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Age and Ageing 2015; 44: 318–321 doi: 10.1093/ageing/afu152 Published electronically 4 December 2014 © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected] SHORT REPORTS Defining ‘recovery’ for delirium research: a systematic review DIMITRIOS ADAMIS1,2, AMANDA DEVANEY2, ELAINE SHANAHAN3, GERALDINE MCCARTHY2,4, DAVID MEAGHER5 1 Research and Academic Institute of Athens, Athens, Greece Department of Psychiatry, Sligo Mental Health Services, Sligo, Ireland 3 Department of Elderly Medicine, University Hospital Limerick, Limerick, Ireland 4 Sligo Medical Academy, National University of Ireland, Galway, Sligo, Ireland 5 Department of Psychiatry, Medical School, University of Limerick, Limerick, Ireland 2 Address correspondence to: D. Adamis. Tel: (+353) 719142111; Fax: (+353) 719144177. Email: [email protected] Abstract Background: delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests that delirium can be associated with incomplete recovery. Despite a growing body of research, a lack of clarity exists regarding definition and outcomes. Objective: to clarify the definition of recovery of delirium used in the literature. Methods: a Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function. Results: fifty-six studies met the inclusion criteria. Only two studies used clinical criteria alone for the diagnosis of delirium; most studies used at least one validated scale—either categorical or continuous severity scales. A variety of 16 different terms were used to define the ‘recovery of delirium’. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments, while others using dichotomous scales (yes/no) defined recovery as one or more days of negative delirium. Conclusion: an agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery, as well as between long- and short-term outcomes. It is proposed that cognitive recovery should be central to defining recovery in delirium. Keywords: delirium, outcome, recovery, remission, response, older people Introduction Delirium has been defined as a syndrome of acute onset, typically over hours or days, followed by a fluctuating course with impaired attention, altered awareness and a variety of cognitive and neuropsychiatric disturbances [1]. Although the natural history of delirium is that of an often acute and frequently reversible condition, evidence suggests that delirium can be associated with incomplete recovery [2], particularly, in elderly individuals and individuals with co-existing dementia [3]. The naturally fluctuating course of delirium and the impact from treatment of underlying precipitating factors complicate efforts to identify a meaningful definition of recovery. To define recovery, Trzepacz et al. [4], suggested a definition of delirium 318 resolution or response as a significant reduction in delirium symptoms below a specified value (often a percent change from baseline) as measured with a severity scale. Closely related to the concept of ‘recovery’ are issues of ‘response’ (which typically relates to initial reduction in symptom load), ‘remission’ (which typically refers to a sustained initial period without major symptoms) and ‘resolution’ (which usually refers to complete symptom reduction) [5, 6]. Inherent to these concepts are issues of degree of change from baseline, duration of observed improvements, extent of residual symptoms and which aspects of any condition should be considered the primary determinant of therapeutic effect. Thus, the definition of recovery in mental disorders, many of which have a propensity for chronicity, is influenced by the specific disorder, e.g. bipolar, Defining ‘recovery’ for delirium research schizophrenia and anxiety disorders, and may emphasise temporal or symptomatic elements [5–9]. Despite the growing delirium literature, there is a lack of clarity and rigor with respect to the terminology pertaining to both definition and recovery. Thus, in an effort to clarify terminology and definitions of recovery in delirium that have been used in the literature, we conducted a systematic literature review, with the aim of investigating approaches to the definition of recovery that have been applied in studies of delirium. CINAHL Plus and PsyInfo databases from 1954 until December 2013. Also, a manual search was performed of reference lists from identified studies. The literature search yielded a total of 1,050 studies in the English language. (Figure 1). The abstracts of these studies were