University of Southern Denmark

Serious Consequences of Malnutrition and Delirium in Frail Older Patients

Rosted, Elizabeth; Prokofieva, Tatiana; Sanders, Suzanne; Schultz, Martin

Published in:Journal of Nutrition in Gerontology and Geriatrics

DOI:10.1080/21551197.2018.1470055

Publication date:2018

Document version:Accepted manuscript

Citation for pulished version (APA):Rosted, E., Prokofieva, T., Sanders, S., & Schultz, M. (2018). Serious Consequences of Malnutrition andDelirium in Frail Older Patients. Journal of Nutrition in Gerontology and Geriatrics, 37(2), 105-116.https://doi.org/10.1080/21551197.2018.1470055

Go to publication entry in University of Southern Denmark's Research Portal

Terms of useThis work is brought to you by the University of Southern Denmark.Unless otherwise specified it has been shared according to the terms for self-archiving.If no other license is stated, these terms apply:

• You may download this work for personal use only. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying this open access versionIf you believe that this document breaches copyright please contact us providing details and we will investigate your claim.Please direct all enquiries to puresupport@bib.sdu.dk

Download date: 06. Aug. 2021

1

Serious consequences of malnutrition and delirium in frail older patients

Elizabeth Rosted1, Tatiana Prokofieva2, Suzanne Sanders2, Martin Schultz3

1 Department of Oncology and Palliative Care, Zealand University Hospital, Roskilde,

Denmark and Department of Regional Health Research Faculty of Health Sciences,

University of Southern Denmark, Odense, Denmark.

2 Medical Department, Copenhagen University Hospital, Hvidovre and Amager,

Copenhagen, Denmark.

3 Department of Internal Medicine and Geriatrics, Herlev, Denmark, University Hospital of

Copenhagen.

2

Introduction

Malnutrition is a well-known condition in geriatric patients and highly prevalent among

acutely sick older patients (1, 2). In Denmark, it is estimated that one third of patients

admitted to geriatric departments are malnourished (3) and that the number of deaths from

malnutrition has increased significantly from 1999 to 2007 (4). A recent meta-analysis

(2014) found an association between malnutrition and an increased risk of death among

older populations with a body mass index (BMI) below 23 kg/m2 (5).

Another common condition present in up to 50% of older hospitalized patients is delirium,

which often has a poor prognosis (6-8). Delirium can be trigged by infections, dehydration

or dementia (9-11), but not all causes of delirium are well understood. When reviewing the

literature it seems that a larger understanding of delirium and its causes is complicated by the

fact that many studies does not make distinctions between delirium and dementia (12). In a

systematic review, Clegg and Young (2011) found that drugs are a risk factor in the

development of delirium (13), especially narcotics and sedatives were found to be associated

with increased risk of delirium, but also anticholinergic drugs presented an independent risk

of delirium (13). Important factors in the development of delirium may therefore be changes

in multiple neurotransmitters, especially regarding the cholinergic and dopaminergic

systems, as they may cause cognitive impairment.

To our knowledge, malnutrition has been a neglected area, in studies of delirium. The brain

has a high nutritional requirement, therefore malnutrition might play an important role in the

development of cognitive dysfunction as well as delirium.

This study examines the connection between delirium and malnutrition in patients admitted

to a geriatric department and describes the possible effects on adverse outcomes defined here

as mortality, discharge to nursing home, readmission to hospital and prolonged length of stay

in hospital.

3

Methods

The study is a descriptive cohort study.

Population

Included were all patients at their first admittance to the Geriatric Department (GD) at the

University Hospital of Copenhagen, Amager during 2012. The hospital is situated in the

Capital of Denmark, and has a catchment-area population of 150,000. Most patients were

admitted directly from the Emergency Department, but they were also transferred from other

medical departments like Cardiology-, Pulmonary- or the General Internal Medical Unit.

Data collection

Data on the patient’s first admission to the GD in 2012 were included in the analysis,

subsequent admissions were excluded. The endpoints were adverse outcomes defined as

prolonged length of hospital stay, discharge to nursing home, readmission to hospital and

mortality.

