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BIBLIOGRAPHIE SUR LE DELIRIUM
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Adamis, D., S. Reich, et al. (2006). "Dysgraphia in elderly delirious medical
inpatients." Aging-Clinical & Experimental Research. Vol. 18(4)(pp 334-339), 2006.
Background and aims: Dysgraphia is a recognized clinical finding in delirium, but
few studies have evaluated handwriting, and results have been inconsistent. In
particular, handwritten signatures, which may be a motor automatism, have not
been previously evaluated in delirious patients. The aim was to assess
abnormalities of signature and spontaneous writing in delirious patients and to
investigate their clinical utility in the detection of delirium. Methods: Secondary
analysis of data was collected from a prospective observational study of acutely
ill inpatients 70 years or older. Mini-Mental State Examination, Confusion
Assessment Method, Delirium Rating Scale, Activities of Daily Living, and
APACHE II were administered to each subject, their signatures were evaluated
from the consent form, and their handwriting from the spontaneous sentence
written as part of the MMSE. Results: The signatures of patients with delirium
were significantly more impaired than those without (Chi-square= 14.749, df=1,
p<0.0001). The sensitivity of the signature for delirium as defined by CAM was
0.54, with specificity of 0.88. Handwriting abnormalities of omission (p=0.018),
illegibility (p=0.034) and spelling (p=0.035) were significantly more common in
delirious patients than others (Chi-square with Fisher's Exact tests. This
difference was mainly attributable to the fact that a large number of delirious
patients were unable to provide any response to the handwriting questions.
Conclusions: An abnormal signature may be an indicator of delirium. People with
delirium have handwriting problems, which may be partly caused by cognitive
impairment but also by disorders of motor function. copyright 2006, Editrice
Kurtis.
Adamis, D., A. Treloar, et al. (2006). "Recovery and outcome of delirium in elderly
medical inpatients." Archives of Gerontology & Geriatrics. Vol. 43(2)(pp 289-298), 2006.
This study investigates the relationships between delirium, cognitive impairment
and acute illness severity with adverse clinical outcomes; in-hospital mortality,
hospital length of stay, or new entry to a care home. It is a prospective
observational study of medical inpatients 70 years or older, with repeated
measurements of cognition, delirium status, delirium severity, and severity of
physical illness every 3 days until the 18th day and then the 28th day of
hospitalization. Of 94 participants, 33 had delirium and 14 recovered during their
hospitalization. Predictor variables for recovery were initial Mini Mental State
Examination (MMSE) (p = 0.003) and severity of delirium at second assessment
(p = 0.02), for mortality initial MMSE (p = 0.002) and for discharge to care home
were initial delirium status (p = 0.008) and age (p = 0.004). Delirious people
newly discharged to care homes stayed longer in hospital than those discharged
to their previous address (p = 0.016). We conclude that delirium is not a transient
disorder. The presence of delirium was not related to measures of the severity of
physical illness or disability. High mortality was associated with delirium but was
specifically associated with cognitive impairment. Prolonged length of stay of
delirious people may depend on discharge destination. copyright 2005 Elsevier
Ireland Ltd. All rights reserved.
Alagiakrishnan, K., T. Marrie, et al. (2007). "Simple cognitive testing (Mini-Cog) predicts
in-hospital delirium in the elderly." Journal of the American Geriatrics Society 55(2):
314-6.
Andrew, M. K., S. H. Freter, et al. (2006). "Prevalence and outcomes of delirium in
community and non-acute care settings in people without dementia: a report from the
Canadian Study of Health and Aging." BMC Medicine 4: 15.
BACKGROUND: While delirium is common among older adults in acute care
hospitals, its prevalence in other settings has been less well studied. We
examined delirium prevalence and outcomes in a large cohort of older Canadians
living outside of acute care. METHODS: In this secondary analysis of the
Canadian Study of Health and Aging, the prevalence of clinically diagnosed
delirium was estimated and five-year survival was compared with that of
individuals with dementia of graded severity. RESULTS: Delirium was very
uncommon (prevalence <0.5%) and was associated with reduced survival,
similar to that of moderate-to-severe dementia. CONCLUSION: In this cohort of
older Canadians, delirium in non-demented people was associated with very low
5-year survival, at levels comparable with advanced dementia. Although it is
common in hospital, delirium is uncommon among older adults in their usual
place of residence, suggesting that it is a potent stimulus to seek medical care.
Anonymous (2007). "'Never been the same since'. Delirium in older people might have
permanent effects on the brain." Harvard Health Letter 32(6): 4.
Anton, E. and J. Marti (2006). "Delirium in older persons.[comment]." New England
Journal of Medicine 354(23): 2509-11; author reply 2509-11.
Aquilina, C. and D. Matthews (2006). "Cognitive impairment precipitated by air travel."
International Journal of Geriatric Psychiatry 21(4): 398-9.
Beaupre, L. A., J. G. Cinats, et al. (2006). "Reduced morbidity for elderly patients with a
hip fracture after implementation of a perioperative evidence-based clinical pathway."
Quality & Safety in Health Care. Vol. 15(5)(pp 375-379), 2006.
Background: Hip fractures, common in the elderly population, result in significant
morbidity and mortality. A study was undertaken to determine how an evidence
based clinical pathway (CP) for treatment of elderly patients with hip fracture
affected morbidity, in-hospital mortality, and health service utilization. Methods: A
pre-post study design using two population based inception cohorts of hip
fracture patients aged >=65 years was used. The control group (n = 678) was
enrolled between July 1996 and September 1997 before implementation of the
pathway and the CP group (n = 663) was enrolled between July 1999 and
September 2000 following pathway implementation. Chart reviews were
completed during study time frames to determine complications, mortality, and
health service utilization. Results: Only nine patients (1%) in the CP group
experienced postoperative congestive heart failure compared with 37 (5%)
control patients (p<0.001). Postoperative cardiac arrythmias were significantly
lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001).
Postoperative delirium occurred in 22% of the CP group and 51% of the control
group (p<0.001). There was no difference in risk adjusted in-hospital mortality
between the two groups. Overall length of stay (LOS) and costs were unchanged
between the groups; however, hospital LOS increased while rehabilitation LOS
decreased in the CP group. Conclusion: Implementation of an evidence based
clinical pathway reduced postoperative morbidity and did not affect in-hospital
mortality or overall costs of inpatient care. The effect of changing trends in
medical care cannot be ruled out, but the reduction in complications in several
clinical areas lends support to the positive impact of the clinical pathway.
Perioperative CP is one successful management approach for this fragile patient
population as patient morbidity was reduced without negatively affecting resource
utilization.
Beaussier, M., H. Weickmans, et al. (2006). "Postoperative analgesia and recovery
course after major colorectal surgery in elderly patients: A Randomized comparison
between intrathecal morphine and intravenous PCA morphine." Reg Anesth Pain Med
31(6): 531-8.
BACKGROUND AND OBJECTIVES: Intrathecal morphine is a widely used
method for postoperative pain relief after major abdominal surgery. The aim of
this randomized, double-blinded study was to compare intrathecal morphine and
intravenous PCA morphine for postoperative analgesia and recovery course after
major colorectal surgery in elderly patients. METHODS: After written informed
consent, patients >70 years of age were prospectively and randomly assigned to
receive either preoperative intrathecal morphine (0.3 mg) and postoperative
patient-controlled (PCA) intravenous morphine (IT morphine) or PCA alone
(group control). Results are presented as mean +/- SD (95% confidence interval).
RESULTS: Twenty-six patients successfully completed the study in each group.
In the IT morphine group, rate of awakening was delayed. Pain intensity and
daily intravenous morphine consumption were significantly reduced 1 and 2 days
after surgery in the IT morphine group (P <.01). Mental function (assessed by
Mini Mental State and Digit Symbol Substitution Test) was similar in both groups.
Episodes of postoperative delirium/confusion occurred similarly in both groups.
Time to ileus resolution and time to ambulation without assistance did not differ
between the 2 groups. The duration of hospitalization was 8.4 +/- 1.7 (7-11) days
and 7.9 +/- 2.0 (6-9.9) days for control and IT morphine, respectively
(nonstatistical difference). Patients in the IT morphine group had longer time to
awakening from anesthesia and experienced more sedation. CONCLUSIONS:
Intrathecal morphine, as compared with intravenous PCA morphine alone,
improves immediate postoperative pain and reduces parenteral morphine
consumption but does not improve postoperative recovery in elderly patients
after major colorectal surgery.
Bellelli, G. and M. Trabucchi (2006). "Outcomes of older people admitted to postacute
facilities with delirium.[comment]." Journal of the American Geriatrics Society 54(2):
380-1.
Bergman, S. A. and D. Coletti (2006). "Perioperative management of the geriatric
patient. Part III: delirium." Oral Surgery Oral Medicine Oral Pathology Oral Radiology &
Endodontics 102(3): e13-6.
Bohner, H. and F. Schneider (2006). "Delirium in older persons.[comment]." New
England Journal of Medicine 354(23): 2509-11; author reply 2509-11.
Bond, S. M., V. J. Neelon, et al. (2006). "Delirium in hospitalized older patients with
cancer." Oncology Nursing Forum Online 33(6): 1075-83.
PURPOSE/OBJECTIVES: To examine key aspects of delirium in a sample of
hospitalized older patients with cancer. DESIGN: Secondary analysis of data
from studies on acute confusion in hospitalized older adults. SETTING: Tertiary
teaching hospital in the southeastern United States. SAMPLE: 76 hospitalized
older patients with cancer (mean age = 74.4 years) evenly divided by gender and
ethnicity and with multiple cancer diagnoses. METHODS: Data were collected
during three studies of acute confusion in hospitalized older patients. Delirium
was measured with the NEECHAM Confusion Scale on admission, daily during
hospitalization, and at discharge. Patient characteristics and clinical risk markers
were determined at admission. MAIN RESEARCH VARIABLES: Prevalent and
incident delirium, etiologic risk patterns, and patient characteristics. FINDINGS:
Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission.
Fourteen of 47 (30%) who were not delirious at admission became delirious
during hospitalization. Delirium was present in 30 patients (39%) at discharge.
Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns
for delirium. CONCLUSIONS: Delirium was common in this sample of
hospitalized older patients with cancer. Patients with delirium were more severely
ill, were more functionally impaired, and exhibited more etiologic patterns than
nondelirious patients. IMPLICATIONS FOR NURSING: Nurses caring for older
patients with cancer should perform systematic and ongoing assessments of
cognitive behavioral performance to detect delirium early. The prevention and
management of delirium hinge on the identification and treatment of the multiple
risk factors and etiologic mechanisms that underlie delirium. The large number of
patients discharged while still delirious has significant implications for
posthospital care and recovery.
Bosisio, M., A. Caraceni, et al. (2006). "Phenomenology of delirium in cancer patients,
as described by the Memorial Delirium Assessment Scale (MDAS) and the Delirium
Rating Scale (DRS)." Psychosomatics 47(6): 471-8.
This study was based on the data collected on a consecutive sample of 106
cancer patients referred for mental status evaluation. All patients were evaluated
by use of the Confusion Assessment Method (CAM) algorithm, the Delirium
Rating Scale (DRS), the Memorial Delirium Assessment Scale (MDAS), and a
question about the subjective perception of delirium. After comparing the
diagnostic criteria of delirium on the DSM-III-R and DSM-IV, authors evaluated
the ability of all DRS and MDAS items to discriminate delirium versus nondelirium patients, testing the difference in the distribution of the individual MDAS
and DRS item scores. Authors also assessed the relationship between delirium
diagnosis and the subjective perception of delirium. The MDAS showed a greater
number of discriminating items. The items that proved to be less discriminating
were "Hallucinations" and "Lability of Mood" on the DRS. Subjective perception
only partially discriminated delirium from non-delirium patients. The way in which
the DRS and MDAS reflected the DSM criteria are therefore partially different.
Boulay, A. (1979). "[Inside the labyrinth of feminine delirium.]." Sante Mentale au
Quebec 4(2): 3-10.
In order to understand the problem of the relationship between woman and
madness, it is important to take history into account. Mental illness consists in the
difficulty to express one's sexual difference in a wide sense (economic, political,
ideological, imaginary and symbolical), this is where history comes into
consideration. Woman, relegated in the far recess of history, deprived of the
possibility to express herself, is today searching for her true expression. As far as
the man's confusion of ideas is concerned, because of his denial of woman, all
he had left was to differentiate himself from himself and therefore creates
symbolic social classes; this thesis is not an idealistic one - it goes without saying
that this symbolical evolution develops itself in interrelation with economic and
material development of society. The masculine confusion of ideas (delire) is
historical while the feminine one is hysterical. This view of mental illness has
political and ideological consequences. The annihilation of the roots of mental
illness will come about only through the elimination of social classes and the real
liberation of woman. This does not mean the rejection of therapeutic work,
revolutions never cured anybody, but the extension of the clinical world to
politics, the breaking down of established practices and interdisciplinarity. In
short term, we have to deal with individuals who feel in themselves the after
effects of an aged social structure, therefore not strictly individual but collective
behaviors. In the long term, only a profound social transformation can limit the
number of victims of the situation. One day maybe every one will be able to
express and achieve themselves in a fully realised communism. This text wanted
to be a locus of information on the historical and political basis of mental illness
and the interconnected role played by the feminine 'delire' (madness).
Boyle, D. A. (2006). "Delirium in older adults with cancer: implications for practice and
research." Oncology Nursing Forum Online 33(1): 61-78.
PURPOSE/OBJECTIVES: To provide a comprehensive review of the literature
and existing evidence-based findings on delirium in older adults with cancer.
DATA SOURCES: Published articles, guidelines, and textbooks. DATA
SYNTHESIS: Although delirium generally is recognized as a common geriatric
syndrome, a paucity of empirical evidence exists to guide early recognition and
treatment of this sequelae of cancer and its treatment in older adults. Delirium
probably is more prevalent than citations note because the phenomenon is
under-recognized in clinical practice across varied settings of cancer care.
CONCLUSIONS: Extensive research is needed to formulate clinical guidelines to
manage delirium. A focus on delirium in acute care and at the end of life
precludes identification of this symptom in ambulatory care, where most cancer
therapies are used. Particular emphasis should address the early recognition of
prodromal signs of delirium to reduce symptom severity. IMPLICATIONS FOR
NURSING: Ongoing assessment opportunities and close proximity to patients'
treatment experiences foster oncology nurses' mastery of this common exemplar
of altered cognition in older adults with cancer. Increasing awareness of and
knowledge delineating characteristics of delirium in older patients with cancer
can promote early recognition, optimum treatment, and minimization of untoward
consequences associated with the historically ignored example of symptom
distress. [References: 212]
Bradley, E. H., T. R. Webster, et al. (2006). "Patterns of diffusion of evidence-based
clinical programmes: A case study of the Hospital Elder Life Program." Quality & Safety
in Health Care. Vol. 15(5)(pp 334-338), 2006.
Background: The effective translation of scientific evidence into clinical practice is
paramount to improving the quality and safety of patient care. However, little is
known about the patterns of diffusion of evidence-based programmes in
healthcare. Objectives: To study the pattern of diffusion of an evidence-based
programme to improve the quality and safety of care for hospitalised older adults.
Methods: The diffusion of the Hospital Elder Life Program (HELP), a multifaceted
programme to reduce delirium in hospitalised adults, was examined. Using a
survey of all hospitals that contacted the HELP Dissemination Project for more
than 2 years, the proportion of hospitals that adopted the programme, the
programme fidelity to the original design in terms of structure and process, and
the perceived reasons for non-adoption were identified. Results: Programme
fidelity was highest among structural features (eg, staffing levels); programme
modifications were more commonplace in processes of care (eg, the participation
of volunteers in patient care interventions). Senior management support and the
programme expense were the most commonly cited reasons for non-adoption of
HELP. Conclusion: Diffusion and take-up rates for this evidence-based
programme were substantial; however, programme fidelity was not complete and
some hospitals did not adopt the programme at all. Clinicians, researchers and
funding agents seeking to promote effective translation of research should be
realistic about diffusion rates and recognise the critical ingredient of senior
management support to propel adoption of evidence-based programmes to
improve quality and safety.
Bruce, A. J., C. W. Ritchie, et al. (2007). "The incidence of delirium associated with
orthopedic surgery: a meta-analytic review." International Psychogeriatrics 19(2): 197214.
Background: The aim of this study was to perform a systematic review and metaanalysis of the literature regarding the incidence of delirium following orthopedic
surgery.Methods: Relevant papers were sourced from online databases and gray
literature. Included studies used a validated diagnostic method to measure the
incidence of delirium in a prospective sample of adult/elderly orthopedic patients.
Data were subject to meta-analysis after stratification by type of surgery (elective
v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A
funnel plot assessed for publication bias.Results: 26 publications reported an
incidence of postoperative delirium of 4-53.3% in hip fracture samples and 3.628.3% in elective samples. Significant heterogeneity was evident, and this
persisted despite stratification. Hip fracture was associated with a higher risk of
delirium than elective surgery both when the cognitively impaired were included
in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6-28.8] vs.
12.1% [95% CI = 9.6-14.6]), and when the cognitively impaired were excluded
(random effects pooled estimate = 25% [95% CI = 15.7-34.7] vs. 8.8% [95% CI =
4.1-13.6]). The funnel plot showed a deficit of small studies showing low risk and
large studies showing high risk. In eight hip fracture studies, the proportion of
delirium cases with a preoperative onset ranged from 34 to 92%.Conclusions:
Delirium occurs more commonly with hip fracture than elective surgery, and
frequently has a preoperative onset when associated with trauma.
Recommendations are made with the aim of standardizing future research in
order to further explore and reduce the heterogeneity and possible publication
bias observed.
Caplan, G. A., J. Coconis, et al. (2006). "Does home treatment affect delirium? A
randomised controlled trial of rehabilitation of elderly and care at home or usual
treatment (The REACH-OUT trial)." Age & Ageing 35(1): 53-60.
BACKGROUND: delirium is a frequent adverse consequence of hospitalisation
for older patients, but there has been little research into its prevention. A recent
study of Hospital in the Home (admission substitution) noted less delirium in the
home-treated group. SETTING: a tertiary referral teaching hospital in Sydney,
Australia. METHODS: we randomised 104 consecutive patients referred for
geriatric rehabilitation to be treated in one of two ways, either in Hospital in the
Home (early discharge) or in hospital, in a rehabilitation ward. We compared the
occurrence of delirium measured by the confusion assessment method.
Secondary outcome measures were length of stay, hospital bed days, cost of
acute care and rehabilitation, functional independence measure (FIM), MiniMental State Examination (MMSE) and geriatric depression score (GDS)
assessed on discharge and at 1- and 6-month follow-up and patient satisfaction.
RESULTS: the home group had lower odds of developing delirium during
rehabilitation [odds ratio (OR) = 0.17; 95% confidence interval 0.03-0.65], shorter
duration of rehabilitation (15.97 versus 23.09 days; P = 0.0164) and used less
hospital bed days (20.31 versus 40.09, P < or = 0.0001). The cost was lower for
the acute plus rehabilitation phases (7,680 pounds versus 10,598 pounds; P =
0.0109) and the rehabilitation phase alone (2,523 pounds versus 6,100 pounds;
P < or = 0.0001). There was no difference in FIM, MMSE or GDS scores. the
home group was more satisfied (P = 0.0057). CONCLUSIONS: home
rehabilitation for frail elderly after acute hospitalisation is a viable option for
selected patients and is associated with a lower risk of delirium, greater patient
satisfaction, lower cost and more efficient hospital bed use.
Caplan, G. A. and E. L. Harper (2007). "Recruitment of volunteers to improve vitality in
the elderly: the REVIVE study." Internal Medicine Journal 37(2): 95-100.
BACKGROUND: Delirium is a common problem for frail, older patients in hospital
and a marker of poor outcome and mortality. The aim of this study was to test a
volunteer-mediated delirium prevention programme for efficacy, costeffectiveness and sustainability on an Australian geriatric ward. METHODS: Two
controlled before-and-after studies were conducted. In study 1, 37 patients (>70
years, admitted to the geriatric wards) were enrolled during 5 months in 2003 for
intensive individual study. Twenty-one patients received usual care and 16
patients received the volunteer-mediated intervention of daily orientation,
therapeutic activities, feeding and hydration assistance, vision and hearing
protocols. In study 2, we examined the effects of a general implementation for
the whole department by measuring use of assistants in nursing, who were
employed for individual nursing of delirious patients. RESULTS: In study 1, we
found a lower incidence (intervention vs control, 6.3% vs 38%; P = 0.032) and
lower severity of delirium (1.2 vs 5.1; P = 0.045). There was a trend towards
decreased duration of delirium (5.0 vs 12.5; P = 0.64). In study 2, use of
assistants in nursing was reduced by 314 h per month suggesting a total annual
saving of 129,186 Australian dollars for the hospital. CONCLUSION: The
programme prevents delirium and improves outcomes for elderly inpatients.
Cost-effectiveness supports the continuation of the programme and extension to
other geriatric units.
Carnahan, R. M., B. C. Lund, et al. (2006). "The Anticholinergic Drug Scale as a
measure of drug-related anticholinergic burden: associations with serum anticholinergic
activity." Journal of Clinical Pharmacology 46(12): 1481-6.
Anticholinergic Drug Scale (ADS) scores were previously associated with serum
anticholinergic activity (SAA) in a pilot study. To replicate these results, the
association between ADS scores and SAA was determined using simple linear
regression in subjects from a study of delirium in 201 long-term care facility
residents who were not included in the pilot study. Simple and multiple linear
regression models were then used to determine whether the ADS could be
modified to more effectively predict SAA in all 297 subjects. In the replication
analysis, ADS scores were significantly associated with SAA (R2 =.0947, P
<.0001). In the modification analysis, each model significantly predicted SAA,
including ADS scores (R2 =.0741, P <.0001). The modifications examined did not
appear useful in optimizing the ADS. This study replicated findings on the
association of the ADS with SAA. Future work will determine whether the ADS is
clinically useful for preventing anticholinergic adverse effects.
Cole, C. S., E. B. Williams, et al. (2006). "Assessment and discharge planning for
hospitalized older adults with delirium." MEDSURG Nursing 15(2): 71-6.
A description of the effects of delirium on attention is provided. Nursing
implications pertinent to appropriate assessment for attention deficits,
interventions to maintain patient safety, and discharge planning for the older
adult with persistent delirium are also discussed. [References: 32]
Cole, M. G., J. McCusker, et al. (2007). "An exploratory study of diagnostic criteria for
delirium in older medical inpatients." Journal of Neuropsychiatry & Clinical
Neurosciences 19(2): 151-156.
The poor prognosis of delirium in older medical inpatients has generated
controversy about the diagnostic criteria for delirium in this population. The goal
of the present study was to explore the presenting symptoms of delirium among
older medical inpatients who did or did not recover from delirium. Patients 65
years or older admitted from the emergency department to medical services were
screened with the Confusion Assessment Method (CAM). Patients with delirium
were assessed at enrollment, several times during the first week, then weekly for
4 weeks using the Delirium Index (DI). Measures at baseline included
demographics, dementia and severity of physical illness. Recovery was defined
as a decline of three points or more on the DI and a final DI score of less than 5
or 4 points in patients with or without dementia, respectively. Of 290 patients who
met DSM-IV criteria for delirium, 65 recovered and 225 did not. Three symptoms
(orientation to person, hyperactivity, and inattention) were associated with
recovery from delirium in older medical inpatients. These results suggest it may
be necessary to place increased emphasis on these presenting symptoms when
diagnosing delirium in this population. [References: 27]
Collins, R. J. (2006). "Medication sleuth: an important role for pharmacists in
determining the etiology of delirium." Consultant Pharmacist 21(4): 293-7.
