DELIRIUM AND PRECIPITANTS AMONG ELDERLY MEDICAL PATIENTS IN A

NIGERIAN HOSPITAL.

Authors: Yaria JO1, Ogunjimi LO1,Adebiyi AO2, Olakehinde OO2, Makanjuola AI, Paddick

SM3, Ogunniyi A1

Departments of 1Medicine, 2Community Medicine, College of Medicine, University of

Ibadan. 3Northumbria Healthcare NHS Foundation Trust, North Shields, UK

Full Address of Corresponding author:

Prof. Adesola Ogunniyi

Department of Medicine

College of Medicine

University of Ibadan

University College Hospital

PMB 5116

Ibadan. Nigeria

E-mail: aogunniyi@comui.edu.ng

Name of sponsor: Nil

Delirium, Precipitants in Elderly Patients in Nigeria

ABSTRACT

Objective

There is paucity of publications on delirium in sub-Saharan Africa (SSA) leaving questions

about the burden of the disease in an environment with lower health care standards and

pervasive poverty. In this article, we report our findings on the prevalence, precipitants and

symptomatology of delirium in elderly patients admitted in a teaching hospital in South-west

Nigeria.

Method

This was a descriptive study involving a pre-planned sample of one hundred and fifty patients

aged 60 years and over, carried out on the medical wards of the University College Hospital,

Ibadan. Patients were assessed for cognitive impairment and delirium using the previously

validated IDEA cognitive screen, and the Confusion Assessment Method (CAM) respectively.

Diagnosis of delirium was made using DSM-IV criteria. Statistical analysis was used to

determine variables and clinical features associated with delirium. Delirium precipitants

identified were also reported.

Results

Using DSM-IV criteria, the frequencies of delirium was 21.3% (95% CI: 14.7–30.0%)

respectively. Patients with delirium were significantly older (p< 0.05). The frequencies of co-

morbid hypertension, and dementia were also higher among patients with delirium. Of those

with delirium, 59.4% had a neurological disease making it the most common precipitant while

all patients with delirium had altered sleep wake cycle, inattention, disorientation, and altered

consciousness.

Conclusion

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Delirium, Precipitants in Elderly Patients in Nigeria

This study showed that attention should be paid to the much-less studied delirium and its

precipitants because of its association with poorer clinical outcome.

INTRODUCTION

Delirium, a multifactorial neuropsychiatric disorder, is common among elderly hospitalized

patients in high-income countries (HICs)[1]. Reports show community prevalence of ≤2% and

hospital frequency as high as 24%[2] on admission, in addition to the 29 – 31% who develop

delirium during hospital admission[3]. Hospital incidence of delirium among the elderly as

high as 56% has also been reported, with figures even higher in intensive care

admissions[2].The presence of delirium during hospital admission has been associated with

poor patient outcome irrespective of the cause[2]. Prolonged hospitalization consequent upon

delirium is a known risk factor for venous embolism, pressure ulcers, and aspiration amongst

other complications[4]. Studies have also shown cognitive and functional decline months after

hospital discharge[4,5]. Delirium is also known to have a strong association with dementia as

delirium accelerates disease progression in dementia; dementia increases the likelihood of

developing delirium[2] with reported cases of dementia diagnosed following in-hospital

acquired delirium[6].

With regards to sub-Saharan Africa (SSA), the increased burden of communicable diseases,

and lower health care resources would suggest delirium to be a prevalent condition. However,

publications about delirium in SSA are very few[7]. In a systematic review of literature on

delirium in SSA from 1975 – 2013, Paddick et al observed that delirium was the main focus of

only one cross-sectional study while another study reported prevalence in the elderly but no

study reported delirium in critical or surgical care[7]. There are no studies in SSA that have

reported prevalence of delirium types – hypoactive, hyperactive, and mixed[2] – which might

3
Delirium, Precipitants in Elderly Patients in Nigeria

be of clinical importance as it is suggested that their mechanisms differ, hence their

prognosis[2].