At arrival to the GD patients were examined by a medical doctor consisting of a full physical

examination as well as a comprehensive medical history, including a detailed assessment of

cognitive impairment and depression. In addition a nurse and a physiotherapist performed

screenings for nutritional deficits and decreased physical function. On daily department

rounds the patients were assessed and treated by the multi-disciplinary geriatric team.

In this study malnutrition was characterized by BMI below 25 kg/m2 combined with loss of

appetite and weight during hospital stay, or a weight loss of more than 5 kg within three

months prior to the admission. This definition was chosen because in our experience BMI

often is overestimated, this due to degeneration of the intervertebral discs and subsequent

shortening of older patients in addition to the fact that the patient’s height in our study was

self-reported and thus based on a memory of the height as it once was.

4

Presence of delirium was based on a clinical assessment and characterized by the following

symptoms; appearing with a sudden start and proceeding with a fluctuating course, altered

attention, consciousness, orientation, memory, perception, and thoughts as well as altered

behavior. Patients were only registered as demented if they had already been diagnosed with

dementia by a Multidisciplinary Memory Clinic prior to admission. All other patients

presenting with cognitive symptoms were registered as cognitive impairment.

Data were extracted from the patient’s journal and the hospital’s administrative database by

a senior Geriatric doctor and entered in to a separate database after discharge. The data

included age, sex, number of medications, comorbidities, length of stay, destination of

discharge, readmission at one and three months, and mortality during hospital stay as well as

one and three months after discharge. As geriatric patients are characterized not only by a

single diagnosis but by multi-morbidity, the number of comorbidities requiring treatment as

well as the diagnoses were registered and included in analyses.

The study was conducted in accordance with the ethical standards set forth in the Helsinki

Declaration (1983), and according to Danish law. Approval from the Regional Ethical

Committee was not required due to the non-biomedical character of the study. The study was

approved and registered with the Danish Protection Agency under the Capital Region of

Denmark’s joint notification of health research.

Statistics

Patient characteristics are presented as means with standard deviation (SD) and as

proportions. Differences in patients with malnutrition and delirium versus those without

were assessed using chi-square test for categorical variables and the t-test for comparison of

means. With the independent variables of interest being malnutrition and delirium, the

dependent variables were days in hospital, readmissions, admission to nursing home and

death. Adjusted results were calculated using backward stepwise logistic regression

5

concerning the potential covariates being age, sex and comorbidities, symptoms of

dehydration, depression, dementia, pain, stroke, urinary tract infection, decreased physical

function and falls. Multivariate comparisons were made using logistic or linear regression. A

p value < 0.05 was considered significant. All statistical procedures were performed using

SPSS for Windows, version 14.0 (SPSS Inc., Chicago, IL, USA). Figures were made using

GraphPad Prism, version 6.01 (GraphPad Software, Inc.,La Jolla, CA , USA).

Results

During 2012, 644 patients were admitted to the Geriatric department, of these 612 (95%)

were registered in the database. The remaining 32 (5%) represent readmissions. The mean

age was 82 years (SD: ±8.8) and 408 patients (67%) were female.

Among the included patients 349 (57%) were diagnosed with malnutrition and 123 (20%)

with delirium; 90 (15%) suffered from both, overall patients had a mean of 12.2 (SD: ±3.4)

comorbidities. Twenty patients died during admission, of these nine suffered from both

malnutrition and delirium and eleven from malnutrition alone. In-hospital mortality for

patients suffering from delirium but not malnutrition was zero (p<0.001). Table 1

summarizes the patients’ characteristics.

Please insert Table 1 here.

It was observed that patients suffering from most of the comorbidities in our data had an

increased risk of both malnutrition and delirium, as seen in Figure 1 and 2.

Please insert Figure 1 and 2 here.

In addition a strong and significant correlation was found between suffering from both

malnutrition and delirium with a correlation coefficient of 0.416 (OR=2.422, 95%CI: 1.565-

3.748, p < 0.001).

