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BIBLIOGRAPHIE SUR LE DELIRIUM
(MEDLINE,CURRENT CONTENTS, COCHRANE) 2005
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Adamis, D., F. C. Martin, et al. (2005). "Capacity, consent, and selection bias in a study
of delirium." Journal of Medical Ethics 31(3): 137-43.
OBJECTIVES: To investigate whether different methods of obtaining informed
consent affected recruitment to a study of delirium in older, medically ill hospital
inpatients. DESIGN: Open randomised study. SETTING: Acute medical service
for older people in an inner city teaching hospital. PARTICIPANTS: Patients 70
years or older admitted to the unit within three days of hospital admission
randomised into two groups. INTERVENTION: Attempted recruitment of subjects
to a study of the natural history of delirium. This was done by either (a) a formal
test of capacity, followed by either a request for consent or an attempt at
obtaining assent from a proxy, or (b) a combined informal capacity/consent
process. MAIN OUTCOME MEASURES: Prevalence and severity of delirium,
and, as case mix measures, length of hospital stay and destination on discharge.
RESULTS: Recruitment of subjects through establishing formal capacity and
then informed consent was less successful (43.9% v 74% of those approached)
and, compared with those recruited through the usual combined capacity/consent
approach, yielded a sample with less cognitive impairment, lower severity of
delirium, lower probability of case note diagnosis of delirium and lower rate of
entering a care home. CONCLUSIONS: Methods of obtaining informed consent
may significantly influence the case mix of subjects recruited to a study of
delirium. Stringent testing of capacity may exclude patients with delirium from
studies, thus rendering findings less generalizable. A different method is
necessary to achieve an ethical balance between respecting autonomy through
obtaining adequate informed consent and avoiding sample bias.
Adamis, D., C. Morrison, et al. (2005). "The performance of the Clock Drawing Test in
elderly medical inpatients: does it have utility in the identification of delirium?" Journal of
Geriatric Psychiatry & Neurology 18(3): 129-33.
The Clock Drawing Test is an often-used test for the detection of cognitive
impairment, but the few studies that have evaluated its utility in delirium have
produced rather inconsistent results. In a longitudinal study of delirium in elderly
medical inpatients, we have investigated the relationships between the Clock
Drawing Test, the presence and severity of delirium, and cognitive impairment.
Using mixed linear model analysis we found that cognitive impairment was the
major factor associated with low Clock Drawing Test scores (P <.0001): neither
the presence nor the severity of delirium had additional significant effect on the
Clock Drawing Test. Thus, we conclude that although the Clock Drawing Test is
a good detector of cognitive impairment, it is not a suitable tool for detection of
delirium in elderly medical inpatients.
Adamis, D., A. Treloar, et al. (2005). "Concurrent validity of two instruments (the
Confusion Assessment Method and the Delirium Rating Scale) in the detection of
delirium among older medical inpatients." Age & Ageing 34(1): 72-5.
Agnoletti, V., L. Ansaloni, et al. (2005). "Postoperative Delirium after elective and
emergency surgery: analysis and checking of risk factors. A study protocol." BMC
Surgery 5(1): 12.
BACKGROUND: Delirum is common in hospitalized elderly patients and may be
associated with increased morbidity, length of stay and patient care costs.