Several questions therefore exist concerning delirium in SSA in particular and probably

developing countries as a whole. In this article, we report our findings on the epidemiology of

delirium with regards to frequency, risk factors and symptomatology in a teaching hospital in

South-west Nigeria.

METHODOLOGY

Study Site.

The study took place between August 2015 and February 2016. It was carried out on the

medical wards of the University College Hospital, Ibadan (UCH). The hospital is a tertiary

institution that receives referral from mostly South-Western Nigeria. The hospital founded in

1948 has roughly 850 bed spaces. One hundred and fifty patients, admitted consecutively on

the medical wards participated in the study.

Study Design.

This was a hospital-based longitudinal descriptive study that involved administration of an

interviewer based questionnaire to patients on medical admissions aged 60 years and over. The

five medical wards were designated as clusters and eligible patients were consecutively

selected from the wards using the admission records as a sampling frame. Recruited

participants were assessed for altered mental states, depressive illness using the Geriatric

Depression Scale (GDS) which had been used in many studies of the elderly in Nigeria[8–10],

cognitive impairment using the previously validated IDEA cognitive screen[11], and screened

with the Confusion Assessment Method (CAM) algorithm by a dedicated medical team trained

in using CAM (see Figure I below).

4
Delirium, Precipitants in Elderly Patients in Nigeria

All participants underwent a detailed assessment of demographics, admission details for

precipitants of delirium amongst other details, and variables that predispose to delirium

including: medications, co-morbid illnesses – sensory impairment, hearing problems, and

visual impairment. Serious illness was defined as the presence of two or more of pyrexia,

tachycardia, increased respiratory rate and hypotension[12]. Assessments were conducted by

trained raters (L.O or J.Y) with established expertise in administration of the various scales

used in the study. A repeat assessment for altered mental states, depressive illness, cognitive

impairment, and the CAM algorithm was carried out 72 or 120 hours after initial assessment

(whichever did not fall on a weekend). This was done to reduce the chances of missing patients

who were truly delirious as delirium is a fluctuating condition. Also, some patients might have

been unwell for assessment on admission. Study participation was discontinued on discharge,

demise or participant’s desire to exit the study. Ethical approval for the IDEA study was

obtained from the University of Ibadan/University College Hospital, Ibadan Health Research

Ethics Committee as well as from the Oyo State Ministry of Health, Ibadan.

Procedures

Confusion Assessment Method

The Confusion Assessment Method (CAM) is a screening instrument developed by Inouye et

al in 1990 that evaluates nine clinical features seen in delirium[13]. It is a widely used

instrument with a number of setting specific adaptations, translations and revalidations[14].

The scale is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R)

delirium criteria. The psychometric properties of the instrument is very good with sensitivity

of 100%; specificity of 95% and inter-observer reliability ranging between kappa of 0.81 and

1.0[13]. The scale has been validated as a diagnostic and screening tool in various populations

and hospital settings[14]. For the diagnosis of delirium, the patient must display just four

5
Delirium, Precipitants in Elderly Patients in Nigeria

features: i) an acute onset; ii) fluctuating course, iii) inattention with disorganized thinking, and

iv) altered consciousness[13]. The other five features – disorientation, memory impairment,

perceptual disturbance, abnormal psychomotor activity, and disturbance in sleep-wake cycle –

were not considered pivotal in diagnosing delirium.

DSM-IV

Delirium was also assessed post hoc by neurologists using DSM-IV consensus agreement.

Information necessary to make the decision was retrieved from case-notes, clinical evaluation

and other hospital documentations.

IDEA Cognitive Screen

Cognitive assessment was carried out using the Identification and Intervention of Dementia for

Elderly Africans(IDEA) cognitive screening tool16,17. The IDEA study cognitive screen which

was validated in two SSA countries has Cronbach’s alpha of 0.81, sensitivity of 100% and

specificity of 96.3%[11] for dementia or major cognitive impairment (dementia or delirium)

Cognitive impairment was defined as an IDEA cognitive screen score of 8 or below. The IDEA

cognitive screen took less than 10 minutes to administer and was not distressing or

inconvenient for recruited patients. Cognitive assessment was carried on the same day as

admission CAM assessment. The IDEA includes items on registration, orientation, verbal

fluency, abstract reasoning, delayed recall and praxis. A stick design task, originally developed

by Baiyewu et al, was used to assess constructional praxis as it has been shown to perform

better in older individuals with limited literacy18.