6

Comparison of patients suffering from both “malnutrition and delirium” to patients suffering

from either one or none of those diagnoses, showed that patients without “malnutrition or

delirium” had a significantly shorter stay in hospital (13 vs 18 days), and fewer were

discharged to nursing homes (5.7% vs 12.1%, 17.8% and 37.8% for no condition, delirium

alone, malnutrition alone and both conditions present, respectively). This, showing that

patients suffering from both “malnutrition and delirium” had an almost four times higher risk

of institutionalization and patient with “malnutrition and no delirium” had an almost three-

fold risk compared to those without either. In addition, significantly more patients suffering

from both “malnutrition and delirium” died after discharge at one month (3.5% vs 13.6%

p<0.001) and at three months (10.4% vs 18.5% p=0.004). Compared to those suffering from

none of these conditions No differences were found concerning age and gender in relation to

malnutrition and delirium. Table 2 presents outcomes in relation to malnutrition and

delirium.

Please insert Table 2 here.

Table 3 summarizes the unadjusted and adjusted correlation between malnutrition, delirium

and endpoints. Patients suffering from only “malnutrition” and “malnutrition and delirium”

had a significantly higher risk of post discharge institutionalization in both unadjusted

(malnutrition OR=3.605; 95% CI: 1.893-6.864, “malnutrition and delirium” OR=10.135;

95% CI: 5.016-20.478), and adjusted analyses (malnutrition OR=2.023; 95% CI: 1.001-

4.090, “malnutrition and delirium” OR=3.647; 95% CI: 1.607-8.278).Futhermore,

significant interactions between post discharge institutionalization and dehydration,

dementia and pain were found (dehydration, OR=2.854, 95% CI: 1.629-5.001, p<0.001;

dementia, OR=3.571; 95% CI: 1.987-6.417, p<0.001; pain OR=1.779; 95% CI: 1.055-3.000,

p=0.031).

7

There were no significant differences in readmission at one month and no significant

interaction terms in the adjusted models. Risk of readmission at three months in the group of

patients suffering from both conditions was significant higher in both the unadjusted

(OR=1.808; 95% CI: 1.052-3.108) and adjusted models (OR 2.236; 95% CI 1.187-4.213).

The only significant interaction found in this model was pain (OR 1.434; 95% CI 1.001-

2.053) p=0.049.

Patients suffering from only “malnutrition” and “malnutrition and delirium” had a

significantly increased risk of death within one month after discharge in both the unadjusted

(malnutrition OR=3.390; 95% CI: 1.507-7.626, “malnutrition and delirium” OR=4.361; 95%

CI: 1.687-11.270) and adjusted models(malnutrition OR 4.233; 95% CI 1.719-10.421,

“malnutrition and delirium” OR=6.886; 95% CI 2.210-21.455). Significant interaction

found in this model was decreased physical function OR=0.284; 95% CI: 0.105-0.769,

p=0.013. Mortality after three months was significantly increased in patients suffering from

malnutrition alone in both the unadjusted (malnutrition OR=2.168; 95% CI: 2.183-3.662)

and adjusted models (OR=2.211; 95% CI: 1.236-3.957). Significant interaction was

dementia OR=2.153; 95% CI: 1.198-3.869, p=0.010.

Please insert Table 3 here.

Discussion

This study examines the connection between malnutrition and delirium and finds a high

proportion of both conditions 57% and 20% respectively in a population of older patients

admitted to a geriatric department. Geriatric patients are characterized by frailty (14) which

is also the case here with a mean age of 82 years and a major burden of disease with a mean

of 12 comorbidities.

8

Patients suffering from both malnutrition and delirium in our study are extraordinary

vulnerable as they suffered from 15 different comorbidities, which is 50% more compared to

patients without either condition. These patients also had a four times higher mortality at one

month and two times higher at three months, a seven times increased rate of discharge to

nursing home, and three more days in hospital compared to patients without these

conditions.

The prevalence of delirium in this cohort was 20%, which was expected when considering

the population of geriatric patients with a high degree of frailty, polypharmacy and multi-

morbidity. In previous studies, delirium is reported to be present in up to 50% of hospitalized

old patients (6-8). Our findings may therefore be perceived as a minimum. Delirium can be

difficult to recognize because of the fluctuation of symptoms, different forms, often lacking

of obvious symptoms and is therefore often underdiagnosed (15).