Delirium is characterized by disturbances of consciousness, attention, cognition,
and perception and is the most common reason for acute cognitive dysfunction in
hospitalized elderly patients. Causes of delirium can be multifactorial, and a
careful medical and medication history can help determine the underlying cause
of behavioral disturbances. A 65-year-old patient with a history of chronic pain,
insomnia, and multiple medical problems, who presented with altered mental
status and aggressive behavior, is described. The patient had taken an overdose
of zolpidem prior to admission, and she required chemical and physical restraints
and one-on-one care for safety. With time and washout of the zolpidem, the
patient's behavior did not improve. On the second day of admission, medication
reconciliation of this patient's medication profile helped to reveal a medication
cause for this patient's delirium. A pharmacist should be included early in the
process of obtaining a medication history. Recommendations for the
management of chronic pain and insomnia in the elderly are presented.
D'Arcy, Y. (2006). "Managing postop pain in a patient who's delirious." Nursing 36(6):
17.
de Jonghe, J. F., K. J. Kalisvaart, et al. (2007). "Early symptoms in the prodromal phase
of delirium: a prospective cohort study in elderly patients undergoing hip surgery."
American Journal of Geriatric Psychiatry 15(2): 112-21.
OBJECTIVES: The authors investigated prodromal delirium symptoms in elderly
patients undergoing hip surgery. METHODS: This was a prospective cohort
study in the setting of a large medical school-affiliated general hospital in
Alkmaar, The Netherlands. Participants were patients undergoing hip surgery
aged 70 and older at risk for delirium. Before surgery, patients were randomized
to low-dose prophylactic haloperidol treatment or placebo. Daily assessments
were based on patient interviews with the Mini-Mental State Examination and
Digit Span test. The Delirium Rating Scale-Revised (DRS-R-98) was used to
measure early symptoms during the prodromal phase before the onset of
delirium. RESULTS: Data of 66 patients with delirium were compared with those
of 35 at-risk patients who did not develop delirium: 14 of 66 patients (21%) had
delirium on the day of surgery or early the day after, 32 of 66 (48%) on the
second day, 14 of 66 on the third, and six of 66 (9%) on the fourth. The average
DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the
comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with
postoperative delirium. Multivariate analysis showed that the early symptoms
memory impairments, incoherence, disorientation, and underlying somatic illness
predict delirium. CONCLUSIONS: Most elderly patients undergoing hip surgery
with postoperative delirium already have early symptoms in the prodromal phase
of delirium. These findings are potentially useful for screening purposes and for
optimizing prevention strategies targeted at reducing the incidence of
postoperative delirium.
de Rooij, S. E., B. C. van Munster, et al. (2006). "Delirium subtype identification and the
validation of the Delirium Rating Scale--Revised-98 (Dutch version) in hospitalized
elderly patients." Int J Geriatr Psychiatry 21(9): 876-82.
BACKGROUND: Delirium is the most common acute neuropsychiatric disorder in
hospitalized elderly. The Dutch version of the Delirium Rating Scale-Revised-98
(DRS-R-98) appears to be a reliable method to classify delirium. The aim of this
study was to determine the validity and reliability of the DRS-R-98 and to study
clinical subtypes of delirium using the DRS-R-98. METHODS: Patients received
the Dutch version of the DRS-R-98, the Mini-Mental State Examination, the
Confusion Assessment Method, and a clinical diagnosis of delirium according to
DSM-IV criteria, and their relatives the Informant Questionnaire Cognitive Decline
in the Elderly. RESULTS: The DRS-R-98 validation cohort (n=65) consisted of 23
patients with delirium, 22 patients with dementia, and 20 non-psychiatric
comparison patients. For the delirium subtype study, a second cohort comprising
54 delirious patients was investigated. Median DRS-R-98 scores significantly
distinguished delirium from dementia and no psychiatric disorder. Inter-rater
reliability (intra-class correlation 0.97) and internal consistency (Crohnbach's
alpha 0.94) were high. Positive scores of DRS-R-98 item 4 (affect liability) and
item 7 (motor agitation) predicted the presence of non-hypoactive delirium, with a
specificity of 89% and a sensitivity of 57%. CONCLUSION: The results show that
the Dutch version of the DRS-R-98 is a valid and reliable measure of delirium
severity and distinguishes patients with delirium from patients with dementia and
comparison patients. Furthermore, the DRS-R-98 is able to exclude hypoactive
delirium.
de Rooij, S. E., B. C. van Munster, et al. (2007). "Cytokines and acute phase response
in delirium." Journal of Psychosomatic Research. Vol. 62(5)(pp 521-525), 2007.
Objective: This study aimed to examine the expression patterns of pro- and antiinflammatory cytokines in elderly patients with and without delirium who were
acutely admitted to the hospital. Methods: All consecutive patients aged 65 years
and older, who were acutely admitted to the Department of Internal Medicine of
the Academic Medical Center, Amsterdam, a tertiary university teaching hospital,
were invited. Members of the geriatric consultation team completed a
multidisciplinary evaluation for all study participants within 48 h after admission,
including cognitive and functional examination by validated measures of delirium,
memory, and executive function. C-reactive protein and cytokines (IL-1beta, IL-6,
TNF-a, IL-8, and IL-10) were determined within 3 days after admission. Results:
In total, 185 patients were included; mean age was 79 years; 42% were male;
and 34.6% developed delirium within 48 h after admission. Compared to patients
without delirium, patients with delirium were older and had experienced
preexistent cognitive impairment more often. In patients with delirium,
significantly more IL-6 levels (53% vs. 31%) and IL-8 levels (45% vs. 22%) were
above the detection limit as compared with patients who did not have delirium.
After adjusting for infection, age, and cognitive impairment, these differences
were still significant. Conclusions: Proinflammatory cytokines may contribute to
the pathogenesis of delirium in acutely admitted elderly patients. copyright 2007
Elsevier Inc. All rights reserved.
DeCarolis, D. D., K. L. Rice, et al. (2007). "Symptom-driven lorazepam protocol for
treatment of severe alcohol withdrawal delirium in the intensive care unit."
Pharmacotherapy 27(4): 510-518.
Study Objective. To compare outcomes of treating alcohol withdrawal delirium
(AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol
benzodiazepine infusions in the intensive care unit (ICU). Design. Retrospective
observational study of a quality improvement project. Setting. Medical intensive
care unit at a Veterans Affairs medical center. Patients. Thirty-six patients who
had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003.
Sixteen episodes (15 patients [historical controls]) occurred before
implementation of the symptom-driven protocol in 1998, and 24 episodes (21
patients) occurred after implementation. Measurements and Main Results.
Outcomes evaluated were time to reach symptom control, total dose of
benzodiazepine, amount of time receiving continuous benzodiazepine infusion,
length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines),
and complications of treatment. The historical control group was treated
according to physician preference, which consisted of continuous-infusion
midazolam without a protocol. The symptom-driven protocol used lorazepam
administered initially as intermittent intravenous doses, progressing to a
continuous intravenous infusion according to a locally developed symptom scale.
The mean +/- SD values for the outcomes in the historical control group versus
the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus
7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam
equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving
benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours
(p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21),
and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43).
Conclusions. Use of a symptom-driven protocol was associated with significantly
decreased time to symptom control, amount of sedative required, and time spent
receiving benzodiazepine infusion compared with historical controls. The use of
the protocol is effective but requires close monitoring to ensure protocol
compliance and to avoid potential propylene glycol toxicity. [References: 43]
Demeure, M. J. and M. J. Fain (2006). "The elderly surgical patient and postoperative
delirium." Journal of the American College of Surgeons 203(5): 752-7.
Derouesne, C. and L. Lacomblez (2007). "[Delirium]." Psychologie et Neuropsychiatrie
du Vieillissement 5(1): 7-16.
Delirium is very common in the elderly. It complicates both psychiatric and
somatic disorders and is associated with reduced survival, poor functional
results, increased duration of hospital stay, and institutionalization. Diagnosis
remains difficult in spite of the improvement of the diagnostic criteria, due to the
polymorphism of the clinical signs and fluctuation of vigilance and cognition. Age
over 70 and previous cognitive impairment are the main risk factors. Precipitating
factors are medical and surgical pathologies, intoxications, especially by
therapeutic drugs. Delirium can reveal or complicate a previous dementia.
Prevention of delirium and care of the delirious patient require the participation of
both the medical and nursing staff.
Dyck, M. J., K. Culp, et al. (2007). "Data quality strategies in cohort studies: lessons
from a study on delirium in nursing home elders." Applied Nursing Research 20(1): 3943.
Data quality has a direct impact on reliability and validity; however, procedures
are usually briefly summarized in the Methods section of reports. Sustaining data
quality and integrity over time can pose serious challenges, prompting the
development of a data quality program based on Donabedian's quality
framework. Although many are familiar with the structure, process, and outcome
components in health care quality, their application to a research project may be
unfamiliar. This article summarizes the data quality program for a cohort study of
nursing home elders with delirium by providing an "insider's view" of procedures
and protocols followed for several years.
Edlund, A., M. Lundstrom, et al. (2006). "Delirium in older patients admitted to general
internal medicine." Journal of Geriatric Psychiatry & Neurology 19(2): 83-90.
Delirium on the day of admission to general internal medicine wards was studied
in 400 consecutive patients aged 70 years and above regarding occurrence,
associated factors, clinical profile, length of hospital stay, and mortality. The
patients were assessed using the Organic Brain Syndrome Scale and the MiniMental State Examination, and delirium was diagnosed according to Diagnostic
and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day
of admission occurred in 31.3% of the patients and was independently
associated with old age, fever on the day of admission (> or = 38 degrees C),
treatment with neuroleptics, impaired vision, male sex, and previous stroke.
Delirious patients had longer hospital stay (15.4 vs 9.5 days, P <.001), a higher
mortality rate during hospitalization (11/125 vs 5/275, P <.001), and a higher 1year mortality rate (45/125 vs 55/275, P =.001). Delirium is a common
complication with often easily identified causes, and it has a serious impact on
outcome for older medical patients.
Egger, S. S., A. Bachmann, et al. (2006). "Prevalence of potentially inappropriate
medication use in elderly patients: comparison between general medical and geriatric
wards." Drugs Aging 23(10): 823-37.
BACKGROUND AND OBJECTIVE: Inappropriate drug use is one of the risk
factors for adverse drug reactions in the elderly. We hypothesised that, in elderly
patients, geriatricians are more aware of potentially inappropriate medications
(PIMs) and may replace or stop PIMs more frequently compared with internists.
We therefore evaluated and compared the prevalence of PIMs as well as
anticholinergic drug use throughout hospital stay in elderly patients admitted to a
medical or geriatric ward. METHODS: In this retrospective cross-sectional study,
800 patients aged > or =65 years admitted to a general medical or geriatric ward
of a 700-bed teaching hospital in Switzerland during 2004 were included. PIMs
were identified using the Beers criteria published in 2003. The prevalence of
anticholinergic drug use was assessed based on drug lists published in the
literature. RESULTS: The prevalence of use of PIMs that should generally be
avoided was similar in medical and geriatric inpatients both at admission (16.0%
vs 20.8%, respectively; p = 0.08) and at discharge (13.3% vs 15.9%,
respectively; p = 0.31). In contrast to medical patients, the reduction in the
prevalence of use of PIMs between admission and discharge in geriatric patients
reached statistical significance (p < 0.05). Overall, the three most prevalent
inappropriate drugs/drug classes were amiodarone, long-acting benzodiazepines
and anticholinergic antispasmodics. At admission, the prevalence of use of PIMs
related to a specific diagnosis was not significantly different between patients
hospitalised to a medical or a geriatric ward (14.0% vs 17.5%, respectively; p =
0.17), as compared with the significant difference evident at hospital discharge
(11.7% vs 23.7%, respectively; p < 0.001). This was largely because of a higher
prescription rate of platelet aggregation inhibitors in combination with lowmolecular-weight heparins and benzodiazepines in patients with a history of falls
and syncope. The proportions of patients taking anticholinergic drugs in medical
and geriatric patients at admission (13.0% vs 17.5%, respectively; p = 0.08) and
discharge (12.2% vs 16.5%, respectively; p = 0.10) were similar. CONCLUSION:
Inappropriate drug use as defined by the Beers criteria was common in both
medical and geriatric inpatients. Compared with internists, geriatricians appear to
be more aware of PIMs that should generally be avoided, but less aware of PIMs
related to a specific diagnosis, and of the need to avoid anticholinergic drug use.
However, the results of this study should be interpreted with caution because
some of the drugs identified as potentially inappropriate may in fact be beneficial
when the patient's clinical condition is taken into consideration.
Ely, E. W., T. D. Girard, et al. (2007). "Apolipoprotein E4 polymorphism as a genetic
predisposition to delirium in critically ill patients.[see comment]." Critical Care Medicine
35(1): 112-7.
OBJECTIVE: To test for an association between apolipoprotein E (APOE)
genotypes and duration of intensive care unit delirium. DESIGN: Prospective,
observational cohort study. SETTING: A 541-bed, community-based teaching
hospital. PATIENTS: Fifty-three mechanically ventilated intensive care unit
patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All
patients were managed with standardized sedation and ventilator weaning
protocols as part of an ongoing clinical trial and were evaluated prospectively for
delirium with the Confusion Assessment Method for the Intensive Care Unit
(CAM-ICU). DNA was extracted from whole blood samples obtained on
enrollment, and APOE genotype was determined using polymerase chain
reaction followed by restriction enzyme digestion by investigators blinded to the
clinical information. Delirium occurred in 47 (89%) patients at some point during
the intensive care unit stay. Of the 53 patients, 12 (23%) had an APOE4 allele
(APOE4+) and 41 (77%) had only APOE2 or APOE3 alleles (APOE4-). APOE4+
patients were younger (53.2 +/- 21.9 vs. 65.4 +/- 13.4, p =.08) and less often
admitted for pneumonia (0% vs. 29.3%, p =.05) compared with APOE4- patients,
yet they had a duration of delirium that was twice as long: median (interquartile
range), 4 (3, 4.5) vs. 2 (1, 4) days (p =.05). No other clinical outcomes were
significantly different between the APOE4+ and APOE4- patients. Using
multivariable regression analysis to adjust for age, admission diagnosis of sepsis
or acute respiratory distress syndrome or pneumonia, severity of illness, and
duration of coma, the presence of APOE4 allele was the strongest predictor of
delirium duration (odds ratio, 7.32; 95% confidence interval, 1.82-29.51, p =.005).
CONCLUSIONS: APOE4 allele represents the first demonstrated genetic
predisposition to longer duration of delirium in humans.
Fann, J. R., C. M. Alfano, et al. (2007). "Impact of delirium on cognition, distress, and
health-related quality of life after hematopoietic stem-cell transplantation." Journal of
Clinical Oncology 25(10): 1223-1231.
Purpose To determine the impact of delirium during the acute phase of
myeloablative hematopoietic stem-cell transplantation (HSCT) on health-related
quality of life (HRQOL), distress, and neurocognitive functioning 30 and 80 days
after transplantation. Patients and Methods Ninety patients completed a battery
assessing HRQOL, distress, and neuropsychological functioning before receiving
their first HSCT. Delirium was assessed three times per week using the Delirium
Rating Scale and the Memorial Delirium Assessment Scale from 7 days before
transplantation through 30 days after transplantation. At 30 days after
transplantation, distress and neurocognitive functioning were assessed. At 80
days after transplantation, HRQOL, distress, and neuropsychological functioning
were re-evaluated. Results After adjusting for confounding factors, patients who
experienced a delirium episode, versus patients who did not, reported
significantly worse depression, anxiety, and fatigue symptoms at 30 days (linear
regression beta s = 0.2, 0.3, and 0.5, respectively; P <.04). At 80 days, patients
with a delirium episode had significantly worse executive functioning (beta = 1.1; P <.02), attention and processing speed (beta s = - 4.7 and - 5.4,
respectively; P <.03), mental health on the Medical Outcomes Study Health
Survey, 12-item short form (beta = - 6.5; P <.02), and anxiety, fatigue, and
cancer and treatment distress symptoms (beta s = 0.4, 0.6, and 0.3, respectively;
P <.03). Conclusion Patients with a malignancy who experience delirium during
myeloablative HSCT showed impaired neurocognitive abilities and persistent
distress 80 days after transplantation. Effective prevention or treatment of
delirium during HSCT may improve both cognitive and psychological outcomes.
[References: 99]
Fann, J. R., C. M. Alfano, et al. (2007). "Impact of delirium on cognition, distress, and
health-related quality of life after hematopoietic stem-cell transplantation." Journal of
Clinical Oncology. Vol. 25(10)(pp 1223-1231), 2007.Date of Publication: 01 APR 2007.
Purpose: To determine the impact of delirium during the acute phase of
myeloablative hematopoietic stem-cell transplantation (HSCT) on health-related
quality of life (HRQOL), distress, and neurocognitive functioning 30 and 80 days
after transplantation. Patients and Methods: Ninety patients completed a battery
assessing HRQOL, distress, and neuropsychological functioning before receiving
their first HSCT. Delirium was assessed three times per week using the Delirium
Rating Scale and the Memorial Delirium Assessment Scale from 7 days before
transplantation through 30 days after transplantation. At 30 days after
transplantation, distress and neurocognitive functioning were assessed. At 80
days after transplantation, HRQOL, distress, and neuropsychological functioning
were re-evaluated. Results: After adjusting for confounding factors, patients who
experienced a delirium episode, versus patients who did not, reported
significantly worse depression, anxiety, and fatigue symptoms at 30 days (linear
regression betas = 0.2, 0.3, and 0.5, respectively; P <.04). At 80 days, patients
with a delirium episode had significantly worse executive functioning (beta = -1.1;
P <.02), attention and processing speed (betas = -4.7 and -5.4, respectively; P
<.03), mental health on the Medical Outcomes Study Health Survey, 12-item
short form (beta = -6.5; P <.02), and anxiety, fatigue, and cancer and treatment
distress symptoms (betas = 0.4, 0.6, and 0.3, respectively; P <.03). Conclusion:
Patients with a malignancy who experience delirium during myeloablative HSCT
showed impaired neurocognitive abilities and persistent distress 80 days after
transplantation. Effective prevention or treatment of delirium during HSCT may
improve both cognitive and psychological outcomes. copyright 2007 by American
Society of Clinical Oncology.
Fick, D. M., D. M. Hodo, et al. (2007). "Recognizing delirium superimposed on
dementia: assessing nurses' knowledge using case vignettes." Journal of
Gerontological Nursing 33(2): 40-7; quiz 48-9.
Delirium is a serious and prevalent problem that occurs in many hospitalized
older adults. Delirium superimposed on dementia (DSD) occurs when a delirium
occurs concurrently with a pre-existing dementia. DSD is typically
underrecognized by medical and nursing staff. The current study measured
nursing identification of DSD using standardized case vignettes, and the Mary
Starke Harper Aging Knowledge Exam (MSHAKE). Results revealed that the
nurses in this study had a high level of general geropsychiatric nursing
knowledge as measured by the MSHAKE, yet had difficulty recognizing DSD
compared to dementia alone and delirium alone. Only 21% were able to correctly
identify the hypoactive form of DSD, and 41% correctly identified hypoactive
delirium alone in the case vignettes. Interventions and educational programs
designed to increase nursing awareness of DSD symptoms could help to
decrease this gap in nursing knowledge.
Flood, K. L., M. B. Carroll, et al. (2006). "Geriatric syndromes in elderly patients
admitted to an oncology-acute care for elders unit." Journal of Clinical Oncology. Vol.
24(15)(pp 2298-2303), 2006.Date of Publication: 20 MAY 2006.
Purpose: The goal of this study was to characterize an elderly population
admitted to a novel Oncology-Acute Care for Elders (OACE) unit, determine the
prevalence of functional dependencies and geriatric syndromes, and examine
their suitability for an interdisciplinary model of care. Patients and Methods: We
conducted a retrospective review of 119 patients age 65 years or older who had
a primary oncologic or hematologic diagnosis and were admitted to the OACE
Unit. Standard geriatric screens were administered to assess mood, functional,
and cognitive status. Demographic and medical data were compiled by review of
patients' medical records. Results: The mean age of the patients was 74.1 years
(standard deviation, 5.9 years). The sample was predominantly white, of equal
sex, had limitations in instrumental and basic activities of daily living, and a mean
length of stay of 6 days. Geriatric syndromes detected by the OACE
interdisciplinary team included cognitive impairment (dementia and/or delirium),
depression, weight loss, and use of high-risk medications. Adverse events such
as falls, restraint use, and pressure sores were rare. Conclusion: In this
descriptive study, many older cancer patients were found to have geriatric
syndromes by the OACE team and these patients were considered appropriate
for an interdisciplinary model of care. Additional studies are needed to compare
the outcomes of hospitalized older oncology patients receiving an OACE
intervention with those patients receiving usual care. copyright 2006 by American
Society of Clinical Oncology.
Fong, H. K., L. P. Sands, et al. (2006). "The role of postoperative analgesia in delirium
and cognitive decline in elderly patients: a systematic review." Anesthesia & Analgesia
102(4): 1255-66.
Postoperative delirium and cognitive decline are adverse events that occur
frequently in elderly patients. Preexisting patient factors, medications, and
various intraoperative and postoperative causes have been implicated in the
development of postoperative delirium and cognitive decline. Despite previous
studies identifying postoperative pain as a risk factor, relatively few clinical
studies have compared the effect of common postoperative pain management
techniques (IV and epidural) or opioid analgesics on postoperative cognitive
status. A systematic search of the PubMed and CINAHL databases identified six
studies comparing different opioid analgesics on postoperative delirium and
cognitive decline and five studies comparing IV and epidural routes of
administering analgesia. Meperidine was consistently associated with an
increased risk of delirium in elderly surgical patients, but the current evidence
has not shown a significant difference in postoperative delirium or cognitive
decline among other more frequently used postoperative opioids such as
morphine, fentanyl, or hydromorphone. The available studies also suggest that IV
or epidural techniques do not influence cognitive function differently. However,
future investigations of sufficient study size and more standardized methods of
defining outcomes are necessary to confirm the current findings. [References:
76]
Fong, T. G., S. T. Bogardus, Jr., et al. (2006). "Cerebral perfusion changes in older
delirious patients using 99mTc HMPAO SPECT." Journals of Gerontology Series ABiological Sciences & Medical Sciences 61(12): 1294-9.
BACKGROUND: Prior studies describe variable cerebral blood flow changes in
delirium. This study aims to investigate cerebral blood flow changes in older
hospitalized patients with delirium, the population in which most cases of delirium
occur. METHODS: Participants included hospitalized general medical patients
aged 65 years and older with documented delirium and no relevant medical
conditions or preexisting abnormalities on neuroimaging prospectively studied
using 99mTc HMPAO single photon emission computed tomography (SPECT)
scans obtained during and after resolution of delirium. Twenty-two patients
enrolled in the study, of whom six completed both scans. All participants
underwent neuropsychological assessment immediately prior to SPECT
scanning. SPECT images were compared across all participants during delirium;
for patients completing paired scans, within-patient comparisons were made.
RESULTS: Visual assessment of SPECT scans revealed perfusion abnormalities
in frontal (5 participants) or parietal regions (6 participants); scans were normal in
11 participants (50%). Region-of-interest analysis identified reduced blood flow (p
<.01) in the left inferior frontal, right temporal, right occipital, and pontine regions.