inspected for the inclusion of relevant studies independently by two investigators (D.A. and A.D.). In cases of discrepancies between the investigators, the full text article was reviewed. Predefined data were extracted by one of the authors. Methods Results Inclusion criteria for studies Fifty-six studies met the inclusion/exclusion criteria and they are summarised in Supplementary data, Appendix S1 available in Age and Ageing online. Studies were included if: (i) they provide explicitly any definition of recovery or remission or relevant information. (ii) they include at least two assessment points in time. Exclusion of studies (i) Duplicated studies. (ii) Studies that investigate recovery in one of the core symptoms or outcomes of delirium (cognition, adaptive function and quality of life) as recovery of one symptom/ element not necessarily means recovery of the whole. (iii) Studies that investigate only subsyndromal delirium. (iv) Studies that investigated delirium in children/adolescents. (v) Alcohol-related delirium studies. (vi) Case studies. (vii) Review articles/commentaries. (viii) Non-English language studies. Description of studies Five were retrospective [10–14], five were secondary analyses of data already collected [15–19] and the rest (n = 46) had a prospective design. Three were case–control studies [10, 20, 21] but with longitudinal designs. Twenty-four of the included studies were trials of different medications or interventions while 32 measured clinical characteristics and outcomes of delirium. The settings in which each study conducted, the study duration, the scales used, the number of delirious patients and the recovery rates of each definition are shown in Supplementary data, Appendix S1 available in Age and Ageing online. Most of the studies examined older populations (minimum mean age of 39.3 in AIDS patients; maximum mean age of 87.4 in long-term facilities). Search keywords/strategy Nomenclature The search keywords used were ‘Delirium’ or ‘acute confusion’ AND ‘recovery’ or ‘reversibility’ or ‘reversible’ or ‘recoverable’ or ‘resolution’ or ‘remission’ or ‘response’ or ‘outcome’ or ‘treatment’. The search included Medline, A variety of terms have been used to describe the outcome of delirium. The most often used was ‘recovery’ (15 studies), but other terminologies included ‘response’ (5), ‘resolution’ (10) ‘improvement’ (3) or ‘sufficient effect of treatment’ (1). Figure 1. Flow chart of included studies. 319 D. Adamis et al. Definitions of outcome Similarly, the definitions of each term varied. Studies that used severity scales such as the MDAS, DRS and DRS-R98 required either cut-off points, which varied even for the same scale across studies (e.g. MDAS ≤10 or <13; DRS-R98 severity scores <15.25 or <10) or percentage reduction in total scores between assessments. Some applied dichotomous scales (yes/ no) such as the CAM with the first day of negative delirium used as the end point [20] while in other studies a longer period ‘delirium-free’ was required (Supplementary data, Appendix S1 available in Age and Ageing online). Discussion From the studies included in this review, it is apparent that a variety of definitions of ‘recovery’ or other similar terms like ‘response’ or ‘remission’ have been used to describe the outcome of delirium in observational and clinical trial studies. The search strategy may have missed some relevant articles, but it is unlikely that markedly different definitions have been used. This inconsistency in terminology can, in part, be explained by the inherent heterogeneity of delirium as a condition (whereby what is considered a ‘good’ response in one population or setting may not be so viewed in others). However, it serves to seriously obfuscate the literature pertaining to outcomes in delirium. Although delirium can have an acute onset with florid symptomatology (e.g. including delusions, hallucinations and psychomotor disturbances), more often the presentation is much quieter with so-called hypoactive delirium which is less phenomenologically compelling or intense but is a more severe form of delirium in terms of many outcomes. Thus, even though acute symptoms may resolve (with reduction in severity scale scores), persistent difficulties can occur such that full resolution of symptoms is not possible. In the existing literature, ‘response’ most often refers to a reduction of clinical symptoms. This term is frequently used in clinical trials and includes a 50% or more