Statistical Analysis

Statistical analysis was carried out using STATA version 12. Demographic data and baseline

clinical characteristics of participants were reported as means (standard deviation) and

proportions were appropriate. Continuous variables were compared by the independent

6
Delirium, Precipitants in Elderly Patients in Nigeria

Student’s t-test. Categorical variables were compared with Pearson’s Chi squared test. Cohen’s

kappa was computed to check the reliability of delirium diagnosis by the DSM-IV and by

CAM.

RESULTS.

The ages of the patients ranged between 60 and 95 years with mean age of 73.2 (7.0) years.

They included 89 (59.3%) male and 61 (40.7%) female participants with 32 (21.3%) being

employed. Most of the participants were educated with just 45 (30.0%) having no formal

education and 101 (67.3%) were currently married. Thirty two (21.3%) patients were noticed

to have coexisting dementia.

The frequencies of delirium using DSM-IV criteria was 32 (21.3%, 95% CI: 14.7–30.0%) as

shown in Figure II. Using CAM, 77 (51.3%) had inattention, 47 (31.3%) demonstrated sudden

onset and fluctuating course, 76 (50.7%) manifested disorganized thinking and 76 (50.7%) had

altered consciousness. Using CAM, 40 (26.7%, 95% CI: 19.5–33.8) patients had delirium.

There was strong agreement between the DSM-IV and CAM with Cohen kappa of 0.83.

Patients’ demographic and clinical characteristics according to delirium status are shown in

Table 1. Mean ages of patients with delirium, 74.5 (7.8) years was similar to those without,

75.0 (7.2) years (t: -1.2, p: 0.007). The proportion of delirious patients with co-morbid

hypertension, 20 (62.5%), was significantly higher than those without delirium, 35 (29.7%),

(X2: 11.7, p<0.001). Also, 13 (40.6%) of the delirious patients were demented compared to 19

(16.1%) of those without delirium (X2: 9.0, p: 0.003). This was different for diabetes, with 5

(15.6%) delirious patients being diabetic compared to 22 (18.6%) non-delirious patients, (X2:

0.2, p: 0.693). The frequency of ‘serious illness,’ as defined earlier, was also higher among

patients with delirium, where 22 (68.7%) had serious illness as opposed to 20 (16.1%) of those

without delirium, (X2: 33.5, p<0.001).

7
Delirium, Precipitants in Elderly Patients in Nigeria

Of the 32 patients diagnosed with delirium, 21 (65.6%) had one, 10 (31.3 %) had two, and 1

(3.1%) had three identifiable precipitating factors. Nineteen (59.4%) were diagnosed with

neurological diseases – head injury, hypertensive encephalopathy, stroke and seizures, 16

(50.0%) had metabolic derangements – abnormal serum electrolyte values, chronic kidney

disease, metabolic acidosis and hyperglycaemia, and 8 (25.0%) had infection. See Table 2. Of

the patients with delirium, 11 (34.4%) were diagnosed with more than one precipitant as

opposed to 10 (7.5%) of the alert patients (X2: 38.9, p<0.001)

Table 3 shows the CAM item frequencies according to delirium status. The frequencies of all

items were higher among patients with delirium i.e., altered sleep wake cycle, psychomotor

disturbance, inattention, disorientation, and altered consciousness. There was also a significant

difference in GDS scores, as participants with delirium have a higher score when compared to

those alert, p<0.001.