Delirium (acute confusional state) is defined as an acute disorder of attention and
cognition. In elderly patients, delirium is often an early indicator of pathophysiological disturbances. Despite landmark studies dating back to the 1940s,
the pathogenesis of Delirium remains poorly understood. Early investigators
noted that Delirium was characterized by global cortical dysfunction that was
associated predominantly with specific electroencephalographic changes. It's
important to understand the risk factors and incidence of Delirium. Some of the
risk factors are already identified in literature and can be summarized in the word
"VINDICATE" which stands for: Vascular, Infections, Nutrition, Drugs, Injury,
Cardiac, Autoimmune, Tumors, Endocrine. Aims of this study are: to re-evaluate
the above mentioned clinical risk factors, adding some others selected from
literature, and to test, as risk factors, a pattern of some genes associated to
cognitive dysfunction and inflammation possibly related to postoperative
Delirium. DESIGN: All patients admitted to our Emergency Unit who are meet our
inclusion/exclusion criteria will be recruited. The arising of postoperative Delirium
will select incidentally two groups (Delirium/non Delirium) and the forward
analysis of correlate risk factors will be performed. As in a typical observational
case/control study we will consider all the exposure factors to which our
population are submitted towards the outcome (presence of Delirium). Our
exposures are the following: ASA, Pain (SVS; VAS), Blood gas analysis (pH; Hb;
pO2; pCO2), Residence pharmacological therapy (BDZ; hypnotics; narcotic
drugs; alcohol; nitrous derivates), Body temperature, Arterial pressure, Heart
frequency, Breath frequency, Na, K, Creatinin, Glicemia, Albumin, Hct, White
blood cells, Glasgow Coma Scale (GCS), Cognitive state (SPMSQ), Functional
state (ADL and IADL), Psychological Distress (HADS), Cumulative Illness Rating
Scale (CIRS), Hypotension (classified in: light; moderate and severe and
duration), Blood loss (classified in: < 2 lt and > 2 lt), Blood transfusions (< 2 lt and
> 2 lt), Quantity of red cells and plasma transfusions, Visual VAS / SVS (timing: III-III post-operative day), Red cells and Plasma transfusions, Blood count
evaluation and Saturation (O2%), Postoperative analgesia (Emilia-Romagna
protocol), Presence of malignant tumoral disease, APACHE Score II. Moreover
the presence of some relevant genetic polymorphisms will be studied in different
genes such as IL-6, IL-10, TNF-alpha, and IL-1 cluster.
Alao, A. O., M. Soderberg, et al. (2005). "Agitation in the medically ill elderly." West
African Journal of Medicine 24(2): 171-4.
Agitation is a common and significant problem in the medically ill elderly. It is
responsible for diminished quality of life for not only the patient, but the
caregivers as well as the patient's relatives. This paper will illustrate the concept
of agitation and different modes of classification. The major emphasis will be
placed on discussing prompt, correct diagnosis of the underlying cause of
agitation and effective treatment of both the cause of agitation and the symptoms
of agitation itself.
Amador, L. F. and J. S. Goodwin (2005). "Postoperative delirium in the older patient."
Journal of the American College of Surgeons 200(5): 767-73.
Anderson, D. (2005). "Preventing delirium in older people." British Medical Bulletin 74:
25-34.
Delirium is a common presentation of acute physical illness in older people.
When complicating a hospital admission it is an independent predictor of poor
outcomes and is poorly detected. Up to 50% of delirium in older people develops
after admission to hospital. The factors that predispose to and precipitate these
incident cases are now recognized and many are related to the process of care.
Controlled studies demonstrate the potential to reduce incident delirium by 3040%, and these interventions are essentially the provision of high-quality care.
The routine use of risk prediction rules for all older people admitted to general
hospitals would identify those at greatest risk and allow the implementation of
care plans that incorporate strategies for prevention and the detection of early
symptoms. There is now sufficient evidence to recommend that this should
become routine practice. [References: 33]
Andrew, M. K., S. H. Freter, et al. (2005). "Incomplete functional recovery after delirium
in elderly people: a prospective cohort study." BMC Geriatrics 5(1): 5.
BACKGROUND: Delirium often has a poor outcome, but why some people have
incomplete recovery is not well understood. Our objective was to identify factors
associated with short-term (by discharge) and long-term (by 6 month) incomplete
recovery of function following delirium. METHODS: In a prospective cohort study
of elderly patients with delirium seen by geriatric medicine services, function was
assessed at baseline, at hospital discharge and at six months. RESULTS: Of 77
patients, vital and functional status at 6 months was known for 71, of whom 21
(30%) had died. Incomplete functional recovery, defined as > or =10 point decline
in the Barthel Index, compared to pre-morbid status, was present in 27 (54%) of
the 50 survivors. Factors associated with death or loss of function at hospital
discharge were frailty, absence of agitation (hypoactive delirium), a cardiac
cause and poor recognition of delirium by the treating service. Frailty, causes
other than medications, and poor recognition of delirium by the treating service
were associated with death or poor functional recovery at 6 months.