reduction in severity of symptoms. However, delirium is caused by physical illness, and in some cases, a perceived response may reflect the impact of treatment of the underling medical condition. Similarly, by using response as an outcome both inclusion criterion and baseline measurement are measured as a single assessment by the same scale. As a consequence, in statistical analysis, the regression to the mean will contribute to an invalid finding of clinical improvement [22]. Moreover, greater baseline severity predicts greater efficacy of medications versus placebo [23], as the magnitude of change is highly dependent upon the initial severity of the symptoms. Remission in other psychiatric disorders (e.g. depression) equates with the symptoms and the signs of the disorder no longer being present. Resolution has also been used as a synonym of remission. In such cases, the use of scales with binary rating (yes/no) is preferable. Of note, the use of remission as an outcome could penalise those with more delirium symptoms and includes a presumption that the cut-off point of scales applied for diagnosis is accurate. Recovery implies an extended period of remission and a return to previous status. However, optimal outcomes for 320 many patients with delirium do not always extend to full recovery as for some, delirium is a marker of deteriorating function, while for others it can act as an accelerating or aggravating factor for underlying dementia [24, 25]. Given that, especially in elderly people, a full recovery may never be achieved, it is perhaps better to define recovery according to a symptomatic status that can be measured by a variety of diagnostic instruments. Recommendations By reviewing the relevant literature, we can suggest that an agreed terminology to define recovery in delirium is required, and that a distinction should be made between symptomatic and general recovery as well as between short- and longterm outcomes. Increasingly, studies have highlighted that although many patients experience symptomatic improvement, others continue to experience significant delirium symptoms for prolonged periods with some ultimately transitioning into persistent states of cognitive impairment and dementia [3]. Psychiatric disorders are chronic and disabling conditions with fluctuations and relapses. However, historically, many of the major advances in psychiatric understanding have followed longitudinal observations. Kraepelin [26], for instance, distinguished manic depression from schizophrenia mainly based on the course of illness and the outcome. Ignoring outcome makes it difficult to distinguish delirium from other cognitive disorders, especially dementia which share many common characteristics [27, 28]. It has been proposed that reversibility of cognition should be a criterion for the definition of delirium [29, 30]; although other work has highlighted the central nature of cognitive impairments to phenomenological profile in delirium [28], we propose that sustained improvement in cognitive function should be a core element in defining therapeutic outcomes in delirium, including ‘response’ where baseline cognitive function is re-established for at least one full day of assessment, ‘recovery’ where this is sustained for more prolonged periods (e.g. at least a week) and that both should be distinguished from ‘symptomatic improvement’ that reflects symptom reduction—including reduction of agitation and related problems with sedative psychotropics. More consistent use of these terms can allow for more meaningful comparison of outcome across studies with better clarity as to the nature of therapeutic response in the complex neuropsychiatric syndrome that is delirium. Key points • There is not a consist terminology to define recovery in delirium. • A distinction should be made between symptomatic and general recovery. • Similarly a distinction needs to be made between short and long term outcomes. • Well defined, practical and feasible criteria for delirium recovery such as cognitive recovery would give a standard upon which to examine factors against. Defining ‘recovery’ for delirium research Conflicts of interest None declared. Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. References Here only the first 30 references have been listed. The full list of references supporting this review is available on Supplementary data, Appendix S2 available in Age and Ageing online. 