Analysis of paired scans revealed reversible abnormalities in three participants (p
<.001), with decreased right parietal perfusion in two participants and increased
left parietal perfusion in one participant. CONCLUSIONS: The results of this
study of a small group of general medical patients are suggestive that frontal or
parietal cerebral perfusion abnormalities occur in delirium, and these findings
need to be confirmed by future, larger studies. These results may help to improve
basic understanding of delirium pathophysiology, to identify long-term changes,
and to evaluate response to treatment over time.
Forrest, J., L. Willis, et al. (2007). "Recognizing quiet delirium." American Journal of
Nursing 107(4): 35-9.
Furlaneto, M. E. and L. E. Garcez-Leme (2006). "Delirium in elderly individuals with hip
fracture: causes, incidence, prevalence, and risk factors." Clinics (Sao Paulo, Brazil)
61(1): 35-40.
OBJECTIVES: To determine the incidence, prevalence, risk factors, and causes
of delirium in elderly individuals with hip fractures, as well as the impact of
delirium on mortality and length of hospital stay. PATIENTS: One hundred and
three patients aged 65 and older with hip fractures were included consecutively
between January 2001 and June 2002. METHOD: Delirium was diagnosed using
the Confusion Assessment Method, applied within the first 24 hours after
admission, and then daily. All patients underwent a global geriatric evaluation
including clinical history, physical examination, laboratory tests, surgical risk
evaluation, and functional and mental evaluations. Patients with delirium (cases)
were compared with patients without delirium (controls). RESULTS: Thirty
(29.1%) patients in this sample met the criteria for delirium, with a prevalence of
16.5% (17/103) and an incidence of 12.6% (13/103). Cognitive and functional
deficits had a significant association with delirium, although only cognitive deficit
was revealed to be an independent risk factor after analysis with the logistic
regression model. The most frequent causes of delirium were drugs and
infections. The hospital stay was significantly longer for patients with delirium
compared with patients in the control group (26.27 versus 14.38 days,
respectively). Mortality showed a tendency to higher levels in patients with
delirium during their hospital stay, although with no statistical significance.
CONCLUSIONS: Delirium is a frequent complication among hospitalized elderly
individuals with hip fractures. It is associated with cognitive and functional
deficits, and it is associated with increases the length of hospital stay and
mortality.
Gareri, P., P. De Fazio, et al. (2007). "Anticholinergic drug-induced delirium in an elderly
alzheimer's dementia patient." Archives of Gerontology & Geriatrics. Vol.
44(SUPPL.)(pp 199-206), 2007.
Drug-induced delirium is a common matter in the elderly and anticholinergics,
together with a number of different drugs, may significantly contribute to the
delirium onset, especially in demented people. We report a case of a probable
anticholinergic drug-induced delirium in an elderly patient. An 80-year-old man
with Alzheimer's dementia presented with wandering, depressed mood with
crying, somatic worries, anedonism and suicide recurrent ideas. A first external
psychiatric assessment led to the diagnosis of melancholic depression and
therapy with haloperidol 2 mg/day, orphenadrine 100 mg daily, amitriptyline 40
mg/day, lorazepam 2 mg/day was started. Two weeks later patient suddenly
developed delirium, characterized by nocturnal agitation, severe insomnia,
daytime sedation, confusion, hallucinations and persecutory delusions. These
symptoms progressively worsened, with the consequent caregiver's stress. A
geriatric consultation axcluded the main causes of delirium, therefore both
Operative Units of Pharmacovigilance and Psychiatry were activated, for a
clinical pharmacological and psychiatric assessment. Haloperidol, amitriptyline
and orphenadrine were promptly dismissed. The patient began a treatment with
quetiapine 25 mg/day for two days, then twice a day, and infusion of saline 1000
ml/day for two days; psychiatric symptoms gradually diminished and therapy with
galantamine was begun. We postulate that this clinical report is suggestive for an
anticholinergic drug- induced delirium since the Naranjo probability scale
indicated a probable relationship between delirium and drug therapy. In
conclusion, a complete geriatric, pharmacological, and psychiatric evaluation
might be necessary in order to reduce the adverse drug reactions in older
patients treated with many drugs. copyright 2007 Elsevier Ireland Ltd. All rights
reserved.
Gaudreau, J. D., P. Gagnon, et al. (2007). "Opioid medications and longitudinal risk of
delirium in hospitalized cancer patients." Cancer 109(11): 2365-73.
BACKGROUND.: Delirium is an important problem in hospitalized cancer
patients. The objective of this study was to determine whether exposure to
corticosteroids, benzodiazepines, or opioids predicted delirium. METHODS.: A
prospective cohort study was conducted in an oncology/internal medicine
population. Patients were assessed continuously for the presence of delirium
until they were discharged by using the Nursing Delirium Screening Scale (NuDESC). Follow-up for outcome began after incident delirium. The primary
outcome was the presence of a delirium event, which was defined as a Nu-DESC
score >1. Strengths of associations of medications with delirium were expressed
as odds ratios (ORs) in univariate and multivariate analyses. RESULTS.: In total,
114 patients (1823 patient-days) met the inclusion criteria for the study. The
mean follow-up from incident delirium was 16 days. The mean number of
delirium events by patient was 6 (total number, 667 delirium events). Analysis by
day on several occasions revealed significant associations between opioids and
delirium. Corticosteroids and benzodiazepines were not associated significantly
with an increased risk of delirium on any given day. Analysis by patient using
generalized estimating equation (GEE) models showed an increased risk of
delirium on any day of follow-up associated with opioid exposure in univariate
analysis (OR of 1.70; P <.0001). The association remained significant after
adjustment for corticosteroid, benzodiazepine, and antipsychotic exposure using
GEE regressions (OR of 1.37; P =.0033). Truncating follow-up at 30 days did not
affect the results (OR of 1.38; P <.032). CONCLUSIONS.: Exposure to opioids
during hospitalization was associated significantly with an increased longitudinal
risk of delirium. Cancer 2007. (c) 2007 American Cancer Society.
Gemert van, L. A. and M. J. Schuurmans (2007). "The Neecham Confusion Scale and
the Delirium Observation Screening Scale: Capacity to discriminate and ease of use in
clinical practice." BMC Nursing 6: 3.
ABSTRACT: BACKGROUND: Delirium is a frequent form of psychopathology in
elderly hospitalized patients; it is a symptom of acute somatic illness. The
consequences of delirium include high morbidity and mortality, lengthened
hospital stay, and nursing home placement. Early recognition of delirium
symptoms enables the underlying cause to be diagnosed and treated and can
prevent negative outcomes. The aim of this study was to determine which of the
two delirium observation screening scales, the NEECHAM Confusion Scale or
the Delirium Observation Screening (DOS) scale, has the best discriminative
capacity for diagnosing delirium and which is more practical for daily use by
nurses. METHODS: The project was conducted on four wards of a university
hospital; 87 patients were included. During 3 shifts, these patients were observed
for symptoms of delirium, which were rated on both scales. A DSM-IV diagnosis
of delirium was made or rejected by a geriatrician. Nurses were asked to rate the
practical value of both scales using a structured questionnaire. RESULTS: The
sensitivity (0.89 - 1.00) and specificity (0.86 - 0.88) of the DOS and the
NEECHAM were high for both scales. Nurses rated the practical use of the DOS
scale as significantly easier than the NEECHAM. CONCLUSION: Successful
implementation of standardized observation depends largely on the consent of
professionals and their acceptance of a scale. In our hospital, we therefore chose
to involve nurses in the choice between two instruments. During the study they
were able to experience both scales and give their opinion on ease of use. In the
final decision on the instrument we found that both scales were very acceptable
in terms of sensitivity and specificity, so the opinion of the nurses was decisive.
They were positive about both instruments; however, they rated the DOS scale
as significantly easier to use and relevant to their practice. Our findings were
obtained from a single site study with a small sample, so a large comparative trial
to study the value of both scales further is recommended. On the basis of our
experience during this study and findings from the literature with regard to the
implementation of delirium guidelines, we will monitor the further implementation
of the DOS Scale in our hospital with intensive consultation.
George, J. and E. B. Mukaetova-Ladinska (2007). "Delirium and C-reactive protein."
Age & Ageing 36(2): 115-6.
Gillis, A. J. and B. MacDonald (2006). "Unmasking delirium." Canadian Nurse 102(9):
18-24.
The authors use a case study to illustrate the risks of delirium in older adult
patients and discuss ways to prevent, identify and manage its occurrence. An
estimated 60 to 80 per cent of hospitalized frail older adults experience at least
one preventable episode of delirium, often leading to prolonged hospitalization,
functional decline, increased morbidity and eventual nursing home placement or
death. Delirium is a medical emergency, characterized by acute onset and a
fluctuating course that is demonstrated by abrupt changes in mental status and
function. It has three categories: hyperactive, hypoactive and mixed. Although
delirium is amenable to expert nursing care, it is unrecognized or misdiagnosed
in up to 70 per cent of older patients. Delirium results from the interplay of
multiple forces associated with illness in the older adult, including drugs,
substance abuse, metabolic disturbances, nutritional deficiencies, fluid
disturbances, acute trauma or illness, infection and impaired physical or
functional ability A proactive strategy for delirium prevention and treatment
targets defined risk factors and the management of physiologic factors that
precipitate delirium. It includes assessment, therapeutic environmental
modification, standardized protocols for physiological interventions and staff
education. [References: 20]
Gold, J. A., B. Rimal, et al. (2007). "A strategy of escalating doses of benzodiazepines
and phenobarbital administration reduces the need for mechanical ventilation in delirium
tremens." Critical Care Medicine 35(3): 724-730.
Objective. Patients with severe alcohol withdrawal and delirium tremens are
frequently resistant to standard doses of benzodiazepines. Case reports suggest
that these patients have a high incidence of requiring intensive care and many
require mechanical ventilation. However, few data exist on treatment strategies
and outcomes for these subjects in the medical intensive care unit (ICU). Our
goal was a) to describe the outcomes of patients admitted to the medical ICU
solely for treatment of severe alcohol withdrawal and b) to determine whether a
strategy of escalating doses of benzodiazepines in combination with
phenobarbital would improve outcomes. Design: Retrospective cohort study.
Setting: Inner-city municipal hospital. Patients. Subjects admitted to the medical
ICU solely for the treatment of severe alcohol withdrawal. Interventions.,
Institution of guidelines emphasizing escalating doses of diazepam in
combination with phenobarbital. Measurements and Main Results: Preguideline
(n = 54) all subjects were treated with intermittent boluses of diazepam with an
average total and maximal individual dose of 248 mg and 32 mg, respectively;
17% were treated with phenobarbital. Forty-seven percent required intubation
due to inability to achieve adequate sedation and need for constant infusion of
sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4
days; p=.09) and higher incidence of nosocomial pneumonia (42 vs. 21% p=.08).
Postguide-line (n = 41) there were increases in maximum individual dose of
diazepam (32 vs. 86 mg; p =.001), total amount of diazepam (248 vs. 562 mg; p
=.001), and phenobarbital use (17 vs. 58%; p =.01). This was associated with a
reduction in the need for mechanical ventilation (47 vs. 22%; p =.008), with
trends toward reductions in ICU length of stay and nosocomial pneumonia.
Conclusions: Patients admitted to a medical ICU solely for treatment of severe
alcohol withdrawal have a high incidence of requiring mechanical ventilation.
Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if
necessary, significantly reduced the need for mechanical ventilation and showed
trends toward reductions in ICU length of stay and nosocomial infections.
[References: 43]
Good, P. (2006). "Re: efficacy, safety, and ethical validity of palliative sedation
therapy.[comment]." Journal of Pain & Symptom Management 31(3): 196-7; author reply
197-8.
Griffiths, R. D. and C. Jones (2007). "Delirium, cognitive dysfunction and posttraumatic
stress disorder." Current Opinion in Anaesthesiology 20(2): 124-9.
PURPOSE OF REVIEW: In the critically ill patient, disease and the therapies we
use impact on brain function. Simple tools are now available to recognise such
problems. This review highlights neuropsychiatric and cognitive observations that
have direct relevance to patient care and outcome. RECENT FINDINGS:
Delirium is a common event, especially the hypoactive forms in the elderly. The
recognition of significant cognitive dysfunction is worrying since it has profound
implications for how we treat and manage patients within intensive care and
beyond. The most important message is that the 'awake' intensive care unit
patient is not necessarily free of significant brain dysfunction. There is also the
added complication of psychological disturbances related to real or imagined
delusional experiences underlying the importance of memory and recall. Longerterm implications, particularly debilitating conditions such as posttraumatic stress
disorder, mean that there is a need for improved post-intensive care unit
rehabilitation care. SUMMARY: Health professionals working with the critically ill
must routinely include the assessment of brain cognitive function. While some of
the consequences may be unavoidable, we need to reassess our sedation and
care practices to ensure we are not confounding the problem. Practical options to
improve outcome are being developed and emphasise that the recovery from
critical illness is psychological as well as physical.
Hala, M. (2007). "Pathophysiology of postoperative delirium: Systemic inflammation as
a response to surgical trauma causes diffuse microcirculatory impairment." Medical
Hypotheses 68(1): 194-196.
Postoperative delirium represents a serious complication after major surgery.
Patients suffer from anxiety, hallucinations and delusions, and have higher
postoperative morbidity and mortality. Generally, the role of acetylcholine
deficiency in delirium pathophysiology is widely accepted. How this pathologic
state evolves in the postoperative period is the topic of this paper. Systemic
inflammation as a response to surgical trauma causes diffuse microcirculatory
impairment. The most relevant pathologies include leukocyte adhesion to vessel
lining, endothelial cell swelling, perivascular oedema, narrowing of capillar
diameters, and towered functional capillary density. These morphological
changes lead to a decrease of nutritive perfusion and to longer diffusion distance
for oxygen. Because acetylcholine synthesis is especially sensitive to low oxygen
tension, symptoms of its deficiency readily develop. Therapeutic toots to
modulate excessive inflammation are available, therefore new strategies of
delirium treatment should be implemented in clinical praxis, as well as in
preventive measures. (c) 2006 Elsevier Ltd. All rights reserved. [References: 5]
Halil, M., E. S. Cankurtaran, et al. (2006). "Elderly patient with delirium after myocardial
infarction." Journal of the National Medical Association 98(4): 648-50.
Delirium is a transient global disorder of cognition. Almost any medical illness or
medication can cause delirium. Here, we report a 71-year-old male who
presented to the emergency department with a sudden change in mental status,
which later resolved. An electrocardiogram was consistent with acute myocardial
infarction. The patient later developed symptoms of delirium, and haloperidol was
administered. The symptoms did not resolve, and risperidone was initiated
instead. The patient subsequently became hypotensive, and treatment was again
changed to olanzapine. He returned to full consciousness with olanzapine
treatment. When the potential hypotensive effects of haloperidol and risperidone
are taken into consideration, in patients with high cardiac risk, olanzapine may
provide a better option for the treatment of delirium.
Hoofring, L., M. Olsen, et al. (2007). "Management of delirium." Oncology (Huntington)
21(4 Suppl): 29-31.
Oncology providers are faced with delirium on a daily basis in both the inpatient
and outpatient settings. Using appropriate screening tests and a comprehensive
delirium safety protocol can empower both providers and family members and
assist in the protection of patients. While delirium cannot always be prevented,
knowledge of its pathophysiology, prevention, and treatment strategies can
minimize the effects and possibly shorten the duration. Treating Ms. B's delirium
and agitation allowed her to spend her remaining time peacefully with her family.
Hopkins, R. O. and J. C. Jackson (2006). "Assessing neurocognitive outcomes after
critical illness: are delirium and long-term cognitive impairments related?" Curr Opin Crit
Care 12(5): 388-94.
PURPOSE OF REVIEW: Critically ill patients have a high risk of developing
neurologic dysfunction including delirium and long-term cognitive impairment. In
this paper we examine possible relationships between delirium and long-term
cognitive impairments and explore this in the context of critical illness. RECENT
FINDINGS: Critical illness and its treatment can lead to neurologic morbidity
including neuropathological abnormalities, delirium, and cognitive impairments.
The association between delirium and long-term cognitive impairments has been
shown in a number of populations. Among intensive care unit cohorts, delirium
appears to be one of many possible causes of cognitive impairments and may be
a leading modifiable cause. The mechanisms of both delirium and intensive care
unit related cognitive impairment remain unclear, although a variety of common
mechanisms have been proposed. SUMMARY: Potential neurologic
consequences of critical illness include delirium and long-term cognitive
impairments. Defining the extent of their association in intensive care unit cohorts
is an important research priority due to the high prevalence of delirium and
persistent cognitive impairments in critically ill patients. Future research should
focus on strategies for the early identification of delirium and cognitive
impairments, elucidating mechanisms of brain injury, and the development and
implementation of therapeutic modalities designed to prevent or decrease
delirium and cognitive morbidity.
Hopkins, R. O. and J. C. Jackson (2006). "Long-term neurocognitive function after
critical illness." Chest 130(3): 869-78.
BACKGROUND: Until relatively recently, critical care practitioners have focused
on the survival of their patients and not on long-term outcomes. The incidence of
chronic neurocognitive dysfunction has been underestimated and underreported,
and only recently has it been studied in critically ill patients. However,
neurocognitive outcomes have been the subject of extensive investigation in
other medical populations for many years. METHODS: Review of the current
literature regarding long-term neurocognitive outcomes following critical illness.
RESULTS: Data from studies to date indicate that critical illness can lead to
significant neurocognitive impairments. The neurocognitive impairments persist
for months and years, and may have important consequences for quality of life,
the ability to return to work, overall functional ability, and substantial economic
costs. The mechanisms of the neurocognitive impairments are not fully
understood but likely include delirium, hypoxia, glucose dysregulation, metabolic
derangements, inflammation, and the effects of sedatives and narcotics among
other factors. The contributions of these factors may be particularly significant in
patients with preexisting vulnerabilities for the development of cognitive
impairments such as mild cognitive impairment, dementia, prior traumatic brain
injury, or other comorbid disorders associated with neurocognitive impairments.
CONCLUSIONS: Current research indicates that neurocognitive sequelae
following critical illness are common, may be permanent, and are associated with
impairments in daily function, decreased quality of life, and an inability to return
to work. Research needs to be done to better understand the prevalence, nature,
risk factors, and nuances of the neurocognitive impairments observed in ICU
survivors.
Hu, H., W. Deng, et al. (2006). "Olanzapine and haloperidol for senile delirium: A
randomized controlled observation." Zhongguo Linchuang Kangfu. Vol. 10(42)(pp 188190), 2006.
Background: Delirium is an acute organic brain syndrome caused by various
reasons, and it is common in elderly patients. Antipsychotics treatment is an
important method to control delirium. Objective: To observe the efficacy of new
antipsychotic agent of olanzapine and the traditional antipsychotic agent of
haloperidol in treating senile delirium. Design: A randomized controlled
observation. Setting: Mental Health Center, the First Affiliated Hospital of
Chongqing University of Medical Sciences. Participants: Totally 175 inpatients
with senile delirium were selected from the First Affiliated Hospital of Chongqing
University of Medical Sciences from September 2001 to September 2003, they
were randomly divided into olanzapine treatment group (n=74), haloperidol
treatment group n=72) and a control group(n=29). There were 111 males
(63.4%) and 64 females (36.6%). Delirium had occurred for a duration of 30
minutes to 17 days, with an average of (3.02+/-2.71) days. The enrolled patients
were clasSified according to the etiological factors of delirium: metabolic (n=68),
toxic (n=47), structural (n=25) and infectious (n=35). Methods: Different
treatments were used in different groups. Control group (n=29): The patients
were only given somatic treatment aiming at delirium, and not any drug for
central nervous system was used. Olanzapine group (n=74): Besides the somatic
treatment aiming at delirium, the pa- tients were given olanzapine (Zyprexa,
produced by Eli Lilly and Company, 5 mg/tablet) taken orally or sublingually
(fasted patients), the initial dosage was 1.25-2.5 mg per day, and then adjusted
to 1.25-20 mg per day. Haloperidol group (n=72): Besides the somatic treatment
aiming at delirium, they were, treated with intramuscular injection of haloperidol
(2.5-10 mg per day). The effects were prospectively observed for 1 week. The
scores were observed before enrollment and at 1-7 days respectively, the
severity of mental disorder and amelioration were evaluated by the clinical global
impression scale-severity of illness (CGI-SI) and global improvement item of
clinical global impression scale (CGI-GI). The dosage and time of administration
was taken as the dosage and time to take effect when the CGI-SI baseline
scores decreased by more than 1 point. Main Outcome Measures: The severity
of mental disorder and amelioration were observed. Results: 1 The scores of
CGI-SI after treatment were significantly de- creased in the olanzapine group,
haloperidol group and control group, and there were significant differences (P <
0.01). 2 The rates of marked effect in the three groups were 82.4%, 87.5% and
31.0%, respectively, and those in the two treatment groups were significantly
different from that in the control group (P < 0.01). 3 Both olanzapine and
haloperidol began to take effect at small dosages, and it was the fasted in the
olanzapine group, folowed by the haloperidol group, and slowest in the control
group. Conclusion: Olanzapine and haloperidol have similar effects in treating
senil-delirium. However, olanzapine is faster to take effect than haloperidol.
Hunter, K. F. and D. Cyr (2007). "The effect of delirium education on use of target PRN
medications in older orthopaedic patients." Age & Ageing 36(1): 98-101.
Inouye, S. K. (2006). "Delirium in older persons.[see comment][erratum appears in N
Engl J Med. 2006 Apr 13;354(15):1655]." New England Journal of Medicine 354(11):
1157-65.
Inouye, S. K., D. I. Baker, et al. (2006). "Dissemination of the hospital elder life program:
implementation, adaptation, and successes." Journal of the American Geriatrics Society
54(10): 1492-9.
OBJECTIVES: To describe the Hospital Elder Life Program (HELP) across
dissemination sites, to detail adaptations, and to summarize advantages across
sites. DESIGN: Cross-sectional survey. SETTING: HELP sites in acute care
hospitals. PARTICIPANTS: Thirteen sites that enrolled 11,344 patients.
MEASUREMENTS: Seventy-five closed- and open-ended questions describing
details of the HELP site, procedures, staffing, outcomes tracked, and
advantages. RESULTS: As of July 1, 2005, HELP had been fully implemented in
13 sites, with a median duration of 24 months (range 6.0-38.0). Although a high
degree of fidelity to the original model was maintained, variations existed in
staffing patterns, outcome tracking, and recommended HELP procedures.
Adaptations were made across multiple domains, including enrollment criteria at
15.4% of sites, screening and assessment tools at 61.5%, and individual
intervention protocols at 15.4% to 30.8%. Local circumstances drove these
adaptations, with the most common reasons being lack of adequate staffing and
logistical constraints. All sites conducted regular HELP staff meetings; other
recommended quality assurance procedures were conducted at 46.2% to 92.3%
of sites. Reported advantages of HELP included providing an educational
resource at 100% of sites, improving hospital outcomes (e.g., delirium and
functional decline) at 100%, providing nursing education and improving retention
at 100%, enhancing patient and family satisfaction with care at 92.3%, raising
visibility for geriatrics at 92.3%, and improving quality of care at 84.6%.
CONCLUSION: This report describes the real-world implementation of HELP
across 13 sites, documents their local adaptations and successes, and provides
insight into how motivated institutions can create change to improve quality of
care for older persons.
Inouye, S. K., Y. Zhang, et al. (2006). "Recoverable cognitive dysfunction at hospital
admission in older persons during acute illness." J Gen Intern Med 21(12): 1276-81.