DISCUSSION

Findings of this study show a delirium frequency that ranges between 21.3% and 26.7% among

the hospitalized elderly individuals depending on the criteria used (DSM-IV vs. CAM) and the

frequency could be as high as 33.8%. The frequency of delirium in this study was comparable

to findings noted in earlier African studies[7]. Previous hospital-based African studies, albeit

limited and retrospective in designs, had reported prevalence estimates that ranged from 15%

to 29.9%[7]. Adeyemi in a study carried out in our centre in 1996 reported a rate of 29.9%[18],

Ola et al in a more recent study carried out in another centre in Nigeria reported a prevalence

of 18.2%[19]. These findings however, were from psychiatric medical services. Winkler et

al[20] and Uwakwe[21] reported about delirium in a medical setting but their selection criteria

made it difficult to generalize their findings. Winkler et al studied only participants with

neurological and psychiatric diagnoses and altered state of consciousness was the outcome of

8
Delirium, Precipitants in Elderly Patients in Nigeria

interest rather than delirium. Uwakwe focused on the ability of non-psychiatrist to identify

mental disorders and reported the prevalence of delirium as 9.4%[21]. The lack of proper

research design and use of other detection criteria could be a valid explanation for the low

prevalence estimates reported in earlier studies. It is also important to note that prevalence of

delirium differs in different hospital environments with the intensive care setting having the

highest prevalence[3] and because of differences in the characteristics of patients studied,

admitting illness and services in different hospitals. This study focused on the elderly, a

peculiar age group that is likely to manifest confusional state with changes in body homeostasis

and also at increased risk of developing dementia[22].

The frequency noted in this study was however within the range of results found in the western

world. Siddiqi et al in a systematic literature review reported prevalence of delirium in medical

in-patients ranging from 10 to 31% at admission[23]. Siddiqi however limited results to studies

in which patients were recruited within a day of admission. This figure is likely to

underestimate the true prevalence rate as hospital admission itself is a risk for delirium. Ryan

et al reported a prevalence of 19.6% using DSM-IV criteria, 20.7% using Delirium Rating

Scale-Revised-98, and 17.6% using the CAM[24]. While these values seemed lower than

results seen in this study, it should be stated that prevalence of delirium varied across the

hospital in their study, and participants in their study were aged 17 – 100 years. Geriatric wards

had the highest while general surgery wards had the lowest at 53.3% and 7.2% respectively[24].

Prevalence in general medical wards of 22.0% was however similar to results in this study and

similar to high-risk surgical patients in their study, 24.4%. The lowest patient age in their study

was 17 years with median age of 69 years. Holden et al in a study carried out among elderly

general medical patients in a New Zealand hospital reported a prevalence of 23.4%[25], a

finding similar to the frequency obtained in this study.

9
Delirium, Precipitants in Elderly Patients in Nigeria

In this study, altered sleep wake cycle, inattention, disorientation, and altered consciousness

were the prominent features with all the delirious patients demonstrating these. While this fits

with the three core domains of delirium phenomenology – attention, circadian disturbance and

higher level thinking, one would be a little worried of a ceiling effect in the application of the

DSM-IV criteria. The use of neurologists however reduced the response and measurement bias

associated with self-administered and non-specialist administered questionnaires. Also, the fact

that the DSM-IV criteria was used to sub-classify these patients with practically all of them

having features from the CAM criteria and a Cohen’s kappa value of 0.83 further adds validity

to these findings. This result could be usefully clinically as the presence of these features

clinically should alert the clinician to the presence of disturbed cerebral functioning.

Aetiologies of delirium are often multi-factorial with complex interactions between different

risk factors – predisposing and precipitating factors[2]. Most predisposing factors are said to

be non-modifiable with cognitive impairment, advancing age, multiple comorbidities and male

sex implicated[2]. However, similar to findings seen by Ola et al[19], socio-demography

variables were not associated with frequency of delirium in this study. Dementia, illness

severity, and sensory impairment as predisposing factor in delirium is known with odd’s ratio

as high as 6.6, 3.9 and 1.9 respectively[26]. This is supported in this study with dementia,

severe illness and sensory impairment more prevalent among the delirious patients.

The causes of delirium noted in this study were similar to previously published results.

