Hannah Roeder, MD, MPH
Delirium is defined by DSM-5 criteria as a change in functional status marked by disturbances in attention and awareness, which develop acutely, fluctuate, and are due to an underlying toxic or medical condition. Delirium frequently affects patients hospitalized with stroke. Its occurrence is associated with worse outcomes; however, there is no effective treatment. In the absence of effective treatment, can we still improve functional outcomes among stroke patients who develop delirium?
In the current study, Reznik and colleagues aim to define the extent of in-hospital delirium following intracerebral hemorrhage (ICH) and identify direct and indirect impacts on patient outcomes. In developing their hypotheses, they recognized that delirium may influence prognostication, intensity of care, and rehabilitation of neurocritical care patients. The authors explored several hypotheses, including that delirium portends worse outcomes, that delirium leads to lower likelihood of discharge to an inpatient rehabilitation facility (IRF), and that discharge disposition mediates poor outcomes. They also explored differences based on whether delirium resolves or persists at hospital discharge.
A retrospective cohort study using a single Comprehensive Stroke Center registry data included over 500 ICH patients with the majority developing in-hospital delirium. The primary outcome was modified Rankin Score at 3 months. When patients with withdrawal of life-sustaining treatment (WLST) or in-hospital death were excluded, about three-quarters of patients who developed delirium had resolution by discharge. As one may have anticipated, delirium, in particular persistent delirium, had a significant association with unfavorable outcomes. Patients with delirium were less likely to be discharged to an IRF, even if their delirium resolved by discharge. Discharge disposition mediated the relationship between delirium and poor outcomes.
As the authors acknowledge, the paper has some limitations. The single center may have institutional practices that are not generalizable, including unique rehabilitation resources and discharge practices. Also, in about three-quarters of patients, the presence and persistence of delirium was established retrospectively via chart review, and distinguishing cognitive deficits from ICH versus delirium based on notes may be unreliable. Other limitations include potential confounding related to other indicators for discharge disposition, underlying causes of delirium, and baseline functional status (although this information was available for a subset of patients in the study).
The paper has important takeaways for stroke and neurocritical care physicians. For many ICH patients, delirium may resolve by hospital discharge. We should always consider the potential reversibility of cognitive deficits when prognosticating. And for patients in whom delirium resolves, one should reassess their ability to participate in rehabilitation and whether discharge to an IRF is appropriate, as discharge disposition significantly affects functional outcomes.