Delirium is an independent predictor of adverse outcomes in older hospital patients.

The relationship between iron status and the restless legs syndrome (RLS) was examined in 18 elderly patients with RLS and in 18 matched control subjects. A rating scale with a maximum score of 10 was used to assess the severity of RLS symptoms. Serum ferritin levels were reduced in the RLS patients compared with control subjects (median 33 micrograms/l vs. 59 micrograms/l, p < 0.01, Wilcoxon signed rank test); serum iron, vitamin B12 and folate levels and haemoglobin levels did not differ between the two groups. Serum ferritin levels were inversely correlated with the severity of RLS symptoms (Spearman's rho -0.53, p < 0.05). Fifteen patients with RLS were treated with ferrous sulphate for 2 months. RLS severity score improved by a median value of 4 points in six patients with an initial ferritin < or = 18 micrograms/l, by 3 points in four patients with ferritin > 18 micrograms/l, < or = 45 micrograms/l and by 1 point in five patients with ferritin > 45 micrograms/l, < 100 micrograms/l. Iron deficiency, with or without anaemia, is an important contributor to the development of RLS in elderly patients, and iron supplements can produce a significant reduction in symptoms.

Objective: to examine the relative frequency and outcome of clinical subtypes of delirium in older hospital patients. Design: prospective observational study. Setting: acute geriatric unit in a teaching hospital. Subjects: 94 patients with delirium from a prospective study of 225 admissions. Measurements: clinical subtypes of delirium were determined according to predefined criteria. Characteristics examined in these subgroups included illness severity on admission, prior cognitive impairment, mortality, duration of hospital stay and hospital-acquired complications. Results: of the 94 patients, 20 (21%) had a hyperactive delirium, 27 (29%) had a hypoactive delirium, 40 (43%) had a mixed hypoactive-hyperactive psychomotor pattern and seven (7%) had no psychomotor disturbance. There were significant differences between the four groups in illness severity (P < 0.05), length of hospital stay (P < 0.005) and frequency of falls (P < 0.05). Patients with hypoactive delirium were sicker on admission, had the longest hospital stay and were most likely to develop pressure sores. Patients with hyperactive delirium were most likely to fall in hospital. There were no differences in aetiological factors between the groups. Conclusion: outcomes of hospitalization differ in different clinical subtypes of delirium.

Sixty patients (mean age 80 years) with cognitive impairment who required parenteral fluids for at least 48 h were randomized to receive either intravenous (i.v.) or subcutaneous (s.c.) fluids. There was no significant difference in the mean volume of fluid prescribed over 48 h in the two groups (s.c. 3.3 litres vs. i.v. 3.6 litres) or in the proportion of prescribed fluids actually administered (s.c. 0.82 vs. i.v. 0.76). After adjusting for baseline differences, there was no difference between serum urea or creatinine levels in the two groups at 48 h. Agitation related to the infusion was reported in 11 (37%) patients receiving s.c. fluids and 24 (80%) patients receiving i.v. fluids (p < 0.005). The cost of the cannulae used during the study was E6.80 for the s.c. group and E28.70 for the i.v. group. Local oedema was noted in 2 patients in the s.c. group and led to re-siting of the infusion in 1 patient. No other complication was noted. These results suggest that s.c. fluid therapy is the treatment of choice in nonurgent situations for confused patients who require parenteral fluids.

Delirium is a common and serious complication of acute illness in elderly patients. The aim of this study was to develop and validate a model for predicting development of delirium in elderly medical inpatients who did not have delirium on admission. Consecutive admissions to an acute geriatric unit underwent standardized cognitive assessment every 48 hours. Delirium was diagnosed according to DSM-3 criteria. Independent predictors of delirium in a derivation group of 100 patients were determined using stepwise logistic regression analysis; the predictive model comprised dementia, severe illness and elevated serum urea. This model performed well in a validation group of 84 patients. We conclude that elderly medical patients can be stratified according to their risk for developing delirium using a simple clinical model.