirium present on admission of hospitalised older patients was associated with admission levels of interferon-{gamma} (IFN-{gamma}) and insulin-like growth factor-I (IGF-I) but not IL-6 or a range of other inflammatory cytokines. [14]

We have used data available from an observational study, designed to investigate clinical, functional and biological factors and outcomes in delirium, to explore further the relationship of in-hospital delirium to subsequent mortality, but have gone further than previous analyses by incorporating investigation of the possible impact of biological factors on this relationship.

For the initial analyses, we tested the following null hypotheses.

1. There will be no differences in the mortality rate during hospitalisation between those who had delirium (prevalent or incident) and those who had no delirium during hospitalisation.
2. There will be no differences in the mortality rate at 6 months between those who had delirium (prevalent or incident) and those who had no delirium during hospitalisation.

Then, for the subgroup of patients for whom additional data was available, we investigated the associations with mortality of putative biological factors related to inflammation and frailty along with clinical measurements of cognition, severity of illness and functional ability.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Key points
 Conflict of interest declaration
 References
 
The full methods of the study have been described in a previous paper[14] and are only briefly described here. The study sample consisted of patients aged 70 years and over in an elderly medical unit of an urban teaching hospital. They had a mixture of medical problems such as acute infection or cardiac failure which required acute hospitalisation. The only inclusion criterion for participation was that patients were admitted to the unit within 3 days of their acute admission to hospital. Thus patients transferred to the unit at a later subacute stage of illness were excluded. Other exclusions were as follows: patients included in the study on a previous admission; patients with known terminal illness; and patients in whom performance of the cognitive tests was precluded by severe aphasia, hearing or visual impairment.

From the 164 participants, blood samples were taken from those who agreed, and 60 of these samples were analysed for cytokines.

Clinical assessments
Each participant was assessed by an experienced clinician: (i) Mini Mental State Examination (MMSE). The score was standardised to give a maximum score of 30 if patients could not complete the sections e.g. due to visual impairment or disabled hands. (ii) The Confusion Assessment Method (CAM), to establish the presence or absence of delirium, (iii) The Delirium Rating Scale (DRS) to measure severity of delirium, (iv) The APACHE II and its subscale Acute Physiology Score APS to measure severity of illness. We omitted arterial pH of APS, to avoid arterial blood sampling of patients. (v) Barthel Index to assess functional dependency, and (vi) The Frailty Scale[15] to assess pre-admission frailty.

Each participant was assessed on entry (day 1 to 3 after hospital admission: first assessment) and then three times at subsequent 3-day intervals, and after 28 days from the first assessment if still in hospital. The Frailty scale was done only on first assessment and Barthel Index at the first and last. Clinical records also were examined for previous and ongoing clinical findings and investigation results including brain scans.

Biological factors
Levels of circulating IFN-{gamma}, interleukin-1 (IL-1) and its receptor, IL-6, Leukaemia Inhibitor Factor (LIF), Tumour Necrosis Factor {alpha} (TNF-{alpha}), IGF-I and CRP were estimated at the time of initial assessment. Serum albumin was noted from the clinical records.

Analyses
Data were analysed with SPSS v12. Each hypothesis was tested using appropriate bivariate statistics. For binary outcomes logistic regression was used with the elimination method being the backwards stepwise likelihood ratio.

Ethics
Participation was based on informed consent from those with capacity to give this, or on agreement from those without this capacity, as previously described[16]. The study, including the above basis for participation, was approved by the local research ethics committee.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Key points
 Conflict of interest declaration
 References
 
Demographic characteristics of the sample
One hundred and sixty-four subjects participated: 54 (32.9%) male, 110 (67.1%) female. Their mean age was 84.6 years (SD 6.57), range 70–104. The patients had a range of acute medical problems and a high prevalence of pre-admission disability. The case-mix was typical of a specialist acute/rehabilitation elderly care service in the UK National Health Service. The mean Barthel Index on first assessment was 14.13 (SD 4.64). The mean length of their hospital stay was 19.4 days, (SD 18.9), range 1–134.