BACKGROUND: While acute illness and hospitalization represent pivotal events
for older persons, their contribution to recoverable cognitive dysfunction (RCD)
has not been well examined. OBJECTIVE: Our goals were to estimate the
frequency and degree of RCD in an older hospitalized cohort; to examine the
relationship of RCD with delirium and dementia; and to determine 1-year
cognitive outcomes. DESIGN: Prospective cohort study. PARTICIPANTS: Four
hundred and sixty patients aged > or =70 years drawn from consecutive
admissions to an academic hospital. MEASUREMENTS: Patients underwent
interviews daily during hospitalization and at 1 year. The primary outcome was
RCD, defined as an admission Mini-Mental State Examination (MMSE) score that
improved by 3 or more points by discharge. RESULTS: Recoverable cognitive
dysfunction occurred in 179 of 460 (39%) patients, with MMSE impairment at
baseline ranging from 3 to 13 points (median=5.0 points). The majority of cases
were not characteristic of either delirium or dementia, as 144 of 179 (80%) cases
did not meet criteria for delirium, and 133 of 164 (81%) cases did not meet
criteria for dementia at baseline. In multivariable analysis controlling for baseline
MMSE level, 3 factors were predictive of RCD: higher educational level,
preadmission functional impairment, and higher illness severity. At 1 year, further
improvement in MMSE score occurred in 38 of 92 (41%) patients with RCD.
Recoverable cognitive dysfunction was independently predictive of 1-year
mortality with an adjusted odds ratio of 1.82 (95% confidence interval [95% CI]
1.03 to 3.20). CONCLUSIONS: Acute illness is accompanied by a high rate of
RCD that is neither characteristic of delirium or dementia. Our observations
underscore the reversible nature of this cognitive dysfunction with continued
improvement over the ensuing year, and highlight the potential clinical
implications of this under-recognized phenomenon.
Irimia, P., E. Martinez-Vila, et al. (2007). "Delirium due to brain microembolism:
Diagnostic value of diffusion-weighted MRI." Journal of Neuroimaging 17(2): 175-177.
Delirum is a common complication in hospitalized patients and it is characterized
by acute disturbances of consciousness, attention, cognition, and perception.
Despite the frequency with which it is observed, ischemic stroke is generally
considered as an unusual cause of delirium. A subtype of brain embolism is
characterized by multiple small emboli in different vascular territories, a condition
known as "brain microembolism." Given the high contrast of acute ischemic
lesions in diffusion weighted imaging (DWI) this technique is particularly helpful
to detect these small infarctions. We present here a patient with pulmonary
metastases who was treated with bronchial artery embolization and who
subsequently developed delirium due to brain microembolism. The embolic
material crossed through pulmonary arteriovenous fistulas, producing multiple
areas of cerebral ischemia. The ischemic lesions could be visualized only on
DWI, and they affected the periventricular region, caudate nucleus, thalamus,
and cerebellum. [References: 15]
Jones, R. N., F. M. Yang, et al. (2006). "Does educational attainment contribute to risk
for delirium? A potential role for cognitive reserve." Journals of Gerontology Series ABiological Sciences & Medical Sciences. Vol. 61(12)(pp 1307-1311), 2006.
Background. The objective of this study was to determine if level of educational
attainment, a marker of cognitive reserve, was associated with the cumulative
risk of delirium among hospitalized elders. Methods. We performed a secondary
analysis of two hospital-based studies. The first (study 1) was an observational
study involving 491 admissions. The second study (study 2) involved consecutive
admissions assigned to the usual care condition in a controlled clinical trial, and
included 461 persons. All participants were elderly (aged 70+) and free from
delirium at admission. The outcome was the occurrence of delirium, as rated by
the Confusion Assessment Method during hospitalization. Results. In study 1 and
2, 22% and 14% of persons developed delirium (cumulative incidence),
respectively. In both studies, risk of delirium was higher among persons with
fewer years of education. Controlling for the effect of age, sex, dementia,
comorbidity, and severity of illness, each year of completed education was
associated with a 0.91 lower odds of delirium (95% confidence interval: 0.87,
0.95): compared to persons with 12 years of education, persons with 7 years of
education had 1.6-fold increased odds of delirium (95% confidence interval: 1.4,
2.0). Conclusion. Hospitalized older persons with low educational attainment are
at increased risk for delirium relative to persons with more education. This finding
may have implications for the role of cognitive reserve in characterizing individual
differences in risk for delirium. Copyright 2006 by The Gerontological Society of
America.
Joosten, E., J. Lemiengre, et al. (2006). "Is anaemia a risk factor for delirium in an acute
geriatric population?" Gerontology. Vol. 52(6)(pp 382-385), 2006.
Background/Objective: Delirium is a common clinical problem in elderly patients.
We aim to investigate whether anaemia is a risk factor for delirium in a
hospitalized geriatric population. Methods: During a 5-month prospective study,
we investigated 190 elderly patients aged 70 years and older with a baseline
Mini-Mental State Examination (short version), Confusion Assessment Method,
demographic, clinical and laboratory data. Results: Thirty-four patients were
identified as delirious and 95 as anaemic according to the WHO criteria.
Stepwise logistic regression revealed that anaemia (haemoglobin level <12 g/l in
women and <13 g/l in men), male sex and a diagnosis of dementia were
independent risk factors for delirium in the total study group. After adjustment for
sex, age, diagnosis of dementia and dehydration, the odds ratio (OR) for
anaemia (2.4; 95 CI = 1.02-5.54) remained significantly associated with delirium.
When the study population was classified in groups according to sex, anaemia
remained a significant risk factor for delirium in men (OR = 3.7; 95% CI = 1.0315.6) after adjustment for the multiple variables but not in women (OR = 1.54;
95% CI = 0.48-4.9). When the haemoglobin levels were stratified into sex-specific
quartiles, the adjusted OR for delirium for men with a haemoglobin level less than
11.1 g/dl was 13.1 (95%CI = 1.17-146). Conclusion: Anaemia is an independent
risk factor for delirium and adds valuable information to previously validated
predictive models in men but not in women and lower haemoglobin levels were
associated with higher risk levels. Copyright copyright 2006 S. Karger AG.
Joshi, S. (2007). "Current concepts in the management of delirum." Missouri Medicine
104(1): 58-62.
Delirium is a serious complication of physical illness that is commonly seen in the
elderly individuals admitted to the hospital. It is associated with increased
mortality, increased length of stay in the hospital, institutionalization and other
complications. Multiple predisposing factors in the elderly them to make
vulnerable delirium. The developing diagnosis of delirium is often missed and the
condition is often poorly managed. There is increasing evidence suggesting that
primary prevention of delirium is the most effective treatment strategy. This
article presents current management for prevention and management of delirium.
[References: 29]
Kalisvaart, K. J., R. Vreeswijk, et al. (2006). "Risk factors and prediction of
postoperative delirium in elderly hip-surgery patients: implementation and validation of a
medical risk factor model." Journal of the American Geriatrics Society 54(5): 817-22.
OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of
elderly hip-surgery patients and to validate a medical risk stratification model.
DESIGN: Prospective cohort study. SETTING: Medical school-affiliated general
hospital in Alkmaar, the Netherlands. PARTICIPANTS: Six hundred three hipsurgery patients aged 70 and older screened for risk factors for postoperative
delirium. MEASUREMENTS: Predefined risk factors for delirium were assessed
on admission. One point was assigned for each of four risk factors present,
resulting in three groups: low, intermediate, and high risk. Baseline screening
and assessment included the Mini-Mental State Examination, the standardized
Snellen test for visual impairment, chart review to determine Acute Physiological
and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine
ratio. The primary outcome was postoperative delirium, as defined using
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and
Confusion Assessment Method criteria. All patients were screened daily for
delirium. RESULTS: Incidence of delirium was 3.8% in the low-risk group
(P<.001), 11.1% in the intermediate-risk group (P=.27, relative risk (RR)=3.0),
and 37.1% in the high-risk group (P<.001, RR=9.8). Cognitive impairment at
admission had the highest predictive value for postoperative delirium (coefficient
of determination=0.15). Contrary to previous findings, age was an independent
predictive factor for delirium. Moreover, postoperative delirium was four times as
frequent in acute patients as in elective hip-replacement patients.
CONCLUSION: The medical risk factor model is valid for elderly hip-surgery
patients. Cognitive impairment, age, and type of admission are important risk
factors for delirium in this surgical population.
Karlidag, R., S. Unal, et al. (2006). "The role of oxidative stress in postoperative
delirium." General Hospital Psychiatry 28(5): 418-23.
AIM: This study aimed to determine a marker that predicts delirium using
preoperative oxidative processes in patients undergoing cardiopulmonary bypass
surgery. METHOD: Twelve of the 50 patients included in the study showed signs
of delirium during postoperative follow-up. The Delirium Rating Scale was used in
patients with delirium according to DSM-IV-TR in the postoperative period.
Venous blood samples were obtained from the patients the day before and the
day after the surgery to determine plasma antioxidant enzyme levels. RESULTS:
While there were no differences in preoperative superoxide dismutase (SOD),
glutathione peroxidase (GSH-Px) and malondialdehyde (MDA) levels in both
groups, catalase (CAT) levels were significantly lower in the delirium group.
Postoperative SOD and MDA levels were also higher in the delirium group, while
the GSH-Px levels were found to be lower when compared with those during the
preoperative period. In the nondelirium group, the postoperative MDA and GSHPx levels were found to be lower than preoperative levels, and postoperative
SOD levels were found to be higher than preoperative levels. CAT levels were
lower in the delirium group when the pre- and postoperative levels were
compared in both groups. The postoperative levels of SOD, GSH-Px and CAT in
the nondelirium group and MDA in the delirium group were significantly higher
than preoperative levels. CONCLUSION: Patients with low preoperative CAT
levels appeared to be more susceptible to delirium than patients with higher CAT
levels.
Kawaguchi, Y., M. Kanamori, et al. (2006). "Postoperative delirium in spine surgery."
Spine Journal: Official Journal of the North American Spine Society 6(2): 164-9.
BACKGROUND CONTEXT: Postoperative delirium is a great concern in the
treatment of hip fracture. However, there have been no reports regarding the
postoperative delirium in spine surgery. PURPOSE: To determine the incidence
and risk factors for postoperative delirium in the patients who have had spine
surgery. STUDY DESIGN/SETTING: The incidence and intraoperative risk
factors of postoperative delirium were retrospectively examined in patients who
had spine surgery during a 3-year period. PATIENT SAMPLE: Three hundred
forty-one patients who underwent spine surgery from 2000 to 2002 were
included. METHODS: The presence of delirium was determened by the
Confusion Assessment Method. Laboratory data were checked preoperatively, at
1 day and 1 week postoperatively. The prognosis of postoperative delirium was
evaluated. RESULTS: Postoperative delirium was found in 13 patients; all of
them were in their 70's or 80's. The incidence of delirium was 12.5% in the
patients over 70 years old. Hemoglobin and hematocrit levels at 1 day after
surgery in the delirium group were significantly lower than those in the control
group. One patient had persistent cognitive dysfunction after surgery. Two
patients who developed postoperative delirium died during the follow-up period.
CONCLUSION: Low concentrations of hemoglobin and hematocrit 1 day after
surgery were risk factors for postoperative delirium. As delirium is thought to
represent not only brain dysfunction, but also impaired general physical
condition, careful observation is necessary for the management of patients with
postoperative delirium.
Kazmierski, J., M. Kowman, et al. (2006). "Preoperative predictors of delirium after
cardiac surgery: a preliminary study." General Hospital Psychiatry 28(6): 536-8.
Preoperative risk factors of postoperative delirium were evaluated in 260 patients
admitted for open heart surgery. The incidence of delirium was 11.5%.
Independent predictors included cognitive impairment, atrial fibrillation, a history
of peripheral vascular disease major depression and advanced age.
Aforementioned factors might be helpful in predicting delirium following cardiac
surgery.
Khan, A. Y., M. N. Kalimuddin, et al. (2007). "Neuropsychiatric manifestations of
phenytoin toxicity in an elderly patient." Journal of Psychiatric Practice 13(1): 49-54.
Kiely, D. K., R. N. Jones, et al. (2007). "Association between psychomotor activity
delirium subtypes and mortality among newly admitted postacute facility patients."
Journals of Gerontology Series A-Biological Sciences & Medical Sciences 62(2): 174-9.
BACKGROUND: Delirium is common among hospitalized elders and may persist
for months. Therefore, the adverse impact of delirium on independence often
occurs in the postacute care (PAC) setting. The effect of psychomotor subtypes
on delirium remains uncertain. The purpose of this study is to examine the
association between psychomotor activity delirium subtypes and 1-year mortality
among 457 newly admitted delirious PAC patients. METHODS: Patients were
screened for delirium on admission to PAC facilities after an acute
hospitalization, and patients with "Confusion Assessment Method"-defined
delirium were enrolled. Psychomotor activity was assessed using the Memorial
Delirium Assessment Scale, and patients were classified as to their delirium
subtype (hyperactive, hypoactive, mixed, or normal). One-year mortality data
were obtained from the National Death Index. A Kaplan-Meier survival analysis
and a proportional hazards analysis using indicator (dummy) variables with
normal psychomotor activity as the referent were performed. RESULTS: The
normal psychomotor activity group had the lowest 1-year mortality rate, followed
by the hyperactive, mixed, then hypoactive groups in increasing order.
Independent of age, gender, comorbidity, dementia, and delirium severity,
hypoactive patients were 1.60 (95% confidence interval [CI], 1.09-2.35) times
more likely to die during the 1-year follow-up period than were patients with
normal psychomotor activity. The hyperactive (hazard ratio = 1.30; 95% CI, 0.732.31) and mixed (hazard ratio = 1.25; 95% CI, 0.72-2.17) psychomotor groups
had nonsignificant elevated risks relative to the normal psychomotor behavior
group. CONCLUSIONS: All three psychomotor disturbance subtypes had an
elevated risk of dying during the 1-year follow-up relative to the normal
psychomotor group, though the hypoactive group had the highest mortality risk
and was the only group with a statistically significantly elevated risk relative to the
normal group.
Kiely, D. K., R. N. Jones, et al. (2006). "Association between delirium resolution and
functional recovery among newly admitted postacute facility patients." Journals of
Gerontology Series A-Biological Sciences & Medical Sciences 61(2): 204-8.
BACKGROUND: Delirium is common among hospitalized elders and may persist
for months. The adverse impact of delirium on independence may increasingly
occur in the postacute care (PAC) setting. The purpose of this study is to
examine the association between delirium resolution and functional recovery in
skilled nursing facilities specializing in PAC. METHODS: Patients were screened
for delirium on admission after an acute hospitalization at PAC facilities. Only
patients with "Confusion Assessment Method"-defined delirium were enrolled.
Delirium and activities of daily living were assessed prehospital, at PAC
admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments
to measure functional ability. Four distinct delirium resolution groups were
created ranging from resolution within 2 weeks without recurrence to no
resolution over 6 months. Repeated-measures analysis of covariance was used
to determine if functional performance differed over time by delirium resolution
status. RESULTS: Among the 393 PAC patients, functional recovery differed
significantly (p <.0001) by delirium resolution status. Patients who resolved their
delirium by 2 weeks without recurrence regained 100% of their prehospital
functional level, whereas patients who never resolved their delirium retained less
than 50% of their prehospital functional level. Patients with slower resolving
delirium and recurrent delirium had intermediate functional outcomes.
CONCLUSIONS: Resolution of delirium among PAC patients appears to be a
prerequisite for functional recovery. Delirium resolution within 2 weeks without
recurrence is associated with excellent functional recovery. Effective strategies to
resolve delirium promptly and prevent its recurrence in the PAC setting will likely
benefit patient rehabilitation and functional recovery.
Kunig, G., S. Datwyler, et al. (2006). "Unrecognised long-lasting tramadol-induced
delirium in two elderly patients. A case report." Pharmacopsychiatry 39(5): 194-9.
We present the cases of two elderly patients with intermittent long-term tramadol
intake against chronic back pain. Over a period of more than two years they
experienced fluctuating confusional states and cognitive deficits, reversible only
after discontinuation of tramadol. According to the DSM IV-criteria, an
unrecognised recurrent tramadol-induced delirium can be diagnosed in both
cases. Although tramadol may represent a well established safe therapy for
chronic non-malignant pain in the elderly, these cases demonstrate that it should
be applied with caution even in healthy subjects.
Kuzak, N., J. R. Brubacher, et al. (2007). "Reversal of salicylate-induced euglycemic
delirium with dextrose." Clinical Toxicology: The Official Journal of the American
Academy of Clinical Toxicology & European Association of Poisons Centres & Clinical
Toxicologists 45(5): 526-9.
Salicylate poisoning inhibits Krebs cycle enzymes and uncouples oxidative
phosphorylation. Under these circumstances, we hypothesize that CNS glucose
supply is sometimes unable to keep up with demand resulting in
hypoglycorrhacia and delirium even in the face of serum euglycemia. Supporting
this conjecture, we report two euglycemic patients with salicylate-induced
delirium who responded to boluses of concentrated dextrose with a prompt
improvement in mental status.
Kwatra, M. M. (2006). "Delirium in older persons.[comment]." New England Journal of
Medicine 354(23): 2509-11; author reply 2509-11.
Lacasse, H., M. M. Perreault, et al. (2006). "Systematic review of antipsychotics for the
treatment of hospital-associated delirium in medically or surgically ill patients." Ann
Pharmacother 40(11): 1966-73.
OBJECTIVE: To determine which antipsychotic is associated with the greatest
efficacy and safety when used for the pharmacotherapeutic management of
delirium in medically or surgically ill patients. DATA SOURCES: MEDLINE,
Current Contents, Cumulative Index of Nursing and Allied Health Literature,
PsycINFO, Biological Abstracts, Cochrane Central Register of Controlled Trials,
and EMBASE databases (all to July 2006) were searched for trials evaluating the
pharmacologic treatment of delirium in medically or surgically ill patients. The key
terms used included delirium, agitation, or acute confusion, and antipsychotics,
phenothiazine, butyrophenone, perphenazine, fluphenazine, clozapine,
trifluorophenazine, loxapine, thioridazine, pimozide, molindone, haloperidol,
methotrimeprazine, chlorpromazine, prochlorperazine, droperidol, risperidone,
quetiapine, ziprasidone, amisulpride, or olanzapine. STUDY SELECTION AND
DATA EXTRACTION: Prospective, randomized, controlled trials comparing the
clinical effects of antipsychotic therapy with placebo or comparing 2 antipsychotic
treatments in an acute care setting were selected. Studies involving dementiaassociated delirium, Alzheimer's disease-associated delirium, emergency
department-associated acute agitation, acute brain trauma-associated agitation,
or agitation secondary to underlying psychiatric afflictions such as depression or
schizophrenia were excluded. All studies were evaluated independently by the 3
authors using a validated evaluation tool. Outcomes related to both efficacy and
safety were collected. Four prospective trials were included in this systematic
review. DATA SYNTHESIS: Antipsychotic agents, either atypical or typical, were
effective compared with baseline for the treatment of delirium in medically or
surgically ill patients without underlying cognitive disorders. Oral haloperidol was
associated with more frequent extrapyramidal side effects, but overall, all agents
were well tolerated. Interpretation of the published evidence is limited by the
small sample sizes, varied patient populations, and comparative agents of the
studies reviewed. CONCLUSIONS: The comparative studies evaluated here
suggest that antipsychotic drugs are efficacious, when compared with baseline,
and safe for the treatment of delirium. Haloperidol remains the most studied
agent. Recommendation of one antipsychotic over another as a first-line
pharmacologic intervention in the treatment of hospital-associated delirium is
limited by the quality and quantity of data available. Better designed and larger
studies evaluating the addition of antipsychotic agents to nonpharmacologic
treatments are needed to measure the true effect of pharmacologic treatment.
Lancon, C. (2007). "[Acute agitation and delirium]." Revue du Praticien 57(2): 207-10.
Lankarani-Fard, A. and S. C. Castle (2006). "Postoperative delirium and Ogilvie's
syndrome resolving with neostigmine." Journal of the American Geriatrics Society 54(6):
1016-7.
Lantz, M. S. (2007). "Postoperative delirium in an elderly male: When the confusion
persists." Clinical Geriatrics. Vol. 15(2)(pp 23-26), 2007.
Delirium is an acute confusional state characterized by a disturbance of
consciousness with fluctuations over time. A reduced ability to focus, sustain, or
shift attention is a central feature of delirium. Sleep-wake cycle disturbances are
common, and abnormalities of cognition, perceptual disturbances, and a reduced
awareness of one's environment typically accompany delirium. The onset of
symptoms in the elderly is typically rapid following the development of the
medical condition, medication effects, substance use, or other multiple factors
that cause delirium. The prevalence of delirium among the hospitalized elderly
ranges from 10% to 40% for medical inpatients to up to 60% for postoperative hip
surgery patients. In this AAGP Psychiatry Rounds column, Dr. Lantz discusses
risk factors of and treatment approaches for delirium.
Leentjens, A. F. and R. C. van der Mast (2005). "Delirium in elderly people: an update."
Current Opinion in Psychiatry 18(3): 325-30.
PURPOSE OF REVIEW: To review recent studies on epidemiology, diagnosis,
pathophysiology, treatment and prevention of delirium in elderly people.
RECENT FINDINGS: There is no evidence that the clinical picture of delirium in
elderly people differs from that in younger patients, although it may run a more
chronic course. Diagnosing delirium in demented patients, however, may be
difficult due to overlap in symptoms of delirium and dementia. Systematic use of
screening and diagnostic instruments may help to diminish the common
underdiagnosis of delirium. Delirium is best understood as the result of multiple
interacting predisposing and precipitating factors. In the elderly, predisposing
factors that make patients more susceptible for delirium include cognitive
dysfunction and older age, while important precipitating factors that directly
cause delirium are any somatic events and the use of anticholinergic drugs.
Delirium has a significant negative prognostic impact on functional and cognitive
outcome, as well as on morbidity and mortality. Haloperidol remains the standard
treatment for delirium, while there is some evidence for the efficacy of
risperidone. Other atypical antipsychotics, as well as cholinesterase inhibitors,
have not yet been sufficiently studied. Results of studies on the effectiveness of
systematic screening of populations at risk and standardized interventions to
prevent delirium have been inconclusive. SUMMARY: In recent years, the
emphasis in the approach to delirium has shifted from ad hoc treatment to
systematic screening and prevention. Interest has been raised in treatment
options other than haloperidol, such as atypical antipsychotics and procholinergic
drugs.
Lepouse, C., C. A. Lautner, et al. (2006). "Emergence delirium in adults in the postanaesthesia care unit." British Journal of Anaesthesia 96(6): 747-53.
BACKGROUND: Emergence delirium in the post-anaesthesia care unit (PACU)
is poorly understood. The goal of this prospective study was to determine
frequency and risk factors of emergence delirium in adults after general
anaesthesia. METHODS: In this prospective study, 1,359 consecutive patients
were included. Contextual risk factors and occurrence of delirium according to
the Riker sedation scale were documented. Groups were defined for the analysis
according to the occurrence or not of agitation, then after exclusion of patients
with preoperative anxiety and neuroleptics, or both, and antidepressants or
benzodiazepines treatments. RESULTS: Sixty-four (4.7%) patients developed
delirium in the PACU, which can go from thrashing to violent behaviour and
removal of tubes and catheters. Preoperative anxiety was not found to be a risk
factor. Preoperative medication by benzodiazepines (OR=1.910, 95% CI=1.1013.315, P=0.021), breast surgery (OR=5.190, 95% CI=1.422-18.947, P=0.013),
abdominal surgery (OR=3.206, 95% CI=1.262-8.143, P=0.014), and long
duration of surgery increased the risk of delirium (OR=1.005, 95% CI=1.0021.008, P=0.001), while a previous history of illness and long-term treatment by
antidepressants decreased the risk (respectively, OR=0.544, 95% CI=0.3150.939, P=0.029 and OR=0.245, 95% CI=0.084-0.710, P=0.010).