CONCLUSION: Pre-existing frailty, cardiac cause of delirium, and poor early
recognition by treating physicians are associated with worse outcomes. Many
physicians view the adverse outcomes of delirium as intractable. While in some
measure this might be true, more skilled care is a potential remedy within their
grasp.
Bell, M. L. and E. F. Wijdicks (2005). "The triumvirate of acute hypertension." Neurology
65(2): E5.
Bellelli, G., S. Speciale, et al. (2005). "Predictors of delirium during in-hospital
rehabilitation in elderly patients after hip arthroplasty." Age Ageing 34(5): 532.
Bergmann, M. A., K. M. Murphy, et al. (2005). "A model for management of delirious
postacute care patients." Journal of the American Geriatrics Society 53(10): 1817-25.
Although delirium has been shown to be a common, morbid, and costly problem
for hospitalized older people, evidence has mounted that it may persist for weeks
or months. Therefore, concern about delirium can no longer be confined to acute
care. After an acute hospitalization, many older people are discharged to
postacute care (PAC) facilities--rehabilitation hospitals and skilled nursing
facilities. Although several models designed to prevent delirium in the hospital
setting have been described, there have been few such efforts in the PAC
setting. This article describes the development of a multifactorial delirium
abatement program (DAP), a new model of care for older patients admitted to the
postacute skilled nursing facility with delirium. The DAP is a nurse-led, unit-based
intervention. The program consists of four modules based on best practices as
defined by the peer-reviewed literature: standardized screening for symptoms
and signs of delirium upon admission to the PAC unit, assessment and treatment
of possible causes of and contributors to delirium, prevention and management
of common delirium complications, and restoration of patient cognitive and selfcare function. This article also presents the process of facility introduction, staff
education on DAP content, and multidisciplinary outreach. Key strategies for
DAP implementation are reviewed. Program adoption challenges and
corresponding model refinements to enhance adherence and overall care quality
are highlighted. Last, clinical adaptation of this research-derived program is
discussed.
Bhat, R. and K. Rockwood (2005). "Inter-rater reliability of delirium rating scales."
Neuroepidemiology 25(1): 48-52.
Delirium continues to be under-recognized despite use of rating scales with
apparently high inter-rater reliability. We analyzed the inter-reliability data of
published rating scales for delirium using a standard questionnaire to evaluate if
the inter-rater reliability was assessed rigorously. Most studies employed a
heterogeneous group of cognitively disordered elderly, however other aspects of
inter-rater reliability estimation were less than rigorous. This suggests that the
reported reliability may be spuriously high, which may have implications on the
ability of clinicians to discriminate delirium from other causes of cognitive
impairment in practice. The methodology of assessing inter-rater reliability of
delirium scales needs to improve and reliability should be evaluated when the
settings of administration change substantially. [References: 33]
Bilwise, D. L., J. H. Lee, et al. (2005). "Feasibility of ambulatory overnight oximetry in
consecutive patients in a dementia clinic." Journal of the American Geriatrics Society
53(3): 545-6.
Boari, B., M. Gallerani, et al. (2005). "A sudden and temporary episode of altered
mental status: a case report." Journal of the American Geriatrics Society 53(2): 350-1.
Bourgeois, J. A. and D. M. Hilty (2005). "Prolonged delirium managed with risperidone."
Psychosomatics 46(1): 90-1.
Bourgeois, J. A., A. K. Koike, et al. (2005). "Adjunctive valproic acid for delirium and/or
agitation on a consultation-liaison service: a report of six cases." Journal of
Neuropsychiatry & Clinical Neurosciences 17(2): 232-8.
The authors present six cases in which valproate was used in patients seen by a
consultation-liaison service (CLS) to manage delirium and/or psychotic agitation.
The intravenous (IV) preparation (Depacon, Abbott Laboratories) was used in
two nothing by mouth (NPO) patients, while the liquid oral preparation
(Depakene, Abbott Laboratories) was used via nasogastric tube (NGT) in the
other patients. All of these cases had suboptimal responses and/or concerning
side effects from conventional therapy with benzodiazepines and/or
antipsychotics. In all six cases, the CLS use of valproic acid combined with
conventional antidelirium medications resulted in improved control of behavioral
symptoms without significant side effects from valproic acid. Consultation-liaison
psychiatrists should consider the addition of valproic acid to control behavioral
symptoms of delirium when conventional therapy is inadequate. This may be
especially advisable when problematic side effects result from more conventional
psychopharmacological management. Specifically, intravenous valproate sodium
may be a viable option for NPO patients.