Delirium
Delirium was present in 42 subjects (25.6%) at initial assessment, developed subsequently in 5 more (3%), and was never present in 117 (71.3%) subjects.

Delirium and mortality during hospitalisation
During hospitalisation 14 of the 164 subjects (8.5%) died. Four of them were from the prevalent delirium group, two from the incident delirium group and eight from the never delirium group. There was no significant association between delirium (incident or prevalent) and death ({chi}2 test, Pearson chi-square value = 1.509, P = 0.219). Therefore the null hypothesis is not rejected.

Delirium and mortality at 6 months in those surviving hospitalisation
Of the 150 who were discharged alive from hospital, 119 (77.3%) were still alive and 21 (14.0%) were dead. Thirteen of them (8.7%) could not be contacted at 6 months and were therefore excluded from this analysis.

From the delirium group (incident and prevalent), 6 died by 6 months, while 15 of the never delirium group had died. There was no significant association between either (i) delirium status during hospitalisation (incident or prevalent) (Pearson chi-square value = 0.009, DF = 1, P = 0.926) or (ii) delirium severity at first assessment (Table 1), and 6-months mortality. Therefore the null hypothesis is not rejected.


View this table:
[in this window]
[in a new window]

  		Table 1. Shows the Mann–Whitney test results between those who were alive and those who died after discharge from hospital (at 6 months) in terms of clinical and biological factors

 
Other associations with mortality

Mortality at 6 months
Gender was not associated with 6 months mortality. Comparisons of the initial values of MMSE, DRS, APACHE II, APS, Frailty scale, age, Barthel Index, cytokines, CRP and albumin in the two groups are shown in Table 1 (Mann–Whitney test, significance differences underlined in bold). This shows that subjects surviving hospitalisation who died within 6 months of hospital admission were older and had higher initial levels of circulating IL-6 and CRP, and lower levels of albumin compared with 6-month survivors. Results did not change when we pooled the data to include the in-hospital deaths.


Mortality and discharge destination
In addition, 6-month mortality was examined in relation to the discharge destination. Significantly more of those who were newly discharged to care homes died during the 6 months (5 out of 12) compared to those who were discharged to their previous address (16 out of 123) (Fisher's Exact Test, P = 0.022).


Predictive model of mortality
Finally, a predictive model, using logistic regression, of overall mortality (in-hospital and 6-months mortality) was conducted using the initial (at first assessment) values. As most of the variables measures were inter-correlated and there was multi-colinearity, some of them were not entered in the initial model. The variables which were examined as predictors of death were as follows: gender, age, Barthel index, MMSE, APS, albumin, IFN-{gamma}, IL-6, and the dichotomous variable delirium or not at any time (incident or prevalent). The final retained model was that presented in Table 2. Significant predictors associated with death were cognitive impairment (as measured with MMSE), low albumin, higher IFN-{gamma}, and IL-6 levels and the interaction of MMSE by gender (male). Once again with this more detailed analysis, delirium was not significantly associated with death. The above model predicts an overall 96.1% of cases (90% for those who died and 97.6% for the live cases), and the c statistics (area under the ROC curve) was 96.8%.


View this table:
[in this window]
[in a new window]

  		Table 2. Shows variables retained in the predictive model of overall mortality

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Key points
 Conflict of interest declaration
 References
 
This study did not find any association between prevalent or incident delirium, or between its severity and mortality during hospitalisation. As reviewed in the introduction there are inconsistent findings on the mortality in delirium during hospitalisation, so the results of this study find agreement with some previous studies, but not with others. There are several possible explanations for the discrepancies. Case-mix depends on local health service configurations. This type of selection bias may produce differences in the distribution of the multiple interacting factors with relevance to both delirium and mortality. These are difficult to identify and therefore to allow in analysis. Case-mix inclusion based on consent is also subject to selection bias depending upon the method and rigour of assessment of capacity[16]. Rates of delirium have a seasonal variation[17] and it is not impossible that mortality rates also vary by season, but there was no seasonal bias in our study.