It was observed that a high percentage of patients with delirium also suffered from

malnutrition (73%), indicating that malnutrition contributes to the development of delirium

in older admitted patients. To the best of our knowledge, this has only been described in one

previous study where there was no follow up after discharge (16). Bourdel-Marchasson et al.

(2004) examined low dietary intake and delirium in geriatric patients and observed a high

prevalence of both malnutrition and delirium, 54% and 12% respectively and a three-fold

increase in discharge to nursing home. Malnutrition was defined as a dietary intake of less

than 1200 calories a day during hospital stay in this study (16). Despite a different and

pragmatic definition, the prevalence of malnutrition in our study, is comparable to Bourdel-

Marchasson et al. (2004). In addition to our findings of the increased risk of

institutionalization, it was found that the combination of malnutrition and delirium also was

associated with an increased risk of death.

9

In this study malnutrition was significantly associated with short-term mortality in both the

unadjusted and adjusted models, despite an increased presence of comorbidities in these

patients. Although it is not surprising to see a high proportion of old malnourished patients

dying following an acute admission, it is nonetheless thought-provoking that it is an easily

treatable condition that tends to be under-prioritized in our present efficient healthcare

system. At one month no confounders were found, at three months only dementia was

associated with death in the confounding analysis, which have been shown in earlier

research (17).

A pronounced increase in discharges to nursing homes in patients who suffered from both

malnutrition and delirium were observed. One reason could be the significantly higher

proportion of comorbidities such as cognitive impairment, dementia, depression and

infections in this group, but the increased risk remained significant in the adjusted models

when malnutrition was present. Bourdel-Marchasson (16) also found a higher rate of

malnourished and delirious patients being discharged to nursing home only to a lesser extent

(three fold vs seven fold).

Patients without presence of malnutrition or delirium had a significantly shorter stay in

hospital which could be expected, as they represent the group with the fewest comorbidities

in our data.

The results presented here indicate that malnutrition is an important and neglected part in the

development of delirium. This is supported by other studies investigating preventive

measures of delirium in geriatric patients, finding that dehydration is a known cause of

delirium, alongside several of the comorbidities listed in table 2 (8). It seems plausible that

nutrition also plays an important role in development of delirium, and the derived adverse

health events, although no previous substantial scientific evidence of this was found in the

literature.

10

To prevent the development of delirium in undernourished old patients during hospital

admission, it is important to consider that older patients can have a long fasting period of up

to 18 hours (18) and that some are unable to eat independently. Thus it is necessary to

routinely provide meals in the Emergency Department and in some cases feed

undernourished and delirious patients through a gastric feeding tube or even intravenously to

prevent complications and adverse health outcomes. In addition, an individual plan for

follow up during and after admission must be implemented and both doctors and nurses

should take malnutrition into account, not only when screening the patient at admittance, but

also as a routine part of daily treatment and follow-up.

Limitations:

This study has some limitations. It was a single center study with retrospective assessment of

data and long-term outcomes beyond three months of discharge were not explored, although

a long-term follow-up presumable would be confounded by the severity of the comorbidities

in these very frail patients. Delirium was diagnosed clinically and not using a validated

functional test why the prevalence probably was underreported, especially regarding the

hypoactive form of delirium. As comorbidity was recorded but not the severity of the

medical illness, we were not able to control for this in our analyses.

On the other hand, it may be considered a strength that the study was prospective and that

95% of all possible patients were included. Also all the comorbidities that needed treatment

during admittance were registered, which allows for a more complete picture of the patients

disease burden.

Conclusion

11

In older patients admitted to a geriatric department, delirium is correlated to malnutrition and

presence of both conditions predicts premature death, admission to nursing home and

prolonged hospital stay.

These findings emphasizes the need to routinely assess all older patients for both

malnutrition and delirium at admission to hospital, preferable as a standardized procedure in

the Emergency Department involving both doctors, nurses and therapists. Also, to prevent

the development of delirium in undernourished geriatric patients a close follow-up must take

place to ensure adequate nutrition to reduce the risk of adverse health outcomes.