Interestingly, it was noted in our study that patients with more than one precipitant were more

likely to be delirious. This may be supported by the fact that delirium is multi-factorial and

results from multiple mechanisms that results in either neurotransmission, neuronal injury,

inflammation, or acute stress event[2]. However, the high rate of neurological causes most

likely reflects the admission pattern of the hospital where the study was carried out. It is

expected that infectious causes should be higher in SSA[7], even Ola et al in a study done in

10
Delirium, Precipitants in Elderly Patients in Nigeria

psychiatric clinic in Nigeria reported that most delirium was due to infections[19]. However,

infectious aetiology were not as prevalent as expected in this study. This may not be surprising

with recent attention drawn to the increase in non-communicable disease in SSA in particular

and low-middle income countries as a whole[27–29], supported with recent publication from

Akinyemi et al were non-communicable diseases far outweighed infectious causes in

accounting for medical admissions[30]. Other possible explanation is the over-zealous use of

antibiotics by healthcare practitioners and the populace[31], and a change in the illness

landscape with an increase in non-communicable disease in SSA.

Conclusion

Based on the DSM-IV criteria, the frequency of delirium in this study was 21.3% but 26.7%

using the CAM. Altered sleep wake cycle, disorientation, inattention and altered consciousness

present in all delirious patients. Co-morbid hypertension, dementia, and depression were

associated factors. It was observed that predisposing and precipitating factors were similar to

earlier documentations however neurological factors and not infectious was the most prevalent

in this study. Associated poorer outcome in the presence of delirium implies that attention is

drawn towards prevention and management of this entity especially in patients with co-morbid

neurological diseases.

Strengths and limitations

The use of more than one diagnostic scale also maximises the diagnostic efficiency. Also, the

use of a face-to-face interview with patients instead of hospital records improved the

authenticity of the result especially as specialists were used to examine and administer the

questionnaire.

The results of this study are not generalizable to all in-hospital admission as only medical

patients were recruited. We would like to point out that important causes of delirium like poly-

11
Delirium, Precipitants in Elderly Patients in Nigeria

pharmacy in the elderly and alcohol abuse were not encountered in this study. Paddick had

alluded to the importance of alcohol in her review of delirium8. Cases due to substance abuse

were more likely to see Mental Health Physicians in our setting. However, designing a study

on delirium that would be generalizable to a large population is very unlikely as the patient

characteristics and quality health care service have large effect on the frequency of delirium.

Conflict of Interest:

None

Description of authors’ roles

Paddick S. M and Ogunniyi A designed the study, supervised the data collection and writing

of the paper, Yaria JO collected the data and assisted with writing the article, Ogunjimi L

collected the data, Adebiyi AO was responsible for the statistical design of the study,

Olakehinde OO2, and Makanjuola AI assisted with the writing of the article.

Acknowledgements

We thank Shafau ET, Tiamiyu BA, Adeoye TR, Bakare AO who carried out the screening

interviews. Mrs. Bisi Olupitan, Messrs John Ipadeola, Babatunde Alabi and Tunde Oludele are

acknowledged for data entry. Mr. Victor Ogaji assisted with data analysis.

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Delirium, Precipitants in Elderly Patients in Nigeria

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[28] Naghavi M, Forouzanfar MH. Burden of non-communicable diseases in sub-Saharan
Africa in 1990 and 2010: Global Burden of Diseases, Injuries, and Risk Factors Study
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[29] Maiyaki M, Garbati M. The burden of non-communicable diseases in Nigeria; in the
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[30] Akinyemi RO, Izzeldin IMH, Dotchin C, Gray WK, Adeniji O, Seidi OA, et al.
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3156.2011.02895.x.

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Delirium, Precipitants in Elderly Patients in Nigeria

Tables and Figures

DAY 1: Demographic information including age, gender and educational level

collected. Also, contact details including mobile telephone numbers, address and
hospital file number.

DAY 1: Delirium risk factors: pyrexia, sensory impairment, hip fracture, cognitive
impairment on admission collected.

DAY 1: Screened with IDEA study six item screen on admission.

DAY 1: CAM assessment completed independently of IDEA

screening tool by health professional.

Participants found to be CAM positive examined to determine the

cause of the delirium wherever possible.

A clinical diagnosis based on available investigations and physical

examination recorded. A relative history to confirm diagnosis
sought wherever possible.