However a major factor may also be that of insufficient power to detect differences in death rates during hospitalisation according to delirium. This study was not designed primarily to investigate death as an outcome, and it was underpowered to do so (26% at {alpha} = 0.05 level). Power (for {alpha} = 0.05 level) was only 32% in one of the largest reported studies[4]. Thus inconsistencies of results between studies may be due to chance.

Neither the presence nor the severity of delirium was associated with long-term mortality, and death at 6 months. Again previous findings vary. Bivariate statistics showed that those who died were older, had higher initial levels of CRP and IL-6, and lower levels of albumin compared to those who were alive at 6 months. It was not unexpected that age was shown to be a factor associated with death. However this did not persist when multivariate statistics were used. The main variables which predicted overall death were MMSE, albumin, IFN-{gamma}, IL-6 levels and the interaction of MMSE by gender (male). In this model CRP was not included because of its high correlation with IL-6 and albumin and inclusion of CRP produced an unstable model.

The relationship between cognitive impairment and mortality was also evident in our previous study[3]. Associations of low albumin levels with mortality were also found in other studies[11, 12]. Previous studies have demonstrated that elevated CRP levels together with higher IL-6 levels are associated with an adverse outcome (including death)[18]. CRP alone or together with IL-6 has been found as predictors of mortality in various study populations[19–21]. The Iowa study of relatively healthy people in the community showed that elevated IL-6 and CRP levels can predict mortality independent of age, sex, body mass index, diabetes, other diseases, as well as known indicators of inflammation for both a relatively short time (less than 2.3 years) but even after long time (more than 4 years). As CRP appears not to increase with age itself and to be under the control of IL-6, its elevation is perhaps secondary to the increase of IL-6. However, explanation of the association of elevated IL-6 with mortality independently of other risk factors and morbidity remains problematic. One example of the interconnection of CRP, IL-6 and albumin is a study[22], which showed increased levels of CRP and reduced levels of albumin in young and middle-aged rhesus monkeys administered low doses of IL-6 for a month.

The IL-6 has also been found as a risk factor for death in previous studies, even in a relatively healthy community sample of elderly people[12, 23]. A study l[12] also demonstrated that in the context of relatively higher IL-6 levels, high albumin levels had some protective effect. It has been suggested that hypoalbuminaemia is a marker of the severity of underlying physical illness[24]. In contrast, it is suggested that increased levels of IL-6 are related not to undiagnosed disease(s) but to ageing[25].

In this study, the inflammatory marker IFN-{gamma} was also a predictor of death. IFN-{gamma} has a dual effect[26]. We have previously found that IFN-{gamma} is associated with both the severity (unpublished data) and speed of recovery from delirium[14].

The original question remains. Why have some previous studies found an association between delirium and death? In the main, because they did not correct for these other factors which have potential pathophysiological significance, but also because of chance. Most of the studies did not have enough power to confidently detect a true difference. As for the studies that have reported no delirium-mortality association, some, like this study, did allow for relevant clinical, cognitive and functional factors. Others have not done so, but their case-mix may have included a different distribution of the predictive factors such as albumin, IL-6 or IFN-{gamma}, which this study suggests are more powerful mortality predictors than delirium itself. Secondary analysis of the data showed that nearly half of those who were newly discharged to care homes died during the 6 months follow-up. Similar results for higher mortality in those newly admitted to care homes have been reported in other studies (e.g.[27–29]). Suggested reasons for this have included those of social causation (that the institutionalisation is the direct cause of death) and of social selection (that the decline in health and proximity to death produce relocation and death)[27].

In summary the findings of this study on in-hospital and 6-months mortality show that mortality may not be directly associated with delirium but the sample size precludes drawing any definite conclusion about this. However, this study shows that other factors may play a role in mortality and although some of these are already known, they need to be taken into account when trying to understand the sequel of an episode of delirium during acute illness in hospital.