Take away points

In geriatric patients delirium is correlated to malnutrition.

When geriatric patients suffer from both malnutrition and delirium they are at

increased risk of premature death, admission til nursing home and prolonged stay in

hospital.

Attention to nutritional status in geriatric patients should be made early in the clinical

pathway and follow-up on a daily basis must be implemented.

12

References

1. Tangvik RJ, Tell GS, Guttormsen AB et al. Nutritional risk profile in a university

hospital population. Clin Nutr. 2014; published online 12 August 2014. doi:

10.1016/j.clnu.2014.08.001. Sparre-Sørensen M, Kristensen GN. Malnutrition related

deaths. Clin Nutr ESPEN. 2016 Oct;15:63-68. doi: 10.1016/j.clnesp.2016.06.001. Epub

2016 Aug 8.

2. Vanderwee K, Clays E, Bocquaert I et al. Malnutrition and nutritional care practices in

hospital wards for older people. J Adv Nurs. 2011 Apr;67(4):736-46. doi:

10.1111/j.1365-2648.2010.05531.x.

3. Annual Report 2010 - Danish Geriatric Database, The Danish Clinical Registries

http://www.danskselskabforgeriatri.dk/skov/dok/%C3%85rsrapport%20geriatri%20201

0%20-%20FINAL.pdf

4. Sparre-Sørensen M, Kristensen. Malnutrition related deaths. GN.Clin Nutr ESPEN.

2016 Oct;15:63-68. doi: 10.1016/j.clnesp.2016.06.001.

5. Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause

mortality in older adults: a meta-analysis. Am J Clin Nutr. 2014 Apr;99(4):875-90. doi:

10.3945/ajcn.113.068122.

6. Fick DM, Steis MR, Waller JL, Inouye SK. Delirium superimposed on dementia is

associated with prolonged length of stay and poor outcomes in hospitalized older adults.

J Hosp Med. 2013 Sep;8(9):500-5. doi: 10.1002/jhm.2077.

7. Ryan DJ, O'Regan NA, Caoimh RÓ et al. Delirium in an adult acute hospital

population: predictors, prevalence and detection. BMJ Open. 2013 Jan 7;3(1). pii:

e001772. doi: 10.1136/bmjopen-2012-001772.

13

8. Khan BA1, Zawahiri M, Campbell NL, et al. Delirium in hospitalized patients:

implications of current evidence on clinical practice and future avenues for research--a

systematic evidence review. J Hosp Med. 2012 Sep;7(7):580-9.

9. Flinn DR, Diehl KM, Seyfried LS, Malani PN. Prevention, diagnosis, and management

of postoperative delirium in older adults. J Am Coll Surg. 2009 Aug;209(2):261-8; quiz

294. doi: 10.1016/j.jamcollsurg.2009.03.008.

10. Tropea J, Slee J, Holmes AC, Gorelik A, Brand CA. Use of antipsychotic medications

for the management of delirium: an audit of current practice in the acute care setting. Int

Psychogeriatr. 2009 Feb;21(1):172-9. doi: 10.1017/S1041610208008028.

11. Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a

systematic review of frequency and prognosis. Age Ageing. 2009 Jan;38(1):19-26. doi:

10.1093/ageing/afn253.

12. Sanford AM, Flaherty JH. Do nutrients play a role in delirium? Curr Opin Clin Nutr

Metab Care. 2014 Jan;17(1):45-50. doi: 10.1097/MCO.0000000000000022.

13. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a

systematic review. Age Ageing. 2011 Jan;40(1):23-9. doi: 10.1093/ageing/afq140.

14. Rosted E, Schultz M, Dynesen H, Dahl M, Sørensen M, Sanders S. The Identification of

Seniors at Risk screening tool is useful for predicting acute readmissions. Dan Med J.

2014 May;61(5):A4828.

15. van Munster BC1, de Rooij SE. Delirium: a synthesis of current knowledge. Clin Med

(Lond). 2014 Apr;14(2):192-5. doi: 10.7861/clinmedicine.14-2-192.