Bracha, H. S., E. Garcia-Rill, et al. (2005). "Postmortem locus coeruleus neuron count in
three American veterans with probable or possible war-related PTSD." Journal of
Neuropsychiatry & Clinical Neurosciences 17(4): 503-509.
The authors investigated whether war-related posttraumatic stress disorder (WRPTSD) is associated with a postmortem change in neuronal counts in the locus
coeruleus (LC) since enhanced central nervous system (CNS) noradrenergic
postsynaptic responsiveness has been previously shown to contribute to PTSD
pathophysiology. Using postmortem neuromorphometry, the number of neurons
in the right LC in seven deceased elderly male veterans was counted. Three
veterans were classified as cases of probable or possible WR-PTSD. All three
veterans with probable or possible WR-PTSD were found to have substantially
lower LC neuronal counts compared to four comparison subjects (three
nonpsychiatric veterans and one veteran with alcohol dependence and delirium
tremens). To the authors' knowledge, this case series is the first report of LC
neuronal counts in patients with PTSD or any other DSM-IV-TR anxiety disorder.
Previous postmortem brain tissue studies of Alzheimer's Disease (AD)
demonstrated an upregulation of NE biosynthetic capacity in surviving LC
neurons. The finding reported is consistent with the similar upregulation of NE
biosynthetic capacity of surviving LC neurons in veterans who developed WRPTSD. Especially if replicated, this finding in WR-PTSD may provide further
explanation of the dramatic effectiveness of propranolol and prazosin for the
secondary prevention and treatment of PTSD, respectively. The LC neurons
examined in this study are probably the origin of the first or second "leg" of what
might be termed the PTSD candidate circuit. Larger neuromorphometric studies
of the LC in veterans with WR-PTSD and in other development-stress-induced
and fear-circuitry disorders are warranted, especially using VA registries.
[References: 38]
Bredthauer, D., C. Becker, et al. (2005). "Factors relating to the use of physical
restraints in psychogeriatric care: a paradigm for elder abuse." Zeitschrift fur
Gerontologie und Geriatrie 38(1): 10-8.
The purpose of this study was to address one component of the complex topic
"elder abuse". A prospective observational study in the psychogeriatric unit of an
acute psychiatric hospital demonstrated that 30% (n=37) of all included patients
(n=122) were physically restrained. The highest incidence (48%) was found in
elderly patients with severe cognitive impairments (diagnosis of dementia and/or
delirium) (n=60). The most commonly used devices of physical restraints were
bed rails (100%), belts (trunk 93%, limbs 40%) and chair-tables ("gerichair")
(41%). Most restraints occurred at the beginning of hospitalization (83%).
Physical restraints were continued for many days and on average of many hours
a day. Patients with low cognitive status and serious mobility impairments
showed a very high risk of being restrained (p=0.015; OR 32.0 [95% CI:2.0515.1]). Inability to perform ADL activities increased the frequency of restraint
use (p=0.035; OR27.7 [95%CI: 1.3-604.1]). As possible co-factors repetitive
disruptive behaviors were found. There was no significant difference between the
frequency of falls in restrained or unrestrained patients during the observational
period, but fall-related fractures (n=2) only occurred in restrained patients. It is
possible that restraints increase the use of benzodiazepines and classical
neuroleptics.These results confirm that physical restraints remain a common
practice in psychogeriatric care. No evidence-based data support the value of
restraints in regard to fall prevention and control of behavioral disturbances in
elderly people with serious mental illness. In contrast, these devices can have
serious adverse effects and mean one of the most severe interventions in
fundamental human rights.
Butler, C. and A. Z. Zeman (2005). "Neurological syndromes which can be mistaken for
psychiatric conditions." Journal of Neurology, Neurosurgery & Psychiatry 76 Suppl 1:
i31-38.
Caeiro, L., C. Menger, et al. (2005). "Delirium in acute subarachnoid haemorrhage."
Cerebrovascular Diseases 19(1): 31-8.