CONCLUSIONS: Preoperative benzodiazepines, breast and abdominal surgery
and surgery of long duration are risk factors for emergence delirium.
Leung, J. M., L. P. Sands, et al. (2006). "Pilot clinical trial of gabapentin to decrease
postoperative delirium in older patients." Neurology 67(7): 1251-3.
In this randomized pilot clinical trial, the authors tested the hypothesis that using
gabapentin as an add-on agent in the treatment of postoperative pain reduces
the occurrence of postoperative delirium. Postoperative delirium occurred in 5/12
patients (42%) who received placebo vs 0/9 patients who received gabapentin, p
= 0.045. The reduction in delirium appears to be secondary to the opioid-sparing
effect of gabapentin.
Leung, J. M., L. P. Sands, et al. (2006). "Nitrous oxide does not change the incidence of
postoperative delirium or cognitive decline in elderly surgical patients." British Journal of
Anaesthesia 96(6): 754-60.
BACKGROUND: Postoperative delirium and cognitive decline are common in
elderly surgical patients after non-cardiac surgery. Despite this prevalence and
clinical importance, no specific aetiological factor has been identified for
postoperative delirium and cognitive decline. In experimental setting in a rat
model, nitrous oxide (N(2)O) produces neurotoxic effect at high concentrations
and in an age-dependent manner. Whether this neurotoxic response may be
observed clinically has not been previously determined. We hypothesized that in
the elderly patients undergoing non-cardiac surgery, exposure to N(2)O resulted
in an increased incidence of postoperative delirium than would be expected for
patients not receiving N(2)O. METHODS: Patients who were >or=65 yr of age,
undergoing non-cardiac surgery and requiring general anaesthesia were
randomized to receive an inhalational agent and either N(2)O with oxygen or
oxygen alone. A structured interview was conducted before operation and for the
first two postoperative days to determine the presence of delirium using the
Confusion Assessment Method. RESULTS: A total of 228 patients were studied
with a mean (range) age of 73.9 (65-95) yr. After operation, 43.8% of patients
developed delirium. By multivariate logistic regression, age [odds ratio (OR) 1.07;
95% confidence interval (CI) 1.02-1.26], dependence on performing one or more
independent activities of daily living (OR 1.54; 95% CI 1.01-2.35), use of patientcontrolled analgesia for postoperative pain control (OR 3.75; 95% CI 1.27-11.01)
and postoperative use of benzodiazepine (OR 2.29; 95% CI 1.21-4.36) were
independently associated with an increased risk for postoperative delirium. In
contrast, the use of N(2)O had no association with postoperative delirium.
CONCLUSIONS: Exposure to N(2)O resulted in an equal incidence of
postoperative delirium when compared with no exposure to N(2)O.
Levine, M., H. Nikkanen, et al. (2006). "Weakness and mental status change." Journal
of Emergency Medicine 30(3): 341-4.
Lim, C. J., C. Trevino, et al. (2006). "Can olanzapine cause delirium in the elderly?"
Annals of Pharmacotherapy 40(1): 135-8.
OBJECTIVE: To report a case of delirium probably caused by the atypical
antipsychotic olanzapine in a 74-year-old man with dementia. CASE SUMMARY:
A 74-year-old white man with a diagnosis of severe dementia of mixed etiology
with behavioral disturbances was admitted to an urban teaching hospital for
increasing agitation in the context of worsening dementia. Olanzapine 2.5 mg
each evening was started for agitation, and the dose was titrated to 5 mg each
evening with additional emergent doses. Memantine, an N-methyl-D-aspartate
antagonist, was increased from the admission dose of 10 mg/day to 15 mg/day.
The patient developed symptoms of delirium on hospital day 4. Neuroleptic
malignant syndrome and other causes of delirium were ruled out. Discontinuation
of olanzapine resulted in resolution of the delirium. DISCUSSION: Antipsychotic
medications are commonly used to treat symptoms of delirium. Atypical
antipsychotics are better tolerated in the elderly because of their fewer adverse
reactions compared with other antipsychotics. Olanzapine has been successfully
used in the treatment of delirium. However, there have been case reports of
delirium associated with olanzapine, probably related to its intrinsic
anticholinergic effect. Application of the Naranjo probability scale indicated a
probable relationship between the onset of delirium and the use of olanzapine in
this patient. As of December 1, 2005, this was the second such report of a case
in the elderly. CONCLUSIONS: Although olanzapine is useful in the treatment of
delirium, elderly patients treated with this drug can develop delirium and hence
should be closely monitored.
Liptzin, B., A. Laki, et al. (2005). "Donepezil in the prevention and treatment of postsurgical delirium." American Journal of Geriatric Psychiatry. Vol. 13(12)(pp 1100-1106),
2005.
Objective: Delirium is a frequent complication of major surgery in older persons.
The authors evaluated the possible benefit of donepezil versus placebo in the
prevention and treatment of postoperative delirium in an older population without
dementia undergoing elective total joint-replacement surgery. Methods: A sample
of 80 patients participated in this randomized, double-blind, placebo-controlled
trial of donepezil. Each participant was evaluated before surgery and then
received donepezil or placebo for 14 days before surgery and 14 days afterward.
Postoperative delirium was assessed with the Delirium Symptom Interview,
Confusion Assessment Method, daily medical record, nurse-observation reviews,
and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also
assessed for each participant. Results: Delirium, diagnosed by DSM-IV criteria,
was found on at least 1 postoperative day in 18.8% of subjects, but there were
no significant differences between the donepezil and placebo groups. When
delirium was present, it lasted only 1 day, and there was no difference between
the groups. Subsyndromal delirium was found on at least 1 postoperative day for
68.8% of subjects, and, when this occurred, lasted 2 days or less, on average.
There was no difference between the groups in the occurrence or duration of
subsyndromal delirium. There was no difference between the groups in
disposition to home or to another facility. Conclusions: This pilot study was
unable to demonstrate a benefit for donepezil in preventing or treating delirium in
a relatively young and cognitively-intact group of elderly patients undergoing
elective orthopedic surgery. Furthermore, postoperative delirium was not a major
problem in this population. copyright 2005 American Association for Geriatric
Psychiatry.
Logan, C. J. and J. T. Stewart (2007). "Treatment of post-electroconvulsive therapy
delirium and agitation with donepezil." Journal of ECT 23(1): 28-9.
Delirium and agitation are commonly encountered after administration of
electroconvulsive therapy (ECT). Management is generally fairly straightforward,
although some patients may have a severe, prolonged, or refractory course. We
recently cared for a 65-year-old man who consistently developed severe and
very prolonged post-ECT delirium that did not respond to typical pharmacological
agents; the duration of delirium was dramatically shortened by the addition of
donepezil. Cholinesterase inhibitors may have a place in mitigating severe and
prolonged post-ECT delirium.
Lonergan, E., A. Britton, et al. (2007). "Antipsychotics for delirium." Cochrane Database
of Systematic Reviews(2): CD005594.
BACKGROUND: Delirium occurs in up to 30% of hospitalised patients and is
associated with prolonged hospital stay and increased morbidity and mortality.
Recently published reports have suggested that the standard drug for delirium,
haloperidol, a typical antipsychotic that may cause adverse extrapyramidal
symptoms among patients, may be replaced by atypical antipsychotics such as
risperidone, olanzapine or quetiapine, that are as effective as haloperidol in
controlling delirium, but that have a lower incidence of extrapyramidal adverse
effects. OBJECTIVES: To compare the efficacy and incidence of adverse effects
of haloperidol with risperidone, olanzapine, and quetiapine in the treatment of
delirium. SEARCH STRATEGY: The trials were identified from a search of the
Specialized Register of the Cochrane Dementia and Cognitive Improvement
Group on 7 August 2006 using the search terms:haloperidol or haldol or
risperidone or risperdal* or quetiapine or seroquel* or olanzapine or zyprexa* or
aminotriazole or sertindole or leponex* or zeldox* or ziprasidone. SELECTION
CRITERIA: Types of studies included unconfounded, randomised trials with
concealed allocation of subjects. For inclusion trials had to have assessed
patients pre- and post-treatment. Where cross-over studies are included, only
data from the first part of the study were examined. Interrupted time series were
excluded. Length of trial and number of measurements did not influence the
selection of trials for study. Where indicated, individual patient data were
requested for further examination. DATA COLLECTION AND ANALYSIS: Two
reviewers extracted data from included trials. Data were pooled where possible,
and analysed using appropriate statistical methods. Odds ratios of average
differences were calculated. Only 'intention to treat' data were included. Analysis
included haloperidol treated patients, compared with placebo. MAIN RESULTS:
Three studies were found that satisfied selection criteria. These studies
compared haloperidol with risperidone, olanzapine, and placebo in the
management of delirium and in the incidence of adverse drug reactions.
Decrease in delirium scores were not significantly different comparing the effect
of low dose haloperidol (< 3.0 mg per day) with the atypical antipsychotics
olanzapine and risperidone (Odds ratio 0.63 (95% CI 10.29 - 1.38; p = 0.25). Low
dose haloperidol did not have a higher incidence of adverse effects than the
atypical antipsychotics. High dose haloperidol (> 4.5 mg per day) in one study
was associated with an increased incidence of extrapyramidal adverse effects,
compared with olanzapine. Low dose haloperidol decreased the severity and
duration of delirium in post-operative patients, although not the incidence of
delirium, compared to placebo controls in one study. There were no controlled
trials comparing quetiapine with haloperidol. AUTHORS' CONCLUSIONS: There
is no evidence that haloperidol in low dosage has different efficacy in comparison
with the atypical antipsychotics olanzapine and risperidone in the management of
delirium or has a greater frequency of adverse drug effects than these drugs.
High dose haloperidol was associated with a greater incidence of side effects,
mainly parkinsonism, than the atypical antipsychotics. Low dose haloperidol may
be effective in decreasing the degree and duration of delirium in post-operative
patients, compared with placebo.These conclusions must be tempered by the
observation that they are based on small studies of limited scope, and therefore
will require further corroborating evidence before they can be translated into
specific recommendation for the treatment of delirium.
Lyons, W. L. (2006). "Delirium in postacute and long-term care." Journal of the
American Medical Directors Association 7(4): 254-61.
Delirium is a classic geriatric syndrome that occurs commonly among the frail
elders who make up many of the residents in postacute and long-term care
facilities. The prevalence of the disorder in these settings may be increasing as a
result of the pressure to reduce hospital length of stay. Clinicians often do not
recognize when patients in their care are delirious, but simple and practical
means exist to allow its diagnosis. Those who practice in long-term care must be
knowledgeable about the risk factors for the disorder, as well as how to
recognize, diagnose, prevent, and treat it. [References: 46]
Macdonald, A., D. Adamis, et al. (2007). "C-reactive protein levels predict the incidence
of delirium and recovery from it [2]." Age & Ageing. Vol. 36(2)(pp 222-225), 2007.
MacLullich, A. M., D. J. Meagher, et al. (2007). "The European delirium association."
Journal of Psychosomatic Research 62(3): 397-8.
Margiotta, A., A. Bianchetti, et al. (2006). "Clinical characteristics and risk factors of
delirium in demented and not demented elderly medical inpatients." Journal of Nutrition,
Health & Aging 10(6): 535-9.
OBJECTIVES: to evaluate the differences in clinical characteristics and risk
factors of delirium in elderly medical inpatients according to the presence or not
of dementia. DESIGN: cross-sectional, observational study. SETTING: acute
medical care unit (ACU) of a general hospital. PARTICIPANTS: 330 patients
aged 65 and older consecutively admitted on a 24-week period.
MEASUREMENTS: Functional status, cognitive abilities, severity of acute illness
(Acute Physiology, Age and Chronic Health Evaluation (APACHE II) score),
Confusion Assessment Method (CAM), Delirium Rating Scale (DRS) and One
Day Fluctuation Scale (ODFS). RESULTS: patients with delirium represent
19.1% of the sample, 41.0% of which had also dementia. Hyperactive form of
delirium was 41.0%; hypoactive 11.0% and mixed 48.0%. In non demented
patients, the delirious patients showed higher APACHE II score, more severe
functional decline, poorer cognitive status respect to not delirious. In demented
patients no differences were found in APACHE II score and cognitive status
among delirious and not delirious subjects. In this group, functional decline (p
=.012), acute infection (p =.007), psychotropic drugs use (p =.028) and severe
hypoalbuminemia (p =.036) represented risk factors for the onset of delirium.
Demented patients had higher perceptual disturbances (p =.040) and less severe
delusions (p =.001), while total DRS score do not differs in the two groups.
According to ODFS, delirium episode was more fluctuating in patients with
dementia. CONCLUSION: clinical characteristics and risk factors of delirium are
different in demented and not demented elderly inpatients. Patients with
dementia are vulnerable to delirium at lower levels of medical acuity than nondemented patients.
McAvay, G. J., P. H. Van Ness, et al. (2007). "Depressive symptoms and the risk of
incident delirium in older hospitalized adults." Journal of the American Geriatrics
Society. Vol. 55(5)(pp 684-691), 2007.
OBJECTIVES: To determine whether specific subsets of symptoms from the
Geriatric Depression Scale (GDS), assessed at hospital admission, were
associated with the incidence of delirium. DESIGN: Secondary analysis of a
prospective cohort study of patients from the Delirium Prevention Trial.
SETTING: General medicine service at Yale New Haven Hospital, March 25,
1995, through March 18, 1998. PARTICIPANTS: Four hundred sixteen patients
aged 70 and older who were at intermediate or high risk for delirium and were not
taking antidepressants at hospital admission. MEASUREMENTS: Depressive
symptoms were assessed GDS, and daily assessments of delirium were
obtained using the Confusion Assessment Method. RESULTS: Of the 416
patients in the analysis sample, 36 (8.6%) developed delirium within the first 5
days of hospitalization. Patients who developed delirium reported 5.7 depressive
symptoms on average, whereas patients without delirium reported an average of
4.2 symptoms. Using a Cox proportional hazards model, it was found that
depressive symptoms assessing dysphoric mood and hopelessness were
predictive of incident delirium, controlling for measures of physical and mental
health. In contrast, symptoms of withdrawal, apathy, and vigor were not
significantly associated with delirium. CONCLUSION: These findings suggest
that assessing symptoms of dysphoric mood and hopelessness could help
identify patients at risk for incident delirium. Future studies should evaluate
whether nonpharmacological treatment for these symptoms reduces the risk of
delirium. copyright 2007, The American Geriatrics Society.
McAvay, G. J., P. H. Van Ness, et al. (2006). "Older adults discharged from the hospital
with delirium: 1-year outcomes." Journal of the American Geriatrics Society 54(8): 124550.
OBJECTIVES: To compare 1-year institutionalization and mortality rates of
patients who were delirious at discharge, patients whose delirium resolved by
discharge, and patients who were never delirious in the hospital. DESIGN:
Secondary analysis of prospective cohort data from the Delirium Prevention Trial.
SETTING: General medicine service at Yale New Haven Hospital, March 25,
1995, through March 18, 1998, with follow-up interviews completed in 2000.
PARTICIPANTS: Four hundred thirty-three patients aged 70 and older who were
not delirious at admission. MEASUREMENTS: Patients underwent daily
assessments of delirium from admission to discharge using the Confusion
Assessment Method. Nursing home placement and mortality were determined at
1-year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at
discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378
(87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients
discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and
157 of 378 (41.5%) patients who were never delirious were admitted to a nursing
home or died. Compared with patients who were never delirious, patients with
delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95%
confidence interval (CI)=1.60-4.35) for nursing home placement or mortality,
whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43). CONCLUSION:
Delirium at discharge is associated with a high rate of nursing home placement
and mortality over a 1-year follow-up period. Interventions to increase detection
of delirium and improvements in transitional care may help reduce these negative
outcomes.
Meagher, D. J., M. Moran, et al. (2007). "Phenomenology of delirium: Assessment of
100 adult cases using standardised measures." British Journal of Psychiatry. Vol.
190(FEB.)(pp 135-141), 2007.
Background: Delirium phenomenology is understudied. Aims: To investigate the
relationship between cognitive and non-cognitive delirium symptoms and test the
primacy of inattention in delirium. Method: People with delirium (n=100) were
assessed using the Delirium Rating Scale-Revised-98 (DRS-R98) and Cognitive
Test for Delirium (CTD). Results: Sleep-wake cycle abnormalities and inattention
were most frequent, while disorientation was the least frequent cognitive deficit.
Patients with psychosis had either perceptual disturbances or delusions but not
both. Neither delusions nor hallucinations were associated with cognitive
impairments. Inattention was associated with severity of other cognitive
disturbances but not with non-cognitive items. CTD comprehension correlated
most closely with non-cognitive features of delirium. Conclusions: Delirium
phenomenology is consistent with broad dysfunction of higher cortical centres,
characterised in particular by inattention and sleep-wake cycle disturbance.
Attention and comprehension together are the cognitive items that best account
for the syndrome of delirium. Psychosis in delirium differs from that in functional
psychoses.
Meyer, R. R., P. Munster, et al. (2007). "Isoflurane is associated with a similar incidence
of emergence agitation/delirium as sevoflurane in young children - a randomized
controlled study." Pediatric Anesthesia 17(1): 56-60.
Background: Children may be agitated or even delirious especially when
recovering from general anesthesia using volatile anesthetics. Many trials have
focused on the newer agents sevoflurane and desflurane but for the widely used
isoflurane little is known about its potential to generate agitation. We investigated
the emergence characteristics of small children after sevoflurane or isoflurane
with caudal anesthesia for postoperative pain control. Methods: After institutional
approval and parental consent, anesthesia was randomly performed with
sevoflurane (n = 30) or isoflurane (n = 29) in children at the age of 3.8 +/- 1.8
years during surgical interventions on the lower part of the body. After induction,
all children received caudal anesthesia with bupivacaine (0.25%, 0.8 ml.kg(-1)).
Postoperatively, the incidences of emergence agitation (EA) and emergence
delirium (ED) were measured by a blinded observer using a ten point scale (TPS;
EA = TPS > 5 ED = TPS > 7) as well as vigilance, nausea/vomiting and
shivering. Results: The two groups were comparable with respect to
demographic data, duration of surgery and duration of anesthesia. There were
also no differences in the period of time from the end of surgery until extubation,
duration of stay in the PACU, postoperative vigilance and vegetative parameters.
Incidence of EA was 30% (9/30) for sevoflurane and 34% (10/29) for isoflurane
during the first 60 min in the PACU (P = 0.785). Likewise, the incidence of ED
was not different between the groups (20% and 24%, respectively). Conclusions:
In our randomized controlled study, we found no difference in the incidence of EA
or ED between sevoflurane and isoflurane. Therefore, the decision to use one or
the other should not be based upon the incidence of EA or ED. [References: 18]
Michaud, L., C. Bula, et al. (2007). "Delirium: guidelines for general hospitals." Journal
of Psychosomatic Research 62(3): 371-83.
OBJECTIVE: Delirium is highly prevalent in general hospitals but remains
underrecognized and undertreated despite its association with increased
morbidity, mortality, and health services utilization. To enhance its management,
we developed guidelines covering all aspects, from risk factor identification to
preventive, diagnostic, and therapeutic interventions in adult patients.
METHODS: Guidelines, systematic reviews, randomized controlled trials (RCT),
and cohort studies were systematically searched and evaluated. Based on a
synthesis of retrieved high-quality documents, recommendation items were
submitted to a multidisciplinary expert panel. Experts scored the appropriateness
of recommendation items, using an evidence-based, explicit, multidisciplinary
panel approach. Each recommendation was graded according to this process'
results. RESULTS: Rated recommendations were mostly supported by a low
level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized
trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of
recommendations were considered appropriate by the experts. Prevention of
delirium and its nonpharmacological management should be fostered.
Haloperidol remains the first-choice drug, whereas the role of atypical
antipsychotics is still uncertain. CONCLUSIONS: While many topics addressed in
these guidelines have not yet been adequately studied, an explicit panel and
evidence-based approach allowed the proposal of comprehensive
recommendations for the prevention and management of delirium in general
hospitals.
Milisen, K., T. Braes, et al. "Cognitive assessment and differentiating the 3 Ds
(dementia, depression, delirium)." Nursing Clinics of North America 41(1): 1-22.
Differentiation between a diminished or altered cognitive functioning asa
consequence of aging and one resulting from serious health problems is critical
in the elderly. An unrecognized cognitive disorder or the worsening of the
impairment may hamper the effectiveness and appropriateness of care and
treatment; therefore, standardized assessment procedures and systematic
monitoring of cognition and behavior are important aspects of the nursing care. of
older adults. In this article, current notions for accurate and comprehensive
cognitive assessment in older persons are delineated. Further, an overview of
epidemiological screening and diagnostic dilemmas of dementia, depression, and
deliriumare provided. [References: 115]
Miller, A. H. and K. K. Mangione (2006). "Does delirium need immediate medical referral
in a frail, homebound elder?" Journal of Geriatric Physical Therapy 29(2): 57-63.
BACKGROUND AND PURPOSE: This case report describes the clinical decision
making process of a physical therapist whose examination of a home bound
elderly woman led to a referral for hospitalization. We illustrate how the use of a
comprehensive systems screen and thorough examination identified a patient
with treatable conditions that required medical care. CASE DESCRIPTION: The
patient was a frail 93-year-old woman. She was referred for home-care physical
therapy with multiple medical comorbidities and functional decline following a
short hospitalization for fall-related injuries. Her function improved after several
visits, but upon resuming treatment after a 2- week hiatus, the patient
demonstrated major decline in cognitive and physical function. OUTCOMES: The
comprehensive systems screen revealed that the patient had increased pallor,
loose and frequent bowel movements, urinary incontinence and increased
frequency of micturition, confusion and apathy, and extreme fatigue. Her
examination showed large declines in scores for Functional Independence
Measures, Mini Mental Status Examination, Berg Balance Test, and Timed Up
and Go. These results were consistent with indicators for delirium, dehydration,
and anemia. The findings were reported to the patient's physician and family
members agreed to have the patient evaluated in the local emergency room.
CONCLUSIONS: This case report illustrates how knowledge of the pathologies
associated with delirium and thorough examination can assist the physical
therapist in making clinical decisions when homecare patients require prompt
medical referral.
Miller, R. R., 3rd and E. W. Ely (2006). "Delirium and cognitive dysfunction in the
intensive care unit." Seminars in Respiratory & Critical Care Medicine 27(3): 210-20.
Delirium remains a non recognized, but highly prevalent, form of organ
dysfunction in the intensive care unit (ICU). Intensive care physicians have
begun to benefit from elucidation of risk factors for delirium in the ICU, some of
which are modifiable, whereas others are not. In the last 5 years, a new tool for
use in detecting delirium among critically ill patients has been adapted, validated,
and found objectively reliable for use at the bedside by nonpsychiatrists.
Moreover, that tool-the Confusion Assessment Method for the Intensive Care
Unit (CAM-ICU)-has enabled determination of the serious sequelae of delirium,
including increased mortality, higher cost, longer length of hospital stay, failure of
extubation, and burdensome long-term cognitive impairment. Although
prevention and treatment options exist, little data guide current pharmacological
approaches to delirium, and nonpharmacological approaches have yet to be fully
adopted by ICUs. Ongoing trials will address some of these limitations, but large
cohort studies within the ICU are needed to further clarify risk factors and to
identify targets to modify the occurrence and course of delirium. Furthermore,
consideration of a continuum may better elucidate the true magnitude of acute
brain dysfunction in the ICU. [References: 84]
Mittal, D., D. Majithia, et al. (2006). "Differences in characteristics and outcome of
delirium as based on referral patterns." Psychosomatics 47(5): 367-75.
