Prevalence, clinical features and outcome of Camq-defined delirium among medical admissions to the Medical Emergency Ward of Mulago Hospital

Abstract

BACKGROUND: Delirium is a complex neuro-psychiatric syndrome with an acute onset and fluctuating course, which is a medical emergency associated with increased morbidity and mortality. Despite its common occurance, delirium has not been well studied in Ugandan settings. OBJECTIVES: The study aimed to determine the prevalence, clinical features and out come of CAMQ defined delirium among medical admissions to the Medical Emergency Ward of Mulago Hospital. METHODS: The design was a cross sectional descriptive study with an analytical and a prospective component. The setting was the Medical Emergency ward, and medical wards of Mulago Hospital, which is a national referral and a university teaching hospital. The patients comprised of consecutive samples of 316 medical admissions (aged ≥ 18 years) to the Medical Emergency ward of Mulago Hospital. Various measurements were done; on admission, respondents were assessed using the Confusion Assessment Method Questionnaire (CAMQ) to diagnose delirium, and the Delirium Rating Scale (DRS) to rate the severity of delirium. The DRS rated delirium severity on hospital days 1 to 7. Delirium outcome measures included total days of delirium, discharges, ran away, observed survival / mortality and transfer profiles of the delirious respondents. RESULTS: Of the 316 patients, 206 (65%) had CAMQ-defined delirium on admission. Full-syndromal delirium constituted 50% of the delirium respondents while 15% had sub-syndromal delirium. Most of their baseline sociodemographic variables, were similar between those with and without delirium (P≥ 0.05 for all), with exception of sex (p=0.002), source of referral from private clinics (p=0.047) and pre admission diagnoses like HIV (P=0.002), diabetes mellitus (p=0.038), hypertension (p=0.0012). There were significant differences between the delirium and delirium respondents on the findings of fever (p=0.002), confused behavior (p=0.002), body swelling (0.019) and loss of consciousness (p=0.001). Significant differences were noted for pre-admission medications including anti-TB drugs (p=0.048), anti-retroviral drugs (p=0.034) and the last time the drugs were used; 1-day (p=0.048), 3-days (p=0.016). There were also significant differences in observed behavioral change, (p=0.020), previous history of behavioral change (p ≤ 0.001), family history of psychiatric illness (p=0.048) and daily alcohol use or ex alcoholics (p=0.027 for each). There were no significant differences in most physical symptoms and diagnoses except for respiratory rate (p=0.005), raised JVP (P=0.004), stiff neck (p=0.001) and the diagnosis of Cryptococcal meningitis (p=0.019). On admission, the majority of delirium respondents belonged to the worst DRS score range (≥21-32) but this had improved by the fifth day. Death occurred among 44(21%) of the delirium respondents with 95% of the deaths occurring within the first 5 days and 80% occurring among those of ≤ 60 years. Overall, the first day probability of survival for delirium respondents was 95% but cumulatively declined to 74% by the sixth day of admission. CONCLUSIONS: There was a high prevalence rate (65%) of delirium among medical admissions to the Medical Emergency Ward of Mulago hospital. Delirium mainly affected young patients and these significantly differed from their non-delirium counterparts in many clinical features including symptoms of fever, confusion, alterations in consciousness, pre-admission medications, and diagnoses of TB, HIV and Cryptococcal meningitis. There was a high mortality rate of 21% among delirium patients even at the short duration or follow up of five days. Delirium should routinely be actively looked for and diagnosed among medical admissions and should always be managed as a medical emergency.