16. Bourdel-Marchasson I, Vincent S, Germain C et al. Delirium symptoms and low dietary

intake in older inpatients are independent predictors of instituonalization: a 1-year

prospective population-based sudy. J Gerontol A Biol Sci Med Sci. 2004 Apr;59(4):350-

4.

14

17. Witlox J1, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA.

Delirium in elderly patients and the risk of postdischarge mortality, institutionalization,

and dementia: a meta-analysis. JAMA. 2010 Jul 28;304(4):443-51. doi:

10.1001/jama.2010.1013.

18. McDonald AJ. Fasting Periods in Older Patients Attending a South London Emergency

Department. Journal of Nutrition in Gerontology and Geriatrics. 2013 32(1):59-70. doi:

10.1080/21551197.2012.722890

15

Table 1. Patient characteristic, n=612

Age, mean (SD) 82 (8.79)

Gender, Female, n (%) 408 (66.7)

Medication at admittance, mean (SD) 8.5 (3.7)

Medication at discharge, mean (SD) 8.2 (3.3)

Length of hospital stay in total, mean (SD) 16.3 (10.66)

Length of stay in the Geriatric Unit, mean (SD) 11.7 (8.90)

Discharge to:

Independent living, n (%) 352 (57.5)

Rehabilitation, n (%) 91 (14.9)

Nursing home, n (%) 97 (15.8)

Died in hospital, n (%) 20 (3.3)

Other, n (%) 52 (8.5)

Comorbidity:

Impaired physical function, n (%) 570 (93.1)

Pain, n (%) 383 (62.6)

Malnutrition, n (%) 349 (57.0)

Anemia, n (%) 326 (53.3)

Cognitive impairment, n (%) 312 (51.0)

Fall, n (%) 301 (49.2)

Arterial hypertension, n (%) 301 (49.2)

Dehydration, n (%) 273 (44.6)

Constipation, n (%) 256 (41.8)

Depression, n (%) 244 (39.9)

Urinary tract infection, n (%) 233 (38.1)

Vitamin D deficiency, n (%) 229 (37.4)

Pneumonia, n (%) 182 (29.7)

Arterial fibrillation, n (%) 176 (28.8)

Stroke, n (%) 155 (25.3)

COPD, n (%) 129 (21.1)

Delirium, n (%) 123 (20.1)

Diabetes, n (%) 114 (18.6)

Heart failure, n (%) 106 (17.3)

Osteoporosis, n (%) 101 (16.5)

16

Cardiac ischemia, n (%) 94 (15.4)

Vitamin B12 deficiency, n (%) 86 (14.1)

Arthritis, n (%) 85 (13.9)

Dementia (diagnosed), n (%) 83 (13.6)

Sodium depletion, n (%) 81 (13.2)

Visual impairment, n (%) 76 (12.4)

Recent fracture, n (%) 72 (11.8)

Back disorder, n (%) 64 (10.5)

Myxedema, n (%) 55 (9.0)

Chronic alcohol abuse, n (%) 50 (8.2)

Ulcers, n (%) 45 (7.4)

Cancer, n (%) 42 (6.9)

Palliation, n (%) 42 (6.9)

Prostatic disease, n (%) 37 (6.0)

Infection with clostridium, n (%) 23 (3.8)

Mb. Parkinson, n (%) 15 (2.5)

17

Table 2. Differences in gender, age, number of medical problems and comorbidity relative to delirium and malnutrition

Non-delirium/ non- malnutrition

Delirium/ non-malnutrition

Non-delirium/ malnutrition

Delirium/ malnutrition

p

(n=230) (n=33) (n=259) (n=90)

Age, mean (SD) 81.2 81.2 81.8 83.8 0.113

Gender, female, n (%) 156 (67.8) 19 (57.6) 174 (67.2) 59 (65.6) 0.804

Days in hospital, mean (SD) 12.9 (7.6) 18.9 (12,6) 18.2 (12,0) 18.4 (10,3) <0.001

Discharge to nursing home, n (%) 13 (5.7) 4 (12.1) 46 (17.8) 34 (37.8) <0.001

Readmission, n=592 (n=230) (n=33) (n=248) (n=81)