The authors studied factors associated with referral of delirium patients to
psychiatry consultation and its outcome implications. Characteristics and
treatment outcomes of delirium patients referred to psychiatry were compared
with those not referred. Referred patients were younger, had a more hyperactive
subtype, greater substance abuse, less comorbid dementia, were more likely to
be recognized as having delirium, and be prescribed medications. Improvement
in referred patients was indicated by lower readmission rate postdischarge. No
differences were noted in length of stay, discharge status, or mortality within 1
year of the index episode. Psychiatric interventions were moderately helpful.
Patients' characteristics and delirium subtypes may influence referral and should
inform future liaison efforts.
Miyaji, S., K. Yamamoto, et al. (2007). "Comparison of the risk of adverse events
between risperidone and haloperidol in delirium patients." Psychiatry & Clinical
Neurosciences. Vol. 61(3)(pp 275-282), 2007.
The aim of this study was to determine the risk of adverse events for risperidone
and haloperidol in delirium patients. The authors conducted a retrospective study
with medical records of 266 Japanese delirium inpatients who were referred to
them between July 2001 and May 2005. Information on gender, age, delirium,
drug therapy, adverse events, death, and other relevant factors was collected
and analyzed for each patient. As a primary antipsychotic drug for the treatment
of delirium, risperidone was used in 93 patients; oral haloperidol was used in 95;
and intravenous or intramuscular haloperidol was used in 61. The incidence of
adverse events was 6.5% for risperidone, 31.4% for oral haloperidol, and 32.8%
for haloperidol injection. The incidence of death during delirium was 3.2% for
risperidone, 2.1% for oral haloperidol, and 13.1% for haloperidol injection. The
incidence of death within 1 year after the onset of delirium was 30.1% for
risperidone, 29.5% for oral haloperidol, and 45.9% for haloperidol injection.
Between risperidone, oral haloperidol, and intravenous or intramuscular
haloperidol the incidence of adverse events was significantly lowest for
risperidone, and the incidence of death during delirium was significantly highest
for intravenous or intramuscular haloperidol. The use of haloperidol as a first-line
drug in delirium patients who can receive the drug orally will not contribute to the
establishment of drug therapy for delirium based on risk-benefit assessment of
the therapy. copyright 2007 The Authors.
Moraga, A. V. and C. Rodriguez-Pascual (2007). "Acurate diagnosis of delirium in
elderly patients." Current Opinion in Psychiatry. Vol. 20(3)(pp 262-267), 2007.
PURPOSE OF REVIEW: Delirium remains one of the most common complicating
diagnoses in ailing elderly patients and a leading cause of morbidity, decreased
quality of life, prolonged hospital stay, institutionalization and mortality. Despite
its clinical importance and health-related costs, it often remains unrecognized or
misdiagnosed. We evaluate currently available tools for the screening and
diagnosis of delirium, their relevance and suitability for use in various clinical
settings, as well as interobserver consistency amongst doctors and other
nonclinician interviewers. RECENT FINDINGS: Extensive clinical trial evidence
has been published recently concerning advances on the three fundamental
elements of delirium assessment in elderly people: identification, severity
assessment and reporting of existing predisposing and precipitating factors.
SUMMARY: Despite advances on the pathophysiology and recognition of
delirium, its detection relies on individual clinical expertise, a high index of
suspicion and repeated cognitive testing of high-risk patients. Delirium diagnosis
remains a clearly underresearched area; particularly, more work is required to
adapt cognitive screening tools for use by nonclinicians, to develop cost-effective
biochemical and molecular diagnostic techniques and to assess the effects of
divulging updated consensus guidelines. copyright 2007 Lippincott Williams &
Wilkins, Inc.
Nassisi, D., B. Korc, et al. (2006). "The evaluation and management of the acutely
agitated elderly patient." Mt Sinai J Med 73(7): 976-84.
Delirium is an organic mental syndrome defined by a global disturbance in
consciousness and cognition, which develops abruptly and often fluctuates over
the course of the day. It is precipitated by medical illness, substance
intoxication/withdrawal or medication effect. Delirium is associated with
significant morbidity and mortality, and is a leading presenting symptom of illness
in the elderly. Elderly patients with altered mental status, including agitation,
should be presumed to have delirium until proven otherwise. The clinical
manifestations of delirium are highly variable. A mental status evaluation is
crucial in the diagnosis of delirium. Medical evaluation and stabilization should
occur in parallel. Life-threatening etiologies including hypoxia, hypoglycemia and
hypotension require immediate intervention. The differential diagnosis of
etiologies of delirium is extensive. Patients with delirium need thorough
evaluations to determine the underlying causes of the delirium. Pharmacological
agents should be considered when agitated patient has the potential to harm
themselves or others, or is impeding medical evaluation and management.
Unfortunately, the evidence to guide pharmacologic management of acute
agitation in the elderly is limited. Current pharmacologic options include the
typical and atypical antipsychotic agents and the benzodiazepines. These
therapeutic options are reviewed in detail.
Nelson, J. E., N. Tandon, et al. (2006). "Brain dysfunction: Another burden for the
chronically critically ill." Archives of Internal Medicine. Vol. 166(18)(pp 1993-1999),
2006.Date of Publication: 09 OCT 2006.
Background: Chronic critical illness is a devastating syndrome of prolonged
respiratory failure and other derangements. To our knowledge, no previous
research has addressed brain dysfunction in the chronically critically ill, although
this topic is important for medical decision making. Methods: We studied a
prospective cohort of 203 consecutive, chronically critically ill adults transferred
to our hospital's respiratory care unit (RCU) after tracheotomy for failure to wean.
We measured prevalence and duration of coma and delirium during RCU
treatment using the Confusion Assessment Method for the Intensive Care Unit
with the Richmond Agitation-Sedation Scale. To assess survivors (at 3 and 6
months after RCU discharge), we used a validated telephone Confusion
Assessment Method. Results: Before hospitalization, most (153 [75.4%]) of the
203 patients in the study were at home, completely independent (115 [56.7%]),
and cognitively intact (116 [82.0%]). In the RCU, 61 (30.0%) were comatose
throughout the stay. Approximately half of patients (66 of 142) who were not in
coma were delirious. Patients spent an average of 17.9 days (range, 1-153 days)
in coma or delirium (average RCU stay, 25.6 days). Half of survivors (79 of 160)
had one of these disturbances at RCU discharge. At 6 months, three fourths
(151) of the study patients were dead or institutionalized; of 85 survivors, 58
(68.2%) were too profoundly impaired to respond to telephone cognitive
assessment, and 53 (62.4%) were dependent in all activities of daily living.
Conclusions: Severe, prolonged, and permanent brain dysfunction is a prominent
feature of chronic critical illness. These data, together with previous reports of
symptom distress and rates of mortality and institutionalization, describe burdens
for chronically critically ill patients receiving continued life-prolonging treatment
and for their families. copyright2006 American Medical Association. All rights
reserved.
Nicholson, J. M. and D. B. Rolfson (2006). "Tobacco withdrawal and post-operative
delirium." Canadian Journal of Geriatrics. Vol. 9(4)(pp 135-138), 2006.
Introduction: Delirium is a common post-operative problem. The pathogenesis of
delirium is multifactorial and includes decreases in neurotransmitters, specifically
acetylcholine. Nicotine, present in cigarettes, may play a role in the genesis of
delirium through nicotinic cholinergic receptors. In hospital, smokers may
experience nicotine withdrawal if they are confined to bed and unable to smoke.
We hypothesized that delirium may be more prevalent in smokers postoperatively. Methods: To examine this we performed two consecutive
retrospective cohort studies of in-patients age 75 years or older, admitted to one
of two large teaching hospitals in northern Alberta between 1999 and 2001 for
total hip arthroplasty. Incident delirium was detected using the Confusion
Assessment Method. Smoking status, medications, and co-morbidities were also
assessed. Results: The incidence of post-operative delirium was 34%. Using a
multivariate analysis of risk factors, there was no evidence that smoking has an
association with post-operative delirium. Conclusions: This suggests that nicotine
withdrawal is not one of the principal factors leading to post-operative delirium.
However, since it may be an easily modifiable although minor contributing factor,
further prospective studies are needed to determine whether nicotine
replacement therapy can affect the rates of delirium in smokers post-operatively.
Norkiene, I., D. Ringaitiene, et al. (2007). "Incidence and precipitating factors of delirium
after coronary artery bypass grafting." Scandinavian Cardiovascular Journal 41(3): 1805.
Objective. To analyze large contemporary patient population, undergoing onpump coronary artery bypass grafting at our institution, and identify the
prevalence and precipitating factors of delirium development. Design. Baseline
demographics, operative data and postoperative outcomes of 1367 consecutive
patients were recorded prospectively and analysed using multivariate logistic
regression analysis, to determine independent predictors of postoperative
delirium development. Results. Delirium was detected in 42 (3.07%) patients.
Eight factors: age more than 65 years, peripheral vascular disease,
Euroscore>/=5, preoperative IABP support, postoperative blood product usage
and postoperative low cardiac output syndrome were independently predicting
delirium development after coronary artery bypass procedures. Postoperative
delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%,
p=0.013), prolonged mechanical ventilation time (9.2+/-3.1 vs. 5.05+/-7.6,
p=0.04) and increased length of intensive care unit stay (6.8+/-4.9 vs. 2.0+/-2.7
days, p=0.001). Conclusions. Delirium is a dangerous complication, prolonging
intensive care unit stay and postoperative mortality. Factors associated with
delirium development are advanced age, peripheral vascular disease, diminished
cardiac function and blood product usage.
Ogawa, M., T. Shinjo, et al. (2006). "Uncommon underlying etiologies of reversible
delirium in terminally ill cancer patients." Journal of Pain & Symptom Management
32(3): 205-7.
Ouimet, S., B. P. Kavanagh, et al. (2007). "Incidence, risk factors and consequences of
ICU delirium." Intensive Care Medicine 33(1): 66-73.
Objective: Delirium in critically ill is reported in 11-80% patients. We estimated
the incidence of delirium using a validated scale in a large cohort of ICU patients
and determined the associated risk factors and outcomes. Design and setting:
Prospective study in a 16-bed-medical-surgical intensive care unit (ICU).
Patients: 820 consecutive patients admitted to ICU for more than 24 h.
Interventions: Tools were: the Intensive Care Delirium Screening Checklist for
delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical
Rating Scale for pain. Risk factors were evaluated with univariate and
multivariate analysis, and factors influencing mortality were determined using
Cox regression. Results: Delirium occurred in 31.8% of 764 patients. Risk of
delirium was independently associated with a history of hypertension (OR 1.88,
95% CI 1.3-2.6), alcoholism (2.03, 1.2-3.2), and severity of illness (1.25, 1.031.07 per 5-point increment in APACHE II score) but not with age or corticosteroid
use. Sedatives and analgesics increased the risk of delirium when used to induce
coma (OR 3.2, 95% CI 1.5-6.8), and not otherwise. Delirium was linked to longer
ICU stay (11.5 +/- 11.5 vs. 4.4 +/- 3.9 days), longer hospital stay (18.2 +/- 15.7
vs. 13.2 +/- 19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher
hospital mortality (26.7% vs. 21.4%). Conclusion: Delirium is associated with a
history of hypertension and alcoholism, higher APACHE II score, and with clinical
effects of sedative and analgesic drugs. [References: 45]
Ouimet, S., B. P. Kavanagh, et al. (2007). "Incidence, risk factors and consequences of
ICU delirium." Intensive Care Medicine 33(1): 66-73.
OBJECTIVE: Delirium in the critically ill is reported in 11-80% of patients. We
estimated the incidence of delirium using a validated scale in a large cohort of
ICU patients and determined the associated risk factors and outcomes. DESIGN
AND SETTING: Prospective study in a 16-bed medical-surgical intensive care
unit (ICU). PATIENTS: 820 consecutive patients admitted to ICU for more than
24 h. INTERVENTIONS: Tools used were: the Intensive Care Delirium Screening
Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and
Numerical Rating Scale for pain. Risk factors were evaluated with univariate and
multivariate analysis, and factors influencing mortality were determined using
Cox regression. RESULTS: Delirium occurred in 31.8% of 764 patients. Risk of
delirium was independently associated with a history of hypertension (OR 1.88,
95% CI 1.3-2.6), alcoholism (2.03, 1.2-3.2), and severity of illness (1.25, 1.031.07 per 5-point increment in APACHE II score) but not with age or corticosteroid
use. Sedatives and analgesics increased the risk of delirium when used to induce
coma (OR 3.2, 95% CI 1.5-6.8), and not otherwise. Delirium was linked to longer
ICU stay (11.5+/-11.5 vs. 4.4+/-3.9 days), longer hospital stay (18.2+/-15.7 vs.
13.2+/-19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital
mortality (26.7% vs. 21.4%). CONCLUSION: Delirium is associated with a history
of hypertension and alcoholism, higher APACHE II score, and with clinical effects
of sedative and analgesic drugs.
Ozsoylar, G., A. Sayin, et al. (2007). "Clarithromycin monotherapy-induced delirium."
Journal of Antimicrobial Chemotherapy 59(2): 331.
Palmer, R. M. (2006). "Perioperative care of the elderly patient." Cleveland Clinic
Journal of Medicine 73 Suppl 1: S106-10.
Perioperative management is typically more complicated in older patients than in
younger patients and requires more assessment and evaluation before surgery
as well as precautionary steps after surgery to manage these high-risk patients.
Palmer, T. R. (2006). "Delirium was likely due to multiple factors, rather than gatifloxacin
induced.[comment]." Journal of the American Geriatrics Society 54(11): 1802; author
reply 1802-3.
Pandharipande, P. and E. W. Ely "Sedative and analgesic medications: risk factors for
delirium and sleep disturbances in the critically ill." Critical Care Clinics 22(2): 313-27.
Sedatives and analgesics are routinely used in critically ill patients, although they
have the potential for side effects, such as delirium and sleep architecture
disruption. Although it should be emphasized that these medications are
extremely important in providing patient comfort, health care professionals must
also strive to achieve the right balance of sedative and analgesic administration
through greater focus on reducing unnecessary or overzealous use. Ongoing
clinical trials should help us to understand whether altering the delivery strategy,
via daily sedation interruption, or protocolized target-based sedation or changing
sedation paradigms to target different central nervous system receptors can
affect cognitive outcomes and sleep preservation in our critically ill patients.
[References: 85]
Pandharipande, P., A. Shintani, et al. (2006). "Lorazepam is an independent risk factor
for transitioning to delirium in intensive care unit patients." Anesthesiology 104(1): 21-6.
BACKGROUND: Delirium has recently been shown as a predictor of death,
increased cost, and longer duration of stay in ventilated patients. Sedative and
analgesic medications relieve anxiety and pain but may contribute to patients'
transitioning into delirium. METHODS: In this cohort study, the authors designed
a priori an investigation to determine whether sedative and analgesic
medications independently increased the probability of daily transition to delirium.
Markov regression modeling (adjusting for 11 covariates) was used in the
evaluation of 198 mechanically ventilated patients to determine the probability of
daily transition to delirium as a function of sedative and analgesic dose
administration during the previous 24 h. RESULTS: Lorazepam was an
independent risk factor for daily transition to delirium (odds ratio, 1.2 [95%
confidence interval, 1.1-1.4]; P = 0.003), whereas fentanyl, morphine, and
propofol were associated with higher but not statistically significant odds ratios.
Increasing age and Acute Physiology and Chronic Health Evaluation II scores
were also independent predictors of transitioning to delirium (multivariable P
values < 0.05). CONCLUSIONS: Lorazepam administration is an important and
potentially modifiable risk factor for transitioning into delirium even after adjusting
for relevant covariates.
Parikh, A. R. and B. I. Liskow (2007). "Manic delirium associated with clomipheneinduced ovulation." Psychosomatics 48(1): 65-66.
Park, Y. S., K. S. Kim, et al. (2006). "[A preliminary survey of nurses' understanding of
delirium and their need for delirium education - in a university hospital -]." Daehan
Ganho Haghoeji 36(7): 1183-92.
PURPOSE: The purpose of this survey was to investigate clinical nurses'
understanding of delirium and their educational need of delirious patient care.
METHOD: A survey questionnaire regarding nurses' general perception and
understanding of delirium, experience with delirious patients and educational
need was developed and conducted with 179 clinical nurses in a university
hospital in Seoul. Data was analyzed using descriptive statistics. RESULTS:
Nurses thought that delirium was one of the most important nursing problems
and they considered it to be more treatable than to be preventable. However, the
majority of nurses were not confident in caring for delirious patients. Nurses
reported that delirium happened most often after surgery, and that possible
contributing factors could be changes in physical environment and anxiety/stress,
as well as medication and long-term isolation. Thirteen nursing interventions
were identified but half of the nurses utilized only one or two of the thirteen. The
most frequently used intervention was reorienting the patient followed by
medication and emotional support, presenting family, and close observation.
99.5% of nurses addressed the importance of professional education on delirium
care, especially in the area of intervention and management. CONCLUSION:
The results support the strong need for development of a multi-component
educational program on delirium care.
Peterson, J. F., B. T. Pun, et al. (2006). "Delirium and its motoric subtypes: a study of
614 critically ill patients." Journal of the American Geriatrics Society 54(3): 479-84.
OBJECTIVES: To describe the motoric subtypes of delirium in critically ill
patients and compare patients aged 65 and older with a younger cohort.
DESIGN: Prospective cohort study. SETTING: The medical intensive care unit
(MICU) of a tertiary care academic medical center. PARTICIPANTS: Six hundred
fourteen MICU patients admitted during a process improvement initiative to
monitor levels of sedation and delirium. MEASUREMENTS: MICU nursing staff
assessed delirium and level of consciousness in all MICU patients at least once
per 12-hour shift using the Confusion Assessment Method for the Intensive Care
Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were
categorized as hypoactive, hyperactive, and mixed type. RESULTS: Delirium
was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458
(57.4%) subjects younger than 65. Mixed type was most common (54.9%),
followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%).
Patients aged 65 and older experienced hypoactive delirium at a greater rate
than younger patients (41.0% vs 21.6%, P<.001) and never experienced
hyperactive delirium. Older age was strongly and independently associated with
hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3),
compared with no delirium in a model that adjusted for other important
determinants of delirium including severity of illness, sedative medication use,
and ventilation status. CONCLUSION: Older age is a strong predictor of
hypoactive delirium in MICU patients, and this motoric subtype of delirium may
be missed in the absence of active monitoring.
Pisani, M. A., K. L. Araujo, et al. (2006). "A research algorithm to improve detection of
delirium in the intensive care unit." Critical care (London, England) 10(4): R121.
INTRODUCTION: Delirium is a serious and prevalent problem in intensive care
units (ICU). The purpose of this study was to develop a research algorithm to
enhance detection of delirium in critically ill ICU patients using chart review to
complement a validated clinical delirium instrument. METHODS: Prospective
cohort study of 178 patients 60 years and older admitted to the Medical ICU. The
Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and a
validated chart review method for delirium were performed daily. We assessed
the diagnostic accuracy of the chart-based delirium method using the CAM-ICU
as the gold standard. We then used an algorithm to detect delirium first using the
CAM-ICU ratings, then chart review when the CAM-ICU was unavailable.
RESULTS: When using both the CAM-ICU and the chart-based review the
prevalence of delirium was 143/178 (80%) patients or 929/1457 (64%) of patientdays. Of these, 292 patient-days were classified as delirium by the CAM-ICU,
and the remainder (n=637 patient-days) were classified as delirium by the
validated chart review method when the CAM-ICU was missing due to weekends
or holidays (404 patient-days), when CAM-ICU was not performed due to stupor
or coma (205 patient-days), and when the CAM-ICU was negative (28 patientdays). Sensitivity of the chart-based method was 64% and specificity was 85%.
Overall agreement between chart and the CAM-ICU was 72%. CONCLUSIONS:
Eight of 10 patients in this cohort study developed delirium in the ICU. Although
use of a validated delirium instrument with frequent direct observations is
recommended for clinical care, this approach may not always be feasible,
especially in a research setting. The algorithm proposed here comprises a more
comprehensive method for delirium detection in a research setting taking into
account the fluctuation that occurs with delirium, a key component to accurately
determining delirium status. Improving delirium detection is of paramount
importance first to advance delirium research and, subsequently to enhance
clinical care and patient safety.
Pitkala, K. H., J. V. Laurila, et al. (2006). "Multicomponent geriatric intervention for
elderly inpatients with delirium: a randomized, controlled trial." Journals of Gerontology
Series A-Biological Sciences & Medical Sciences 61(2): 176-81.
BACKGROUND: Delirium is a common syndrome with poor prognosis affecting
elderly inpatients. Treatment is mainly based on common sense with wide
variations in practice. We investigated whether intensified, multicomponent
geriatric treatment could improve the prognosis of delirious patients. METHODS:
We performed a randomized, controlled trial of 174 patients with delirium in six
general medicine units from an acute hospital in Helsinki, Finland. The
intervention group received individually tailored geriatric treatment. The primary
endpoint was the sum of those deceased individuals and the patients
permanently institutionalized. Secondary endpoints included the number of days
in hospitals and other institutions, delirium intensity, and cognition. RESULTS:
The mean age of patients was 83 years, and 31% had previous dementia. The
intervention group (N = 87) received significantly more acetylcholinesterase
inhibitors (58.6% vs 9.2%), atypical antipsychotics (69.8% vs 30.2%), specialist
consultations (49.4% vs 28.7%), hip protectors (88.5% vs 3.4%), physiotherapy
(87.4% vs 47.1%), and fewer conventional neuroleptics (8.0% vs 23.0%) than did
the control group (N = 87). During the 1-year follow-up, 60.9% of the intervention
group and 64.4% of controls were either deceased or permanently
institutionalized (p =.638). The intervention group spent a mean of 126 days in
institutions, and the control group 140 days (p =.688). Delirium was, however,
alleviated more rapidly during hospitalization, and cognition improved
significantly at 6 months in the intervention group. CONCLUSIONS: Faster
alleviation of delirium and improved cognition justify good, comprehensive
geriatric care for these patients although treatment produced no significant
improvements in hard endpoints of prognosis.
Plaschke, K., C. Thomas, et al. (2007). "Significant correlation between plasma and
CSF anticholinergic activity in presurgical patients." Neuroscience Letters. Vol.
417(1)(pp 16-20), 2007.Date of Publication: 24 APR 2007.
Previous studies have suggested a possible link between cognitive impairment
and anticholinergic burden as reflected by high serum anticholinergic activity
(SAA). Thus, we hypothesized a close relationship between anticholinergic
activity in cerebral spinal fluid (CSF) and blood. However, it has never been
convincingly demonstrated that peripheral anticholinergic activity correlates with
central anticholinergic levels in presurgical patients. Therefore, anticholinergic
activity was measured in blood and CSF from 15 patients with admission
scheduled for urological surgery to compare peripheral and central
anticholinergic level. Blood and CSF probes were taken after routine
premedication and before spinal anesthesia. Anticholinergic activity was
determined by competitive radioreceptor binding assay for muscarinergic
receptors. Correlation analysis was conducted for peripheral and central
anticholinergic levels. The mean anticholinergic levels were 2.4 +/- 1.7 in the
patients' blood and 5.9 +/- 2.1 pmol/mL of atropine equivalents in CSF.