DSM-IV delirium diagnosis completed independently by physician

– all screen positive and 10% of screen negative individuals chosen
by drawing lots.

CAM positivity and DSM-IV diagnosis and likely aetiology recorded

in medical notes and brought to the attention of attending medical
teams where appropriate

DAY 1: Those remaining in hospital on day 3 re-screened with IDEA cognitive screen
and CAM.

Figure I: At a Glance Flowchart – Delirium Study Protocol

15
Delirium, Precipitants in Elderly Patients in Nigeria

Hospital Admissions during Study Period.

150 patients selected.

59 with altered 70 with 68 over 87 with

consciousness impaired short medical
cognition period aetiology

27 didn’t fulfil 38 didn’t fulfil 36 didn’t fulfil 55 did not

DSM-IV DSM-IV DSM-IV fulfil DSM-IV
criteria criteria criteria criteria

32 with Delirium (DSM-IV criteria)

Figure II: Selected Patients, prevalence of delirium at both assessments. DSM-IV, the

Diagnostic and Statistical Manual of Mental Disorders (DSM).

16
Delirium, Precipitants in Elderly Patients in Nigeria

Table 1: Socio-demographic and Clinical Characteristics of Recruited Patients.

Alert Delirium Statistic p

Age (Mean, SD) 72.8 (6.8) 74.5 (7.8) -1.2 0.219

Gender (N, %)

Male 69 (58.4) 20 (62.5) 0.2 0.681

Female 49 (41.5) 12 (37.5)

Hypertension (N, %) 35 (29.7) 20 (62.5) 11.7 0.001

Diabetes (N, %) 22 (18.6) 5 (15.6) 0.2 0.693

†Serious Illness (N, %) 20 (16.9) 22 (68.7) 33.5 <0.001

¶Dementia (N, %) 19 (16.1) 13 (40.6) 9.0 0.003

*Sensory Impairment (N, %) 11 (9.3) 3 (9.4) 0.993

*Fisher’s exact test used.

†Serious illness was defined as the presence of two or more of pyrexia, tachycardia, increased respiratory rate
and hypotension [12]
¶Dementia was defined as the presence of impaired cognition and daily functioning.

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Delirium, Precipitants in Elderly Patients in Nigeria

Table 2: Possible Aetiology of Delirium.

Frequency (N=32)† Proportion

Metabolic 16 50.0

Infective 9 28.1

Neurological 19 59.4

*Patients with more than one metabolic cause were counted once.
† Of the 32 patients diagnosed with delirium, 21 (65.6%) had one, 10 (31.3 %) had two, and 1 (3.1%) had three
identifiable precipitating factors.
*Of the 16 with metabolic aetiology, 3 (18.7%) had hyperglycaemia, 3 (18.7%) had chronic kidney disease, and
10 (62.5%) had electrolyte derangement.
Of the 9 with infective causes, 2 (22.2%) had pneumonia, while 7 (77.8%) had sepsis.
Of the 19 with neurological causes, 14 (73.7%) had stroke, 2 (10.5%) had hypertensive encephalopathy, 1
(5.3%) had head injury while 2 (10.5%) had seizures.

Table 3: Comparison of Clinical Features among Groups.

Alert Delirium Statistic p

Sleep Wake Cycle (N, %) 36 (30.5) 32 (100.0) 49.1 <0.001

Psychomotor Disturbance (N, %) 59 (50.0) 9 (28.1) 4.9 0.027

Emotional Disturbance (N, %) 51 (43.2) 30 (93.7) 25.9 <0.001

Inattention (N, %) 45 (38.1) 32 (100.0) 38.6 <0.001

Acute Onset (N, %) 24 (20.3) 23 (71.9) 31.1 <0.001

Disorientation 44 (37.3) 32 (100.0) 39.6 <0.001

Altered Consciousness 44 (37.3) 32 (100.0) 39.6 <0.001

Memory Impairment 40 (33.9) 31 (96.9) 40.0 <0.001

Geriatric Depression Score 5.8 (3.8) 10.9 (4.0) -6.7 <0.001

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