   Key points
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
Conflict of interest declaration
 References
 

  • The relationship between delirium and mortality of older hospital inpatients is unclear.
  • This prospective observational study shows that a 6-month mortality of medical inpatients is associated with Mini Mental State Examination (MMSE), albumin, Interferon-{gamma} (IFN-{gamma}), and IL-6 levels assessed early during hospital admission, after controlling of other factors.
  • Higher mortality is also associated with new admissions from hospital to care homes.
  • Further studies of delirium and mortality need to have adequate power, and also to further investigate and initially control the above biological factors.


   Conflict of interest declaration
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Conflict of interest declaration
References
 
The authors have reported no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Conflict of interest declaration
 References
 

  1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in patients: a systematic literature review. Age Ageing (2006) 35:350–64.[Abstract/Free Full Text]
  2. O'Keeffe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc (1997) 45:174–8.[Web of Science][Medline]
  3. Adamis D, Treloar A, Martin FC, Macdonald AJD. Recovery and outcome of delirium in elderly medical inpatients. Arch Gerontol Geriatr (2006) 43:289–98.[CrossRef][Web of Science][Medline]
  4. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med (1998) 13:234–42.[CrossRef][Web of Science][Medline]
  5. Rockwood K, Cosway S, Carver D, Jarrett P, Stadnyk K, Fisk J. The risk of dementia and death after delirium. Age Ageing (1999a) 28:551–6.[Abstract/Free Full Text]
  6. Curyto KJ, Johnson J, TenHave T, Mossey J, Knott K, Katz IR. Survival of hospitalized elderly patients with delirium: a prospective study. Am J Geriatr Psychiatry (2001) 9:141–7.[CrossRef][Web of Science][Medline]
  7. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med (2002) 162:457–63.[Abstract/Free Full Text]
  8. Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc (1992) 40:601–6.[Web of Science][Medline]
  9. Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ (1993) 149:41–6.[Abstract]
  10. Campbell SE, Seymour DG, Primrose WR, for the ACMEplus Project. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age Ageing (2004) 33:1–6.[Free Full Text]
  11. Iwata M, Kuzuya M, Kitagawa Y, Iguchi A. Prognostic value of serum albumin combined with serum C-reactive protein levels in older hospitalized patients: continuing importance of serum albumin. Aging Clin Exp Res (2006) 18:307–11.[Web of Science][Medline]
  12. Reuben DB, Ferrucci L, Wallace R, et al. The prognostic value of serum albumin in healthy older persons with low and high serum interleukin-6 (IL-6) levels. J Am Geriatr Soc (2000) 48:1404–7.[Web of Science][Medline]
  13. Macdonald A, Adamis D, Treloar A, Martin F. C-reactive protein levels predict the incidence of delirium and recovery from it. Age Ageing (2007) 36:222–5.[Free Full Text]
  14. Adamis D, Treloar A, Martin FC, Gregson N, Hamilton G, Macdonald AJD. APOE and cytokines as biological markers for recovery of prevalent delirium in elderly medical inpatients. Int J Geriatr Psychiatry (2007) 21:1–7.[Medline]
  15. Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet (1999) 353:205–6.[CrossRef][Web of Science][Medline]
  16. Adamis D, Martin FC, Treloar A, Macdonald AJD. Capacity, consent, and selection bias in a study of delirium. J Med Ethics (2005) 31:137–43.[Abstract/Free Full Text]
  17. Balan S, Leibovitz A, Freedman L, et al. Seasonal variation in the incidence of delirium among the patients of a geriatric hospital. Arch Gerontol Geriatr (2001) 33:287–93.[CrossRef][Web of Science][Medline]
  18. Silvestri A, Vitale C, Ferretti F, Onorati D, Fini M, Rosano GM. Plasma levels of inflammatory C-reactive protein and interleukin-6 predict outcome in elderly patients with stroke. J Am Geriatr Soc (2004) 52:1586–7.[CrossRef][Web of Science][Medline]
  19. Volpato S, Guralnik JM, Ferrucci L, et al. Cardiovascular disease, interleukin-6, and risk of mortality in older women: the women's health and aging study. Circulation (2001) 103:947–53.[Abstract/Free Full Text]
  20. Roubenoff R, Parise H, Payette HA, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study. Am J Med (2003) 115:429–35.[CrossRef][Web of Science][Medline]
  21. Evrin PE, Nilsson SE, Oberg T, Malmberg B. Serum C-reactive protein in elderly men and women: association with mortality, morbidity and various biochemical values. Scand J Clin Lab Invest (2005) 65:23–31.[CrossRef][Web of Science][Medline]
  22. Binkley NC, Sun WH, Checovich MM, Roecker EB, Kimmel DB, Ershler WB. Effects of recombinant human interleukin-6 administration on bone in rhesus monkeys. Lymphokine Cytokine Res (1994) 13:221–6.[Web of Science][Medline]
  23. Bruunsgaard H, Ladelund S, Pedersen AN, Schroll M, Jorgensen T, Pedersen BK. Predicting death from tumour necrosis factor-alpha and interleukin-6 in 80-year-old people. Clin Exp Immunol (2003) 132:24–31.[CrossRef][Web of Science][Medline]
  24. Lindesay J, Rockwood K, Macdonald A. Delirium in Old Age (2002) Oxford, New York: Oxford University Press.
  25. Godbout JP, Johnson RW. Interleukin-6 in the aging brain. J Neuroimmunol (2004) 147:141–4.[CrossRef][Web of Science][Medline]
  26. De Simone R, Levi G, Aloisi F. Interferon gamma gene expression in rat central nervous system glial cells. Cytokine (1998) 10:418–22.[CrossRef][Web of Science][Medline]
  27. Aneshensel CS, Pearlin LI, Levy-Storms L, Schuler RH. The transition from home to nursing home mortality among people with dementia. J Gerontol B Psychol Sci Soc Sci (2000) 55:S152–62.[Abstract/Free Full Text]
  28. van Dijk PT, van de Sande HJ, Dippel DW, Habbema JD. The nature of excess mortality in nursing home patients with dementia. J Gerontol (1992) 47:M28–34.[Web of Science][Medline]
  29. Shapiro E, Tate R. Survival patterns of nursing home admissions and their policy implications. Can J Public Health (1988) 79:268–74.[Web of Science][Medline]
Received 22 December 2006; accepted in revised form 21 May 2007.