BACKGROUND: Delirium may be a presenting feature in acute subarachnoid
haemorrhage (SAH). The aim of this study was to investigate the risk factors for
delirium in acute SAH and to analyse the relation between delirium and location
and amount of haematic densities and hydrocephalus. METHODS: We assessed
delirium in a sample of 68 consecutive patients with acute (< or =4 days) SAH
(33 aneurysmal, 33 non-aneurysmal, including 9 with perimesencephalic
haemorrhage), before aneurysmal treatment, using DSM-IV-R criteria and the
Delirium Rating Scale (DRS). DRS scores were related to: (1) the total amount of
haematic densities at 10 basal cisterns/fissures and in the 4 ventricles, using a
validated rating scale, (2) the haematic densities in the prepontine cistern and the
convexity of the brain and (3) hydrocephalus, using the bicaudate index, obtained
from a review of admission CT scans. RESULTS: Eleven acute SAH patients
presented with delirium. Older age (U = 316.5, p = 0.04), alertness disturbance
(chi(2) = 5.1, p = 0.02, OR = 7.6, 95% CI = 1.5-37.3), aphasia (U = 61.5, p =
0.007) and a Hunt and Hess score >2 (U = 362.5, p = 0.02) were associated with
delirium. Higher amounts of intraventricular haematic densities (chi(2) = 4.43, p =
0.04, U = 158, p = 0.001) and hydrocephalus (U = 215, p = 0.009) were also
associated with higher DRS scores. Two delirious patients had basofrontal
haematomas. CONCLUSIONS: Delirium was detected in 16% of acute SAH
patients. Intraventricular bleeding, hydrocephalus and basofrontal haematomas
contribute to the pathogenesis of delirium, through damage to anatomical
networks subserving sustained attention, declarative memory and the expression
of emotional behaviour.
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), Mini-
Mental 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 <= 0.0001). The cost was lower for the
acute plus rehabilitation phases (7,680 pound versus 10,598; pound P = 0.0109)
and the rehabilitation phase alone (2,523 pound versus 6,100; pound P <=
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. [References: 31]
Cavaliere, F., F. D'Ambrosio, et al. (2005). "Postoperative delirium." Current Drug
Targets 6(7): 807-14.
Delirium is a global impairment of upper brain functions caused by an organic
substrate. It is frequently observed in the postoperative period, particularly in
elderly people. Vascular and orthopedic surgery and long-duration surgery are
associated with a higher incidence of postoperative delirium. When it occurs,
postoperative delirium makes patient management much more difficult, increases
costs, and, above all, causes severe discomfort to the patient. Delirium is also
associated with higher postoperative mortality and morbidity, and with delayed
functional recovery, but it is still unclear whether worse prognosis is directly
caused by delirium or results from the neurological damage of which delirium is
simply a symptom. Drug therapy should be part of a complex approach to
prevent and treat this complication. Neuroleptics like haloperidol and droperidol,
and benzodiazepines are usually employed in order to control symptoms like
agitation, restlessness, and altered perceptions. Atypical neuroleptics, like
risperidone, have not yet been studied in postoperative delirium, although some
case reports in which they were successfully used have been published.
Physiostigmine is effective in delirium caused by anticholinergic syndrome;
vitamins may be useful in alcoholics; melatonin use has been suggested in order
to prevent and treat delirium by normalizing sleep-wake cycle alterations.
Environmental interventions are often costless and may be very useful to prevent
and treat postoperative delirium in patients at risk. [References: 80]
Chae, B. J. and B. J. Kang (2005). "A case of delirium and subsequent pancytopenia
associated with the oral loading of valproic acid." Journal of Clinical Psychiatry 66(6):
801-2.
Chassagne, P., L. Druesne, et al. (2005). "Mental confusion in the elderly." Presse
Medicale 34(12): 863-868.
The prevalence of delirium in hospitalized patients aged 80 years or older ranges
from 35 to 50%. Its onset is acute, recovery is erratic, and the principal
differential diagnosis is dementia. Hypoactive confusion is a clinical form that
should not be ignored. Prognosis is severe with impairments in activities of daily
living and high mortality. Risk factors are age (older than 80 years), dementia,
sensory impairments, dehydration, sleep deprivation and immobility. Initial
treatment must focus on identifying the cause of the delirium. Primary
nonpharmacological prevention in subjects at risk is possible and effective.