1. APA. Diagnostic and Statistical Manual of Mental Disorders DSM- 5, 5th edition. Washington, DC: American Psychiatric Association, 2013. 2. Witlox J, 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; 304: 443–51. 3. MacLullich AM, Beaglehole A, Hall RJ, Meagher DJ. Delirium and long-term cognitive impairment. Int Rev Psychiatry 2009; 21: 30–42. 4. Trzepacz PT, Bourne R, Zhang S. Designing clinical trials for the treatment of delirium. J Psychosom Res 2008; 65: 299–307. 5. Rush AJ, Kraemer HC, Sackeim HA et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology 2006; 31: 1841–53. 6. Tohen M, Frank E, Bowden CL et al. The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders. Bipolar Disord 2009; 11: 453–73. 7. Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull 2006; 32: 432–42. 8. Leucht S, Davis JM, Engel RR, Kissling W, Kane JM. Definitions of response and remission in schizophrenia: recommendations for their use and their presentation. Acta Psychiatr Scand Suppl 2009; 438: 7–14. 9. O’Donovan C. Achieving and sustaining remission in depression and anxiety disorders: introduction. Can J Psychiatry 2004; 49(3 Suppl. 1): 5S–9S. 10. Boettger S, Friedlander M, Breitbart W, Passik S. Aripiprazole and haloperidol in the treatment of delirium. Aust N Z J Psychiatry 2011; 45: 477–82. 11. Cobb JL, Glantz MJ, Nicholas PK et al. Delirium in patients with cancer at the end of life. Cancer Pract 2000; 8: 172–7. 12. Lu JH, Chan DK, O’Rourke F et al. Management and outcomes of delirious patients with hyperactive symptoms in a secured behavioral unit jointly used by geriatricians and pyschogeriatricians. Arch Gerontol Geriatr 2011; 52: 66–70. 13. Schwartz TL, Masand PS. Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry 2000; 2: 10–2. 14. Sipahimalani A, Masand PS. Olanzapine in the treatment of delirium. Psychosomatics 1998; 39: 422–30. 15. Boettger S, Breitbart W. An open trial of aripiprazole for the treatment of delirium in hospitalized cancer patients. Palliat Support Care 2011; 9: 351–7. 16. Bond SM, Neelon VJ, Belyea MJ. Delirium in hospitalized older patients with cancer. Oncol Nurs Forum 2006; 33: 1075–83. 17. Cole MG, You Y, McCusker J, Ciampi A, Belzile E. The 6 and 12 month outcomes of older medical inpatients who recover from delirium. Int J Geriatr Psychiatry 2008; 23: 301–7. 18. McAvay GJ, Van Ness PH, Bogardus ST Jr et al. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc 2006; 54: 1245–50. 19. White S, Eeles E, O’Mahony S, Bayer A. Delirium and C-reactive protein. Age Ageing 2008; 37: 123–4; author reply 4. 20. Bellelli G, Speciale S, Morghen S, Torpilliesi T, Turco R, Trabucchi M. Are fluctuations in motor performance a diagnostic sign of delirium? J Am Med Dir Assoc 2010; 12: 578–83. 21. Choi SH, Lee H, Chung TS et al. Neural network functional connectivity during and after an episode of delirium. Am J Psychiatry 2012; 169: 498–507. 22. Fava M, Evins AE, Dorer DJ, Schoenfeld DA. The problem of the placebo response in clinical trials for psychiatric disorders: culprits, possible remedies, and a novel study design approach. Psychother Psychosom 2003; 72: 115–27. 23. Papakostas GI, Fava M. Does the probability of receiving placebo influence clinical trial outcome? A meta-regression of double-blind, randomized clinical trials in MDD. Eur Neuropsychopharmacol 2009; 19: 34–40. 24. Fong TG, Jones RN, Shi P et al. Delirium accelerates cognitive decline in Alzheimer disease. Neurology 2009; 72: 1570–5. 25. Gross AL, Jones RN, Habtemariam DA et al. Delirium and long-term cognitive rrajectory among persons with dementia. Arch Intern Med 2012; 172: 1324–31. 26. Kraepelin E. Psychiatrie: ein Lehrbuch für Studirende und Aerzte. 6. vollständig umgearb. Aufl ed. Leipzig, Germany: J.A. Barth; 1899. 27. Macdonald AJ, Treloar A. Delirium and dementia; are they distinct? J Am Geriatr Soc 1996; 44: 1001–2. 28. Meagher D, Trzepacz PT. Phenomenological distinctions needed in DSM-V: delirium, subsyndromal delirium, and dementias. J Neuropsychiatry Clin Neurosci 2007; 19: 468–70. 29. Treloar AJ, Macdonald AJ. Outcome of delirium: Part 1. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the Reversible Cognitive Dysfunction Scale among acute geriatric inpatients. Int J Geriatr Psychiatry 1997; 12: 609–13. 30. Treloar AJ, Macdonald AJ. Outcome of delirium: Part 2. Clinical features of reversible cognitive dysfunction--are they the same as accepted definitions of delirium? Int J Geriatr Psychiatry 1997; 12: 614–8. Received 22 February 2014; accepted in revised form 11 September 2014 321