Interestingly, the anticholinergic activity in CSF was about 2.5-fold higher than in
patients' blood. A significant linear correlation was detected between blood and
CSF levels. Therefore we conclude that SAA levels adequately reflect central
anticholinergic activity. When patients receiving or not receiving anticholinergic
medication were compared, anticholinergic activity tended to increase in blood
and CSF after receiving anticholinergic medication >=4 weeks (p > 0.05).
copyright 2007 Elsevier Ireland Ltd. All rights reserved.
Polderman, K. H. (2007). "Screening methods for delirium: don't get confused!"
Intensive Care Medicine 33(1): 3-5.
Polycarpou, P., E. Anastassiades, et al. (2007). "From the heart to the soul."
Nephrology Dialysis Transplantation 22(3): 945-8.
Potter, J., J. George, et al. (2006). "The prevention, diagnosis and management of
delirium in older people: concise guidelines." Clinical Medicine 6(3): 303-8.
Delirium (acute confusional state) is a common condition in older people,
affecting up to 30% of all older patients admitted to hospital. Patients who
develop delirium have high mortality, institutionalisation and complication rates,
and have longer lengths of stay than non-delirious patients. Delirium is often not
recognised by clinicians, and is often poorly managed. Delirium may be
prevented in up to a third of older patients. The aim of this guideline update is to
aid prevention as well as the recognition of delirium and to provide guidance on
how to manage these complex and disadvantaged patients.
Ramirez-Bermudez, J., M. Lopez-Gomez, et al. (2006). "Frequency of delirium in a
neurological emergency room." Journal of Neuropsychiatry & Clinical Neurosciences
18(1): 108-12.
The authors present a cross-sectional survey designed to evaluate the presence
of delirium in patients with neurological emergencies. Two hundred and two
patients were included in the study: 14.9% of subjects had delirium; 62.4% had
no arousal disturbances; and 22.7% presented a coma or stupor state. Findings
revealed that the presence of a cerebral infection, the presence of multiple
etiologies, and the location of lesions in the frontal and temporal lobes were all
associated with delirium. Results substantiate that delirium is a frequent
occurrence in neurological patients and that the presence of multiple etiologies
must be investigated in each patient.
Ranhoff, A. H., R. Rozzini, et al. (2006). "Delirium in a sub-intensive care unit for the
elderly: occurrence and risk factors." Aging-Clinical & Experimental Research 18(5):
440-5.
BACKGROUND AND AIMS: The objective was to study occurrence and risk
factors of delirium in a new model of care, the Sub-Intensive Care Unit for the
elderly (SICU), which is a level of care between that offered by ordinary wards
and intensive care. METHODS: A prospective observational study of 401
consecutively admitted patients, 60+ years, in a four-bed SICU in the geriatric
ward of a general hospital. Delirium was detected by the Confusion Assessment
Method (CAM) at admission (prevalent) and during SICU stay (incident).
Impaired function (Barthel Index) and/or IADL two weeks prior to admission
identified disability, and additional Mini-Mental State Examination (MMSE) <18 at
discharge identified probable dementia. RESULTS: Delirium was detected in 117
patients (29.2%). Of these 62 (15.5%) had delirium at admission and a further 55
developed delirium during their time in the SICU. Delirium occurred in 19 (11.4%)
of the "robust" (no dementia or disability), 28 (24.1%) of the disabled and 70
(58.4%) of the demented patients (p<0.001). Prevalent delirium was found in 8
(4.8%), 11 (9.5%) and 43 (36.1%) (p<0.001) and incident in 11 (6.6%), 17
(14.7%) and 27 (22.7%) (p<0.001) of the robust, disabled, and demented
patients respectively. Heavy alcohol use, maximum intake of 7 or more drugs,
and the use of a bladder catheter were independently associated with delirium.
CONCLUSIONS: Delirium was common in the SICU, and patients with probable
dementia had the highest risk. They tended to have delirium at admission,
whereas patients without dementia, although less at risk, were more prone to
developing delirium during their stay in the SICU.
Rea, R. S., S. Battistone, et al. (2007). "Atypical antipsychotics versus haloperidol for
treatment of delirium in acutely ill patients." Pharmacotherapy 27(4): 588-94.
Delirium is common in acutely ill patients and can result in substantial morbidity if
left untreated. Atypical antipsychotics have been postulated to be safer and more
effective than haloperidol for treatment of this condition. To evaluate the role of
atypical antipsychotics versus haloperidol for treatment of delirium in hospitalized
acutely ill adults, we searched MEDLINE (1977-September 2006) and
International Pharmaceutical Abstracts (1997-September 2006) for Englishlanguage publications of clinical trials that compared atypical antipsychotics and
haloperidol. Four comparative studies were identified: one double-blind,
randomized study (risperidone vs haloperidol), one single-blind, randomized
study (olanzapine vs haloperidol), and two retrospective studies (olanzapine vs
haloperidol and quetiapine vs haloperidol). These studies demonstrated that
atypical antipsychotics are as efficacious as haloperidol. In addition, they appear
to be associated with a lower frequency of extrapyramidal effects, and thus are
safer than haloperidol. However, these conclusions are based on a limited
number of studies; larger comparative trials are needed to elucidate the role of
atypical antipsychotics for treating delirium in this population.
Richins, M. and I. Agell (2006). "Delirium in the elderly: the importance of accurate
diagnosis.[comment]." British Journal of Hospital Medicine 67(1): 46; author reply 46.
Rigney, T. S. (2006). "Delirium in the hospitalized elder and recommendations for
practice." Geriatric Nursing 27(3): 151-7.
Delirium is a mental disorder of acute onset and fluctuating course, characterized
by disturbances in consciousness, orientation, memory, thought, perception, and
behavior. It occurs in up to 50% of elderly hospital inpatients, many with
preexisting dementia, and is associated with significant increases in functional
disability, length of hospital stay, rates of death, and health care costs. Despite
its clinical importance, delirium often remains undetected or misdiagnosed as
dementia or other psychiatric illness. Awareness of the etiologies and risk factors
of delirium should enable nurses to focus on patients at risk and to recognize
delirium symptoms early. Knowledge of pharmacological and
nonpharmacological treatments for delirium will provide the nurse with an arsenal
of potential interventions in the care of the delirious hospitalized elder.
[References: 49]
Roberts, B. L., C. M. Rickard, et al. (2006). "Patients' dreams in ICU: recall at two years
post discharge and comparison to delirium status during ICU admission. A multicentre
cohort study." Intensive & Critical Care Nursing 22(5): 264-73.
Discharged intensive care unit (ICU) patients often recall experience vivid
dreams, hallucinations or delusions. These may be persecutory in nature and are
sometimes very frightening. It is possible that these memories stem from times
when the patient was experiencing delirium, a common syndrome in the critically
ill. Routine screening for delirium in ICU is becoming more prevalent, however,
little has been published comparing the objective development of delirium
(patient observations using screening tools) and patients' subjective recollection
of dreams and unreal experiences in the ICU. This study describes the
relationship between observed behaviour during ICU admission and the
subjective memories of ICU experiences amongst 41 participants in three ICUs
up to 24 months post discharge. Overall, 44% of patients (n=18) recalled dreams
during their ICU admission. There was a trend to increased prevalence of
dreaming (50% versus 39%) amongst the 18 patients who were delirious during
their ICU admission than in the 23 non-delirious patients. Dreaming was
significantly associated on logistic regression with increased length of stay (OR
1.39, 95% CI 1.08-1.79, p=0.01), but not delirium status (OR 1.56, 95% CI 0.455.41, p=0.49). A longer ICU stay was significantly associated with the experience
of ICU dreaming. As many dreams are disturbing, we suggest providing
information and counselling about delirium to patients who remain in ICU for
longer periods.
Rubin, F. H., J. T. Williams, et al. (2006). "Replicating the Hospital Elder Life Program in
a community hospital and demonstrating effectiveness using quality improvement
methodology." Journal of the American Geriatrics Society 54(6): 969-74.
OBJECTIVES: To evaluate a replication of the Hospital Elder Life Program
(HELP), a quality-improvement model, in a community hospital without a
research infrastructure, using administrative data. DESIGN: A pretest/posttest
quality-improvement study. SETTING: A 500-bed community teaching hospital in
western Pennsylvania. PARTICIPANTS: Four thousand seven hundred sixtythree hospitalized patients aged 70 and older admitted to one nursing unit over
3.5 years. INTERVENTION: Application of the HELP multicomponent
intervention targeting patients at risk for delirium. MEASUREMENTS: A proxy
measure for delirium was developed using administrative data to calculate
delirium rate and differences in variable costs of care and length of stay for
patients before and after the intervention. Similar calculations were used in
delirious patients for variable costs and length of stay before and after the
intervention. Satisfaction surveys were administered to nursing staff and patient
families before and after the intervention. RESULTS: The intervention reduced
the absolute rate of delirium according to proxy report 14.4% from baseline,
which represented a relative reduction in risk of 35.3% (P=.002). Total costs on
this 40-bed nursing unit were reduced $626,261 over 6 months. Satisfaction of
nursing staff and families was high in the intervention group. In addition, the
intervention showed sustained benefits over time and remains funded by the
hospital. CONCLUSION: HELP can be successfully replicated in a community
hospital, yielding clinical and financial benefits.
Rudolph, J. L., R. N. Jones, et al. (2006). "Impaired executive function is associated
with delirium after coronary artery bypass graft surgery." Journal of the American
Geriatrics Society 54(6): 937-41.
OBJECTIVES: To determine the extent to which preoperative performance on
tests of executive function and memory was associated with delirium after
coronary artery bypass graft (CABG) surgery. DESIGN: Prospective
observational cohort study. SETTING: Two academic medical centers and one
Department of Veterans Affairs medical center in Massachusetts.
PARTICIPANTS: Eighty subjects without preoperative delirium undergoing
CABG or CABG-valve surgery completed baseline neuropsychological
assessments with validated measures of memory and executive function.
MEASUREMENTS: Beginning on postoperative Day 2, a battery to diagnose
delirium was administered daily. Confirmatory factor analysis (CFA) was used to
define two cognitive domain composites (memory and executive function). The
loading pattern of neuropsychological measures onto the latent cognitive
domains was determined a priori. Poisson regression was used to model the
association between neuropsychological performance and cognitive domain
composite scores and risk of postoperative delirium. The association was
expressed as the difference between impaired (0.5 standard deviations (SDs)
below mean) and nonimpaired (0.5 SDs above mean) performers. RESULTS:
Forty subjects (50%) developed delirium. Measures of memory function were not
significantly related to delirium. Of the executive function measures, verbal
fluency, category fluency, Hopkins Verbal Learning Test learning, and backward
recounting of days and months were significantly related to delirium.
Preoperative mental status was a strong predictor of postoperative delirium. After
controlling for age, sex, education, medical comorbidity, mental status, and the
other cognitive domain, CFA cognitive domain composites suggest that risk for
delirium is specific for executive functioning impairment (relative risk (RR) = 2.77,
95% confidence interval (CI) = 1.12-6.87) but not for memory impairment (RR =
0.49, 95% CI = 0.19-1.25). CONCLUSION: Worse preoperative performance in
executive function was independently associated with greater risk of developing
delirium after CABG.
Sampson, E. L., P. R. Raven, et al. (2007). "A randomized, double-blind, placebocontrolled trial of donepezil hydrochloride (Aricept) for reducing the incidence of
postoperative delirium after elective total hip replacement." International Journal of
Geriatric Psychiatry 22(4): 343-9.
OBJECTIVES: This was a pilot, phase 2a study to assess methodological
feasibility and the safety and efficacy of donepezil in preventing postoperative
delirium after elective total hip replacement surgery in older people without preexisting dementia. The hypothesis was that donepezil would reduce the
incidence of postoperative delirium. METHODS: A double blind, placebo
controlled, parallel group randomized trial was undertaken. Patients were block
randomized pre-operatively to receive placebo or donepezil 5 mg immediately
following surgery and every 24 h thereafter for a further three days. The main
outcome was the incidence of delirium (using the Delirium Symptom Interview).
The secondary outcome was length of hospital stay. RESULTS: Thirty-three
patients (mean age 67 years; 17 males, 16 females) completed the study (19
donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse
events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not
significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil
vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p =
0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1
days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78)
(t([31]) = 1.73: p = 0.09). CONCLUSIONS: The experimental paradigm was
feasible and acceptable. Donepezil did not significantly reduce the incidence of
delirium or length of hospital stay, however for both outcomes there was a
consistent trend suggesting possible benefit. The sample size required for a
definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.
Sandhaus, S., F. Harrell, et al. (2006). "Here's HELP to prevent delirium in the hospital."
Nursing 36(7): 60-2.
Satyanarayana, S. and B. Campbell (2006). "Gatifloxacin-induced delirium and
psychosis in an elderly demented woman." Journal of the American Geriatrics Society
54(5): 871.
Scott, J., D. Pache, et al. (2007). "Prolonged anticholinergic delirium following
antihistamine overdose." Australasian Psychiatry 15(3): 242-4.
Objective: A case of anticholinergic delirium in a female adolescent is described,
exploring the pharmacokinetic reasons for the prolonged time course and
reviewing the management provided. Conclusion: A 14 year old female
hospitalised for depression ingested large quantities of promethazine and
cyproheptadine. A severe anticholinergic delirium ensued which resolved after
six days, much longer than the expected duration. The likely cause of the
prolonged delirium was the interaction of promethazine and fluvoxamine through
the inhibition of the CYP2D6 enzyme. The patient's young age, the severity of the
poisoning and the use of drugs with anticholinergic properties to manage the
delirium may also have contributed. The delirium may have been reversed had a
cholinesterase inhibitor been provided soon after the overdose.
Seaman, J. S., J. Schillerstrom, et al. (2006). "Impaired oxidative metabolism
precipitates delirium: a study of 101 ICU patients." Psychosomatics 47(1): 56-61.
Data from 101 consecutively admitted intensive care unit (ICU) patients were
examined to determine whether oxidative metabolic stress existed within the 48
hours before delirium onset. The occurrence of pneumonia and sepsis at any
time during hospitalization was also recorded. Delirium was defined
retrospectively with the Confusion Assessment Method (CAM). Older patients
were found to develop delirium more frequently than younger patients. There
were no differences in illness severity (APACHE II) between those who
developed delirium and those who did not. Three measures of oxygenation
(hemoglobin, hematocrit, pulse oximetry) were worse in the patients who later
developed delirium. Two measures of oxidative stress (sepsis, pneumonia)
occurred more frequently among those diagnosed with delirium. Hence, patients
with indicators of oxidative dysfunction developed delirium more frequently, and
this was not linked to illness severity.
Seitz, D. and S. S. Gill (2006). "Perioperative haloperidol to prevent postoperative
delirium.[comment]." Journal of the American Geriatrics Society 54(5): 861; author reply
861-3.
Sheng, A. Z., Q. Shen, et al. (2006). "Delirium within three days of stroke in a cohort of
elderly patients." Journal of the American Geriatrics Society 54(8): 1192-8.
OBJECTIVES: To evaluate the incidence of stroke, risk factors for stroke, and
outcomes in elderly stroke patients with delirium. DESIGN: Cohort study with 12month follow-up. SETTING: Bankstown-Lidcombe Hospital, a 450-bed teaching
hospital of the University of New South Wales, Sydney, Australia.
PARTICIPANTS: One hundred fifty-six stroke patients aged 65 and older
recruited over 1 year. MEASUREMENTS: Incidence of delirium (defined in
accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, criteria) within 3 days poststroke, length of hospital stay, discharge
destination, short- and long-term mortality, Functional Independence Measure
(FIM) scores, and Mini-Mental State Examination (MMSE) scores. RESULTS:
Thirty-nine (25%) elderly stroke patients had delirium within 3 days after stroke.
Logistic regression analysis found that older age (P=.04), hemorrhagic stroke
(P=.02), metabolic disorders (P=.003), dementia prestroke (P=.02), Glasgow
Coma Scale (GCS) score less than 15 on admission (P<.001), and inability to lift
both arms on admission (P=.03) were independent predisposing factors for
delirium. Patients who had a cardioembolic stroke (odds ratio (OR)=5.58) or total
anterior circulation infarction (OR=3.42) were also more likely to develop
delirium. Patients with delirium were associated with higher 6- and 12-month
mortality (P<.05), lower 12-month FIM and MMSE scores, and a higher 12-month
institutionalization rate. CONCLUSION: Delirium occurred frequently in acute
stroke patients aged 65 and older. Factors independently associated with
delirium included old age, intracerebral hemorrhage, metabolic factors, prestroke
dementia, initial GCS less than 15, and inability to lift both arms on admission.
Patients with delirium had higher long-term mortality and a worse functional
outcome.
Shinno, H., S. Hikasa, et al. (2006). "Three patients with hemophagocytic syndrome
who developed acute organic brain syndrome." General Hospital Psychiatry 28(5): 4557.
INTRODUCTION: We describe three patients with hemophagocytic syndrome
(HPS) who developed acute organic brain syndrome. All three presented with
high-grade fever and twilight state, and were admitted to our hospital. After
admission, delirium developed in all three. As delirium improved, various other
psychiatric symptoms, including hallucinations, agitation, hypoactivity, affective
lability and insomnia, were noted. DISCUSSION: When treated with steroid
hormones, immunoglobulin and neuroleptics, all patients demonstrated
improvement in their psychiatric symptoms, as well as in their general condition
and laboratory findings. Ultimately, they all recovered and were discharged.
CONCLUSION: It needs to be noted that organic brain syndrome might be
observed at the onset of HPS. Consequently, early diagnosis and treatment for
psychiatric symptoms, as well as for HPS, are crucial.
Short, M. R. and P. S. Winstead (2007). "Delirium dilemma." Orthopedics 30(4): 273276.
Siddiqi, N., R. Stockdale, et al. (2007). "Interventions for preventing delirium in
hospitalised patients." Cochrane Database of Systematic Reviews(2): CD005563.
BACKGROUND: Delirium is a common mental disorder with serious adverse
outcomes in hospitalised patients. It is associated with increases in mortality,
physical morbidity, length of hospital stay, institutionalisation and costs to
healthcare providers. A range of risk factors has been implicated in its aetiology,
including aspects of the routine care and environment in hospitals. Prevention of
delirium is clearly desirable from patients' and carers' perspectives, and to
reduce hospital costs. Yet it is currently unclear whether interventions for
prevention of delirium are effective, whether they can be successfully delivered in
all environments, and whether different interventions are necessary for different
groups of patients. OBJECTIVES: Our primary objective was to determine the
effectiveness of interventions designed to prevent delirium in hospitalised
patients. We also aimed to highlight the quality and quantity of research evidence
to prevent delirium in these settings. SEARCH STRATEGY: We searched the
Specialized Register of the Cochrane Dementia and Cognitive Improvement
Group on 28th September, 2005. As the searches in MEDLINE, EMBASE,
CINAHL and PsycINFO for the Specialized Register would not necessarily have
picked up all delirium prevention trials, these databases were searched again on
28th October, 2005. We also examined reference lists of retrieved articles,
reviews and books. Experts in this field were contacted and the Internet searched
for further references and to locate unpublished trials. SELECTION CRITERIA:
Randomised controlled trials evaluating any interventions to prevent delirium in
hospitalised patients. DATA COLLECTION AND ANALYSIS: Data collection and
quality assessment were performed by three reviewers independently and
agreement reached by consensus. MAIN RESULTS: Six studies with a total of
833 participants were identified for inclusion. All were conducted in surgical
settings, five in orthopaedic surgery and one in patients undergoing resection for
gastric or colon cancer.Only one study of 126 hip fracture patients comparing
proactive geriatric consultation with usual care was sufficiently powered to detect
a difference in the primary outcome, incident delirium. Total cumulative delirium
incidence during admission was reduced in the intervention group (OR 0.48 [95%
CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to
treat' of 5.6 patients to prevent one case. The intervention was particularly
effective in preventing severe delirium. In logistic regression analyses adjusting
for pre fracture dementia and Activities of Daily Living impairment, there was no
reduction in effect size, OR 0.6, but this no longer remained significant [95% CI
0.3,1.3]. There was no effect on the duration of delirium episodes, length of
hospital stay, and cognitive status or institutionalisation at discharge. There was
also no significant difference in cumulative delirium incidence between treatment
and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI
0.59, 1.36]).In another trial of low dose haloperidol prophylaxis, there was no
difference in delirium incidence but the severity and duration of a delirium
episode, and length of hospital stay were all reduced.We identified no completed
studies in hospitalised medical, care of the elderly, general surgery, cancer or
intensive care patients. In outcomes, no studies examined for death, use of
psychotropic medication, activities of daily living, psychological morbidity, quality
of life, carers or staff psychological morbidity, cost of intervention and cost to
health care services. Outcomes were only reported up to discharge, with no
studies reporting medium or longer-term effects. AUTHORS' CONCLUSIONS:
Research evidence on effectiveness of interventions to prevent delirium is
sparse. Based on a single study, a programme of proactive geriatric consultation
may reduce delirium incidence and severity in patients undergoing surgery for hip
fracture. Prophylactic low dose haloperidol may reduce severity and duration of
Silverstein, J. H., M. Timberger, et al. (2007). "Central nervous system dysfunction after
noncardiac surgery and anesthesia in the elderly." Anesthesiology 106(3): 622-8.
Simon, S. E., M. A. Bergmann, et al. (2006). "Reliability of a structured assessment for
nonclinicians to detect delirium among new admissions to postacute care." Journal of
the American Medical Directors Association 7(7): 412-5.
OBJECTIVE: To evaluate the interrater reliability of a structured delirium
assessment method for nonclinician interviewers in elderly patients newly
admitted for postacute care. DESIGN: Prospective assessment using dyads of
nonclinician raters. SETTING: Postacute (Medicare) units at 6 skilled nursing
facilities. PARTICIPANTS: Forty elderly patients newly admitted for postacute
care from medical or surgical units at acute care hospitals. MEASUREMENTS:
Subjects underwent dual delirium assessments within 5 days of admission. The
standardized delirium assessment included the Mini-Mental Status Exam and
Digit Span to assess overall cognitive function, the Delirium Symptom Interview
to elicit specific delirium symptoms, the Memorial Delirium Assessment Scale to
measure the severity of delirium, and the Confusion Assessment Method (CAM)
to make the diagnosis of delirium. A coding protocol that linked observations to
specific coding was used to improve reliability. RESULTS: The structured
delirium assessment process produced very high interobserver agreement for all
instruments. Kappa for agreement on delirium diagnosis was 0.95.
CONCLUSIONS: Nonclinician interviewers using a structured delirium
assessment achieved reliability that rivaled or exceeded that of trained clinical
assessors in other studies. Nonclinicians may offer an effective alternative for the
assessment of delirium among postacute patients in skilled nursing facilities.
Ski, C. and B. O'Connell (2006). "Mismanagement of delerium places patients at risk."
Australian Journal of Advanced Nursing 23(3): 42-6.
OBJECTIVE: This paper discusses the problem of delirium and the challenges of
accurately assessing, preventing and managing patients with delirium in an acute
care setting. PRIMARY ARGUMENT: Acute confusion, also known as delirium, is
misdiagnosed and under-treated in up to 94% of older patients in hospitals. With
the ageing population, this problem will increase dramatically in the Australian
setting. Managing patients with delirium is challenging not only for the
management of their basic nursing care needs but also because they are prone
to adverse events such as falls and medication problems. In order to address this
issue it is vital that health care professionals routinely assess patients for signs of
delirium. The current 'gold standard' for assessing delirium is the use of the
Confusion Assessment Method (CAM) which has been developed based on the
diagnostic criteria set by the Diagnostic and Statistical Manual of Mental
Disorders DSM-IV and can be used by non-psychiatrists. Further, increased
attention should be given to the prevention and management of delirium and the
use of orientation and validation therapy. CONCLUSION: Research indicates that
early identification and intervention can help to limit any negative effects or
adverse events. Increasing knowledge and awareness of early detection and
efficient management of delirium is the first step toward prevention. [References:
42]
Speciale, S., G. Bellelli, et al. (2007). "Delirium and functional recovery in elderly
patients.[comment]." Journals of Gerontology Series A-Biological Sciences & Medical
Sciences 62(1): 107-8; author reply 108.