[References: 32]
Cohendy, R., A. Brougere, et al. (2005). "Anaesthesia in the older patient." Current
Opinion in Clinical Nutrition & Metabolic Care 8(1): 17-21.
PURPOSE OF REVIEW: Clinical anaesthesia and analgesia address a growing
number of elderly surgical patients. Ageing modifies physiology,
pharmacokinetics and pharmacodynamics, and comorbidity is a common
occurrence in the elderly. Therefore, based on recent information regarding
perioperative outcome, indications and techniques should be individualized.
RECENT FINDINGS: Clinical studies have highlighted the occurrence of
postoperative cognitive dysfunction in elderly patients, and have given some
information on its risk factors. As pain was found to be one of the most important
of these, this review is also focused on the management of perioperative pain.
Recently published studies have compared epidural analgesia and parenteral
analgesics; others have described the handling of parenteral opioids for
postoperative analgesia in elderly patients, and the opioid-sparing effect of
multimodal analgesia. SUMMARY: Postoperative cognitive dysfunction (POCD)
is quite frequent. If late POCD seemed not related to the type of anaesthesia and
analgesia provided, early POCD (interval delirium) was found to be related to
perioperative haematocrit and transfusion requirement and to postoperative pain.
Epidural analgesia using local anaesthetics and/or opioids was found to be
probably better than parenteral opioids for the control of postoperative pain and
the prevention of postoperative morbidity and mortality. However, well
implemented protocols of parenteral analgesics could be nearly as efficient.
[References: 22]
Contin, A. M., J. Perez-Jara, et al. (2005). "Postoperative delirium after elective
orthopedic surgery." International Journal of Geriatric Psychiatry 20(6): 595-7.
de Jonghe, J. F., K. J. Kalisvaart, et al. (2005). "Delirium-O-Meter: a nurses' rating scale
for monitoring delirium severity in geriatric patients." International Journal of Geriatric
Psychiatry 20(12): 1158-66.
BACKGROUND: Delirium is a common psychiatric disorder in general hospital
elderly patients. Several delirium screening tests exist. Few nurse based delirium
severity measures are available. The aim of this study was to evaluate the
Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and
sensitive measure of delirium severity. METHODS: Analysis of cross sectional
and repeated assessments data. Participants were 92 elderly general hospital
patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no
delirium) and 12 with other psychiatric disorders or no mental disorder. Measures
were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRSR-98), Delirium Observation Scale (DOS), Behavioural observation scale for
geriatric inpatients (GIP) and Mini Mental State Examination (MMSE). RESULTS:
The majority of DOM items show a (near-) normal score distribution. Reliability of
the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class
Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item
scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining
almost half of variance and a smaller 'Psychotic/Behavioural' factor. The twofactor model results support the conceptual distinction between hyperactive and
hypoactive delirium. DOM observations differentiated delirium from non delirium
patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE
and GIP apathy and cognitive sub scales, but less so to the GIP affective
disturbances subscale, indicating convergent and divergent validity. Temporal
difference scores calculated for DRS-R-98 and DOM assessments on
subsequent days were also highly related (rho = 0.80-0.95). CONCLUSIONS:
The newly constructed DOM is a brief and valid nurses' behavioural rating scale
that can be useful for measuring different aspects of delirium and for efficiently
monitoring delirium severity in elderly patients. Copyright (c) 2005 John Wiley &
Sons, Ltd.
de Rooij, S. E., M. J. Schuurmans, et al. (2005). "Clinical subtypes of delirium and their
relevance for daily clinical practice: a systematic review." International Journal of
Geriatric Psychiatry 20(7): 609-15.