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Age AgeingHome page
N. Collins, M. R. Blanchard, A. Tookman, and E. L. Sampson
Detection of delirium in the acute hospital
Age Ageing, November 16, 2009; (2009) afp201v1.
[Full Text] [PDF]

Home page
 Br. J. PsychiatryHome page
E. L. Sampson, M. R. Blanchard, L. Jones, A. Tookman, and M. King
Dementia in the acute hospital: prospective cohort study of prevalence and mortality
The British Journal of Psychiatry, July 1, 2009; 195(1): 61 - 66.
[Abstract] [Full Text] [PDF]

Home page
 PsychosomaticsHome page
M. Gonzalez, G. Martinez, J. Calderon, L. Villarroel, F. Yuri, C. Rojas, A. Jeria, G. Valdivia, P. P. Marin, and M. Carrasco
Impact of Delirium on Short-Term Mortality in Elderly Inpatients: A Prospective Cohort Study
Psychosomatics, May 1, 2009; 50(3): 234 - 238.
[Abstract] [Full Text] [PDF]

Home page
 Age AgeingHome page
G. Bellelli, S. Morghen, R. Turco, and M. Trabucchi
Delirium in older people: an epiphenomenon of incipient death or a separate biological process?
Age Ageing, May 1, 2008; 37(3): 353 - 354.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
36/6/644    most recent
afm094v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Adamis, D.
Right arrow Articles by Martin, F. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Adamis, D.
Right arrow Articles by Martin, F. C.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?