1 month, n (%) n=591 53 (23.0) 7 (21.2) 62 (25.1) 18 (22.2) 0.843

3 months, n (%) n=545 88 (39.6) 14 (42.4) 102 (46.4) 38 (54.3) 0.026

Death, n=592 (n=230) (n=33) (n=248) (n=81)

1 month, n (%) 8 (3.5) 0 27 (10.9) 11 (13.6) <0.001

3 months, n (%) 24 (10.4) 2 (6.1) 50 (20.2) 15 (18.5) 0.004

Number of medical problems, mean (SD)

10.44 (3.18) 12.70 (3.18) 12.73 (2.97) 15.00 (3.07) <0.001

Comorbidity:

Cognitive impairment, n (%) 77 (33.5) 29 (87.9) 122 (47.1) 84 (93.3) <0.001

Palliation, n (%) 3 (1.3) 0 21 (8.1) 18 (20.0) <0.001

Dehydration, n (%) 41 (17.8) 9 (27.3) 149 (57.5) 74 (82.2) <0.001

Dementia (diagnosed), n (%) 20 (8.7) 3 (9.1) 30 (11.6) 30 (33.3) <0.001

Urinary tract infection, n (%) 70 (30.4) 17 (51.5) 95 (36.7) 51 (56.7) <0.001

Infection with clostridium, n (%)

2 (0.9) 2 (6.1) 11 (4.2) 8 (8.9) 0.002

Anemia, n (%) 105 (45.7) 17 (51.5) 148 (57.1) 56 (62.2) 0.002

Depression, n (%) 79 (34.3) 10 (30.3) 110 (42.5) 45 (50.0) 0.005

Arthritis, n (%) 43 (18.7) 4 (12.1) 27 (10.4) 11 (12.2) 0.026

Arterial hypertension, n (%) 121 (52.6) 24 (72.7) 118 (45.6) 38 (42.2) 0.029

18

Table 3. Risk of readmission and mortality within one and three in patients relative to malnutrition and delirium*

Non-malnutrition/ Delirium Malnutrition/Non-delirium Malnutrition/Delirium

OR (CI 95%) P OR (CI 95%) P OR (CI 95%) P

Unadjusted model

Discharged to nursing home

2.302 (0.703-7.536) 0.168 3.605 (1.893-6.864) <0.001 10.135 (5.016-20.478) <0.001

Readmission 1 month

0.899 (0.370-2.188) 0.815 1.137 (0.748-1.730) 0.548 0.954 (0.520-1.751) 0.880

Readmission 3 month

1.122 (0.535-2.354) 0.761 1.329 (0.912-1.938) 0.139 1.808 (1.052-3.108) 0.032

Death within 1 month

0.000 (0.000-) 0.998 3.390 (1.507-7.626) 0.003 4.361 (1.687-11.270) 0.002

Death within 3 month

0.554 (0.125-2.460) 0.437 2.168 (2.183-3.662) 0.004 1.951 (0.967-3.937) 0.062

Adjusted model

Discharged to nursing home

2.390 (0.694-8.236) 0.167 2.023 (1.001-4.090) 0.050 3.647 (1.607-8.278) 0.002

Readmission 1 month

0.974 (0.392-2.418) 0.955 1.382 (0.872-2.190) 0.168 1.473 (0.736-2.946) 0.274

Readmission 3 month

1.194 (0.557-2.561) 0.649 1.361 (0.899-2.060) 0.145 2.236 (1.187-4.213) 0.013

Death within 1 month

0.000 (0.000-) 0.998 4.233 (1.719-10.421) 0.002 6.886 (2.210-21.455) 0.001

Death within 3 month

0.610 (0.133-2.792) 0.524 2.211 (1.236-3.957) 0.008 1.873 (0.817-4.293) 0.138

*Non-delirium patients with no malnutrition were chosen as reference group with OR = 1. Confounders included in the adjusted model is age, gender, dehydration, depression, dementia, pain, stroke, urinary tract infection, impaired physical function and fall.

19