Spiller, J. A. and J. C. Keen (2006). "Hypoactive delirium: assessing the extent of the
problem for inpatient specialist palliative care." Palliative Medicine 20(1): 17-23.
Delirium is a common problem and cause of distress among patients with
palliative care needs. The focus to date has been on managing the patient with
agitated, hyperactive delirium, as these patients are very noticeable within the
palliative care setting. This study in two parts shows that palliative care patients
with agitated delirium are a minority of the total proportion of those with delirium.
Part I: 100 acute admissions to a specialist palliative care unit were assessed
and while 29% were found to have delirium, 86% of these had the hypoactive
subtype of delirium. We also demonstrated a positive correlation between high
ratings on a depression screening tool and delirium severity ratings. Part II: 8
specialist palliative care units took part in a point prevalence study of delirium
over a 48-hour period. One hundred and nine patients were assessed and while
29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype.
Patients with hypoactive delirium may be much less noticeable or may be
misdiagnosed as having depression or fatigue and the results of this study would
advocate the routine use of delirium screening tools in all palliative care settings.
Stenvall, M., B. Olofsson, et al. (2007). "A multidisciplinary, multifactorial intervention
program reduces postoperative falls and injuries after femoral neck fracture."
Osteoporos Int 18(2): 167-75.
INTRODUCTION: This study evaluates whether a postoperative multidisciplinary,
intervention program, including systematic assessment and treatment of fall risk
factors, active prevention, detection, and treatment of postoperative
complications, could reduce inpatient falls and fall-related injuries after a femoral
neck fracture. METHODS: A randomized, controlled trial at the orthopedic and
geriatric departments at Umea University Hospital, Sweden, included 199
patients with femoral neck fracture, aged >/=70 years. RESULTS: Twelve
patients fell 18 times in the intervention group compared with 26 patients
suffering 60 falls in the control group. Only one patient with dementia fell in the
intervention group compared with 11 in the control group. The crude
postoperative fall incidence rate was 6.29/1,000 days in the intervention group vs
16.28/1,000 days in the control group. The incidence rate ratio was 0.38 [95%
confidence interval (CI): 0.20 - 0.76, p = 0.006] for the total sample and 0.07
(95% CI: 0.01-0.57, p=0.013) among patients with dementia. There were no new
fractures in the intervention group but four in the control group. CONCLUSION: A
team applying comprehensive geriatric assessment and rehabilitation, including
prevention, detection, and treatment of fall risk factors, can successfully prevent
inpatient falls and injuries, even in patients with dementia.
Stenvall, M., B. Olofsson, et al. (2006). "Inpatient falls and injuries in older patients
treated for femoral neck fracture." Arch Gerontol Geriatr 43(3): 389-99.
A prospective inpatient study was performed at the Orthopedic and Geriatric
Departments at the Umea University Hospital, Sweden, to study inpatient falls,
fall-related injuries, and risk factors for falls following femoral neck fracture
surgery. Ninety-seven patients with femoral neck fracture aged 70 years or older
were included, background characteristics, falls, injuries, and other postoperative
complications were assessed and registered during the hospitalization. There
were 60 postoperative falls among 26/97 patients (27%). The postoperative fall
event rate was 16.3/1000 Days (95% CI 12.2-20.4). Thirty two percent of the falls
resulted in injuries, 25% minor, and 7% serious ones. In multiple regression
analyses, delirium after Day 7, HRR 4.62 (95% CI 1.24-16.37), male sex 3.92
(1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with
inpatient falls. Forty-five percent of the patients were delirious the day they fell.
Intervention programs, including prevention and treatment of delirium and
sleeping disturbances, as well as better supervision of male patients, could be
possible fall prevention strategies. Improvement of the quality of care and
rehabilitation, with the focus on fall prevention based on these results, should be
implemented in postoperative care of older people.
Straker, D. A., P. A. Shapiro, et al. (2006). "Aripiprazole in the treatment of delirium."
Psychosomatics 47(5): 385-91.
Antipsychotic drugs are the primary treatment for symptoms of delirium, but their
side effects can be problematic. Treatment of delirium with aripiprazole has yet to
be evaluated. The authors report on 14 patients with delirium treated with
aripiprazole. Twelve patients had a >or=50% reduction in Delirium Rating Scale,
Revised-98 scores, and 13 showed improvement on Clinical Global Impression
scale scores. There was a low rate of adverse side effects. Aripiprazole may be
an appropriate first-line agent for the treatment of delirium because of its minimal
effect on QTc interval, weight, lipids, and glucose levels. Controlled comparison
studies should be performed to confirm this impression.
Sylvestre, M. P., J. McCusker, et al. (2006). "Classification of patterns of delirium
severity scores over time in an elderly population." International Psychogeriatrics. Vol.
18(4)(pp 667-680), 2006.
Objectives: To describe and classify individual trajectories of 15-day changes in
delirium severity. Methods: A longitudinal hospital-based study was carried out
with 230 medical inpatients aged 65 and over admitted to St Mary's Hospital in
Montreal, Canada, between 1996 and 1999, diagnosed with delirium at
enrollment, and who had at least four measurements of delirium severity during
the next 15 days. Delirium severity was assessed using the Delirium Index (DI).
To classify patients' individual trajectories, we applied a new method that relies
on principal factor analysis and cluster analysis. We used multiple linear
regression to investigate if clusters were associated with DI scores measured at
an 8-week follow-up. Multivariable Cox's proportional hazards regression was
used to assess whether the clusters were associated with survival over the next
12 months. Results: Individual patterns were classified into five clusters: Steady
(n = 89, 38.9%), Fluctuating (n = 36, 15.7%), Worsening (n = 15, 6.6%), Fast
Improve-ment (n = 26, 11.3%), and Slow Improvement (n = 63, 27.5%). The Fast
Improvement cluster had much lower prevalence of dementia (38.5% vs. 55.6%
to 77.8% in other clusters, p = 0.003). Subjects whose 2-week patterns were
classified as Fast or Slow Improvement had a significantly lower DI at 8 weeks
than those in the Steady or Fluctuating clusters. The Worsening cluster had the
largest percentage of deaths. The Fast Improvement and Worsening clusters
initially had a high risk of death in the first 2 weeks (adjusted relative risks of
approximately 3 and 6, respectively) but that risk decreased rapidly thereafter.
Conclusion: Two-week trajectories of delirium severity were associated with
short-term mortality and delirium severity at 8-week follow-up. copyright 2006
International Psychogeriatric Association.
Tabet, N., R. Stewart, et al. (2006). "Male gender influences response to an educational
package for delirium prevention among older people: a stratified analysis." International
Journal of Geriatric Psychiatry 21(5): 493-7.
BACKGROUND: Increasing evidence is pointing towards the efficacy of
intervention programmes in decreasing the incidence of delirium among older
people admitted to hospital. We have previously shown that an educational
package directed at doctors and nurses significantly decreased the point
prevalence of delirium among older people on a general medical ward. It is not
yet established whether specific and 'fixed' patients' characteristics influence the
rate of response to such an intervention. METHODS: A secondary, exploratory
stratified analysis was carried out to determine whether age, sex and presence of
dementia might influence the effect of the intervention through a delirium
educational package. This information is important in order to increase the
effectiveness of preventive measures across various patients' subgroups.
RESULTS: Male gender (OR 0.17, 0.05-0.65) significantly (p = 0.030) and
positively influence the response to the educational package compared to female
gender (OR 1.04, 0.38-2.81). Neither age nor the presence of underlying
dementia was associated with a significant influence on the rate of response to
the delirium prevention package. CONCLUSION: Staff may be more likely to
implement an earlier and more effective intervention for males who are perceived
as presenting a higher risk to themselves and others. The results reported
highlight the need to increase staff's vigilance to female patients whose
prodromal symptoms of delirium may be underemphasised. Understanding
different sub-group responses to preventive educational packages for delirium is
an important consideration if these are to be applied widely.
Takeuchi, T., K. Furuta, et al. (2007). "Perospirone in the treatment of patients with
delirium." Psychiatry & Clinical Neurosciences 61(1): 67-70.
Perospirone is a recently developed atypical antipsychotic with potent serotonin
5-HT2 and dopamine D2 antagonist activity. Other atypical antipsychotics
including risperidone, quetiapine and olanzapine have been widely used for
treatment, not only for schizophrenia symptoms but also for delirium, because of
their low potential to induce extrapyramidal disturbances. In the present study the
effectiveness and safety of perospirone in patients with delirium are described.
Thirty-eight patients with DSM-IV delirium were given open-label perospirone. To
evaluate the usefulness of perospirone, scores from 13 severity items of the
Delirium Rating Scale-Revised-98 were assessed. Data were gathered from
October 2003 to September 2004. Perospirone was effective in 86.8% (33/38) of
patients, and the effect appeared within several days (5.1 +/- 4.9 days). The
initial dose was 6.5 +/- 3.7 mg/day and maximum dose of perospirone was 10.0
+/- 5.3 mg/day. There were no serious adverse effects. However, increased
fatigue (15.2%), sleepiness (6.1%), akathisia (3.0%) and a decline in blood
pressure (3.0%) were observed. It is proposed that perospirone may be another
safe and effective atypical antipsychotic drug for the treatment of delirium
symptoms in hospitalized patients. This is a preliminary open trial, and further
randomized double-blind placebo-controlled tests are needed.
Tippett, V. (2007). "Hypoactive delirium: assessing the extent of the problem." Palliative
Medicine 21(2): 161; author reply 161-2.
van der Cammen, T. J., H. Tiemeier, et al. (2006). "Abnormal neurotransmitter
metabolite levels in Alzheimer patients with a delirium." Int J Geriatr Psychiatry 21(9):
838-43.
BACKGROUND: Delirium is a complex neuropsychiatric syndrome with an acute
onset and fluctuating course. Several studies have suggested the presence of
disturbed cholinergic, dopaminergic and serotonergic pathways in delirium as
well as in Alzheimer's disease. Abnormal concentrations of amino acids and of
neurotransmitter metabolites have been found in plasma, platelets and
cerebrospinal fluid of AD patients, and in plasma and CSF of patients with a
delirium. The aim of this study was to investigate amino acid and
neurotransmitter metabolite levels in plasma of AD patients with a concurrent
delirium. METHODS: In a case-control study of patients suffering from
Alzheimer's disease (AD) with concurrent delirium, we investigated the
contribution of delirium to some biochemical parameters in blood.We compared
plasma amino acid and neurotransmitter metabolite levels of 17 delirious AD
patients with those of 17 age- and gender-matched non-delirious AD patients and
29 age- and gender-matched controls. RESULTS: Homovanillic acid (HVA) and
5-hydroxyindoleacetic acid (5-HIAA) levels were higher in delirious AD patients
than in controls, but only HVA concentrations were higher in delirious AD patients
than in non-delirious AD patients. CONCLUSIONS: Our findings suggest that
central dopaminergic and serotonergic turnover are increased in AD patients with
delirium and that the high dopaminergic turnover might reflect the consequences
of delirium.
van Rijswijk, R. and C. van Guldener (2006). "A delirious patient with opioid intoxication
after chewing a fentanyl patch." Journal of the American Geriatrics Society 54(8): 12989.
van Zyl, L. T. and D. P. Seitz (2006). "Delirium concisely: condition is associated with
increased morbidity, mortality, and length of hospitalization." Geriatrics 61(3): 18-21.
Delirium is a common neuropsychiatric condition that affects 15% to 70% of
elderly medical and surgical patients. It tends to be a transient disorder, although
long-term complications are not uncommon. Medical comorbidity is the rule, and
predisposing, as well as precipitating, factors are important to consider in its
management. Major risk factors for delirium include advanced age, cognitive
impairment, and chronic medical illness. Delirium is associated with several
adverse outcomes including mortality, increased length of hospital stay,
increased risk of dementia, and high rates of institutional placement. Delirium is
distressing for patients, families, and staff. Nonpharmacologic-integrated
intervention programs may improve outcome and may be incorporated into the
overall medical management.
Vida, S., G. G. Du Fort, et al. (2006). "An 18-month prospective cohort study of
functional outcome of delirium in elderly patients: Activities of daily living." International
Psychogeriatrics. Vol. 18(4)(pp 681-700), 2006.
Objectives: To examine delirium, chronic medical problems and
sociodemographic factors as predictors of activities of daily living (ADL), basic
ADL (BADL) and instrumental ADL (IADL). Methods: A prospective cohort study
of four groups of elderly patients examined in the emergency department (ED):
those with delirium, dementia, neither, and both. All were aged 66 years or older
and living at home. Delirium was assessed with the Confusion Assessment
Method and dementia with the Informant Questionnaire on Cognitive Decline in
the Elderly. Demographic variables and chronic medical problems were
ascertained with questionnaires. Outcome was ADL at 6, 12 and 18 months,
measured with the ADL subscale of the Older Americans Resources and
Services instrument. Results: Univariate analyses suggested significantly poorer
ADL, particularly IADL, at 18 months in the delirium versus the non-delirium
group, in the absence of dementia only. Statistically significant independent
predictors of poorer ADL at 18 months in the non-dementia groups were poorer
initial ADL, stroke, Parkinson's disease, hypertension and female sex.
Independent predictors of poorer BADL at 18 months in the non-dementia groups
were poorer initial BADL, Parkinson's disease, stroke, cancer,
colds/sinusitis/laryngitis, female sex and hypertension. Independent predictors of
poorer IADL at 18 months in the non-dementia groups were poorer initial IADL,
stroke, never-married status, colds/sinusitis/laryngitis, arthritis and hypertension,
with Parkinson's disease showing a non-significant but numerically large
regression coefficient. Conclusion: Rather than finding delirium to be a predictor
of poorer functional outcome among survivors, we found an interaction between
delirium and dementia and several plausible confounders, primarily chronic
medical problems, although we cannot rule out the effect of misclassification or
survivor bias. copyright 2006 International Psychogeriatric Association.
von Gunten, A., C. Bula, et al. "[The differential diagnosis of cognitive disorders in
general practice: dementia and delirium]." Revue Medicale Suisse 3(98): 389-90.
Cognitive deficits are frequently encountered in primary care settings, in
particular in the elderly. Screening of these deficits is recommended and aims at
identifying subjects who are likely to benefit from treatment. In the event of either
positive screening or cognitive complaint, further somatic, cognitive,
psychopathological, and functional assessment should be performed and
possible consequences on family caregivers sought. Laboratory tests and neuroimaging are often necessary. This multi-dimensional assessment may require the
expertise of a memory clinic to distinguish normal aging, mild cognitive
impairment, and to identify the different organic and functional aetiologies of the
dementia syndrome and delirium.
Voyer, P., M. G. Cole, et al. (2006). "Prevalence and symptoms of delirium
superimposed on dementia." Clinical Nursing Research 15(1): 46-66.
Delirium is a frequent syndrome among patients who are elderly. People who are
older with cognitive impairment who are institutionalized are at increased risk of
developing delirium when hospitalized. In addition, their prior cognitive
impairment makes detecting their delirium a challenge. This study goal was to
describe the effect of severity of prior cognitive impairment on delirium
prevalence and symptom presentation among patients who were older and were
newly admitted to an acute care hospital. A total of 104 were included in this
descriptive study and screened for delirium. The results showed that the
prevalence of delirium increased according to the severity of the patients' prior
cognitive impairment. Except for disorganized thinking, all symptoms of delirium
were similar among patients with mild, moderate, and severe prior cognitive
impairment. The study concluded that training nurses to recognize subtle
changes in mental status among those patients who were older with prior
cognitive impairment may prevent the underdetection of delirium.
Voyer, P., J. McCusker, et al. (2006). "Influence of prior cognitive impairment on the
severity of delirium symptoms among older patients." Journal of Neuroscience Nursing
38(2): 90-101.
Delirium is common among hospitalized elderly patients with prior cognitive
impairment. Detecting delirium superimposed on dementia is a challenge for
nurses and doctors. As a result, delirium among demented elderly patients is of
increasing interest to healthcare professionals. So far, studies have failed to
describe how symptoms of delirium are altered by severity of dementia. This
would be valuable information to improve the rate of detection by nurses of
delirium among demented patients. However, until now no research has
examined the effect of severity of prior cognitive impairment on the severity of
delirium symptoms among institutionalized older patients. This study describes
the effect of severity of prior cognitive impairment on the severity of delirium
symptoms among institutionalized older patients with delirium at the time of their
admission to an acute care hospital. One hundred four institutionalized elderly
people were included in this study and screened for delirium using the confusion
assessment method. Patients with delirium (n = 71) were evaluated with the
delirium index to determine the severity of the symptoms of delirium. The results
showed that the severity of prior cognitive impairment influences the severity of
most of the symptoms of delirium, particularly disordered attention, orientation,
thought organization, and memory. Thus, taking into account the severity of prior
cognitive impairment could help nurses to detect delirium among older patients.
Voyer, P., J. McCusker, et al. (2007). "Factors associated with delirium severity among
older patients." Journal of Clinical Nursing 16(5): 819-31.
AIM: The goal of this study was to determine whether the factors associated with
delirium varied according to the severity of the delirium experienced by the older
patients. BACKGROUND: Delirium among older patients is prevalent and leads
to numerous detrimental effects. The negative consequences of delirium are
worse among older adults with severe delirium compared with patients with mild
delirium. There has been no study identifying those factors associated with
delirium severity among long-term care older patients newly admitted to an acute
care hospital. DESIGN: This is a descriptive study. METHODS: This is a
secondary analysis study of institutionalized older patients newly admitted to an
acute care hospital (n = 104). Upon admission, patients were screened for
delirium with the Confusion Assessment Method and severity of delirium
symptoms were determined by using the Delirium Index. RESULTS: Of the 71
delirious older patients, 32 (45.1%) had moderate-severe delirium while 39
(54.9%) presented mild delirium. In univariate analyses, a significant positive
relationship was observed between the level of prior cognitive impairment and
the severity of delirium (p = 0.0058). Low mini-mental state examination (MMSE)
scores (p < 0.0001), the presence of severe illness at the time of hospitalization
(p = 0.0016) and low functional autonomy (BI: p = 0.0017; instrumental activities
of daily living: p = 0.0003) were significantly associated with moderate-severe
delirium. Older patients suffering from mild delirium used significantly more drugs
(p = 0.0056), notably narcotics (p = 0.0017), than those with moderate-severe
delirium. Results from the stepwise regression indicated that MMSE score at
admission and narcotic medication use are the factors most strongly associated
with the severity of delirium symptoms. CONCLUSIONS: This present study
indicates that factors associated with moderate-severe delirium are different from
those associated with mild delirium. Given the result concerning the role of
narcotics, future studies should evaluate the role of pain management in the
context of delirium severity. RELEVANCE TO CLINICAL PRACTICE: As
moderate-severe delirium is associated with poorer outcomes than is mild
delirium, early risk factor identification for moderate-severe delirium by nurses
may prove to be of value in preventing further deterioration of those older
patients afflicted with delirium.
Wacker, P., P. V. Nunes, et al. (2006). "Post-operative delirium is associated with poor
cognitive outcome and dementia." Dementia & Geriatric Cognitive Disorders 21(4): 2217.
The objective of the present study is to evaluate the association between the
occurrence of delirium and the cognitive outcome in elderly subjects. Hospital
files of 572 patients who underwent hip or knee replacement between 1998 and
2004 were examined. A sample of 90 elderly subjects (31 with evidence of postoperative delirium), non-demented at baseline, was screened for cognitive
decline and dementia. Diagnosis of dementia was highly associated with the
occurrence of delirium. The relative risk for the diagnosis of dementia among
subjects with previous history of delirium, according to the IQcode screening,
was 10.5 (95% CI: 3.3-33.2). Such patients had a significantly higher mean
IQcode score (3.75) as compared to controls (3.1; p < 0.001). Cognitive functions
most affected in these patients were memory, orientation and abstract thinking.
We conclude that the occurrence of post-operative delirium in cognitively
unimpaired elderly subjects is associated with a worse cognitive outcome and an
increased risk of dementia. Copyright 2006 S. Karger AG, Basel.
Walker, J. T., S. P. Lofton, et al. (2006). "The home health nurse's role in geriatric
assessment of three dimensions: depression, delirium, and dementia." Home
Healthcare Nurse 24(9): 572-8; quiz 579-80.
Wang, M. D. (2006). "Perioperative haloperidol usage for delirium
management.[comment]." Journal of the American Geriatrics Society 54(5): 860-1;
author reply 861-3.
Wang, Y., L. P. Sands, et al. (2007). "The Effects of Postoperative Pain and Its
Management on Postoperative Cognitive Dysfunction." Am J Geriatr Psychiatry 15(1):
50-59.
To determine risks for postoperative cognitive dysfunction (POCD), the authors
conducted a prospective cohort study of 225 patients >/=65 years of age
undergoing noncardiac surgery. Cognitive testing using the Word List, Verbal
Fluency, and Digit Symbol tests was conducted for each patient preoperatively
and 1 and 2 days postoperatively in patients without postoperative delirium.
POCD was defined as meeting statistical criteria for decline from the patient's
preoperative performance levels on at least two of the three cognitive tests.
Multivariate logistic regression analysis determined the association between pain
and postoperative analgesia with POCD after controlling for demographics,
comorbidities, preoperative level of cognitive and daily functioning, preoperative
medications, duration and type of anesthesia, and adverse events. Patients were
on average 72 years old and 13% of patients experienced POCD on day 1, 7%
on day 2, and 15% had POCD on either day 1 or day 2 after the surgery.
Multivariate regression analyses revealed that only postoperative analgesia was
associated with the development of POCD. Compared with those receiving
postoperative analgesia through a patient-controlled analgesia device that
administered opioids intravenously, those who received postoperative analgesia
orally were at significantly lower risk for the development of POCD (odds ratio:
0.22; 95% confidence interval: 0.06-0.80; Wald chi-square = 5.36, df = 1, p =
0.02). Older patients undergoing noncardiac surgery who are not delirious can
experience significant declines in cognitive functioning postoperatively. Those at
least risk of experiencing POCD were those who received postoperative
analgesia orally.
Watson, R. (2007). "Editorial: Nazis, rats and whales in the aquarium: the experience of
delirium." Journal of Clinical Nursing 16(5): 809.
White, C., M. A. McCann, et al. (2007). "First do no harm. Terminal restlessness or
drug-induced delirium." Journal of Palliative Medicine 10(2): 345-51.
Terminal restlessness is a term frequently used to refer to a clinical spectrum of
unsettled behaviors in the last few days of life. Because there are many
similarities between the clinical pictures observed in terminal restlessness and
delirium, we postulate that at times what is referred to as terminal restlessness
may actually be an acute delirium sometimes caused by medication used for
symptom control. It is important therefore to consider the causes for this
distressing clinical entity, treat it appropriately, and ensure the treatment provided
does not increase its severity. This brief review aims to consider the medications
that are commonly used toward the end of life that may result in a picture of
delirium (or terminal restlessness). These include opioids, antisecretory agents,
anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and
nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise
awareness regarding the recognition and diagnosis of delirium and to highlight
the fact that delirium may be reversible in up to half of all cases. Good
management of delirium has the potential to significantly improve patient care at
the end of life.
Young, J. and S. K. Inouye (2007). "Delirium in older people." BMJ 334(7598): 842-6.