BACKGROUND: Delirium is a disorder that besides four essential features
consists of different combinations of symptoms. We reviewed the clinical
classification of clusters of symptoms in two or three delirium subtypes. The
possible implications of this subtype classification may be several. The
investigation and exploration of clinical subtypes of delirium may provide
information concerning the etiology, the pathogenesis, and the prognosis of
delirium, but also may have therapeutic consequences. METHODS: We
searched several database for English-language articles. Selected articles were
cross-checked for other relevant publications. DATA SYNTHESIS AND
CONCLUSION: We conducted a systematic review and retrieved ten clinical
studies. The studies described in this review show different results, partly due to
methodological problems and possibly by lack of a standard classification for
delirium subtypes. According to the present literature a useful and reproducible
method to classify (patterns of) symptoms in delirium subtypes seems to be the
general rating of and division in to psychomotor subtypes. The Memorial Delirium
Assessment Scale (MDAS) and the Dublin Delirium Assessment Scale (DAS)
appear to be reliable methods, together with the new version of the Delirium
Rating Scale (DRS-R-98). Copyright 2005 John Wiley & Sons, Ltd. [References:
39]
Duggal, M. K., A. Singh, et al. (2005). "Olanzapine-induced vasculitis." American
Journal Geriatric Pharmacotherapy 3(1): 21-4.
INTRODUCTION: Elderly patients are particularly vulnerable to adverse drug
reactions as a result of polypharmacy and metabolic changes associated with
aging. We present a case of leukocytoclastic vasculitis induced by olanzapine, a
medication commonly used in elderly patients. CASE SUMMARY: An 82-year-old
woman was admitted to the extended-care center for short-term rehabilitation
after prolonged hospitalization for a pulmonary embolism requiring mechanical
ventilation. The pulmonary problem resolved, but her hospitalization and
subsequent rehabilitation were complicated by agitated delirium, which was
treated with olanzapine and modification of contributory factors. At the time of
admission to the rehabilitation facility, the patient had been receiving warfarin for
2 weeks and olanzapine for 6 days. On the eighth day after initiation of
olanzapine, erythematous skin lesions developed on dependent areas. The
international normalized ratio for warfarin was within the acceptable range;
however, because warfarin has been associated with subcutaneous bleeding
presenting as petechiae and ecchymosis, subcutaneous enoxaparin was
substituted for warfarin. The skin lesions continued to worsen over the next week
and developed into palpable lesions. Biopsy of the rash revealed leukocytoclastic
vasculitis. In the absence of another cause, olanzapine was discontinued and the
rash improved significantly. When the agitation recurred, risperidone was
initiated, but the patient experienced dizziness with this agent. Olanzapine was
resumed and the skin lesions recurred. Olanzapine was then changed to
quetiapine, and the skin lesions improved over the next few weeks.
DISCUSSION: Olanzapine is commonly used in elderly patients to control
behavioral disturbances associated with dementia, delirium, and other psychiatric
disorders. Leukocytoclastic vasculitis is an infrequently reported adverse drug
reaction with olanzapine. Its exact pathogenic mechanism is unknown, but both
cell-mediated and humoral immunity appear to play important roles. Because
drug-induced vasculitis has an identical clinical presentation and identical
serologic/pathologic parameters to idiopathic forms of vasculitis, a high index of
suspicion is necessary for its accurate diagnosis. CONCLUSIONS: Because
adverse drug reactions are common in elderly patients taking multiple
medications, physicians should be vigilant when starting new medications and
should attempt to eliminate unnecessary medications. Clinicians should be aware
of the potential for leukocytoclastic vasculitis in association with olanzapine.
Erhart, S. M., A. S. Young, et al. (2005). "Clinical utility of magnetic resonance imaging
radiographs for suspected organic syndromes in adult psychiatry." Journal of Clinical
Psychiatry 66(8): 968-73.
OBJECTIVE: In psychiatric practice, adult patients are most commonly referred
for magnetic resonance imaging (MRI) to screen for suspected organic medical
diseases of the central nervous system that can mimic psychiatric syndromes.
We identified the most common signs and symptoms prompting MRIs to
establish the predictive value of these signs and symptoms for clinically pertinent
organic syndromes. METHOD: This study was a retrospective chart review of
psychiatric patients at the Veterans Affairs Greater Los Angeles Health Care
Center (Los Angeles, Calif.) who were referred for MRI of the brain between
1996 and 2002. Patients referred for evaluation of dementia were excluded. The
specific indications leading clinicians to obtain MRI were identified and grouped.
In order to offset the uncertain significance of many MRI findings, for this study,
the predictive value of each indication was calculated based on the percentage of
patients in whom clinical management changed in response to MRI findings
rather than on the percentage with any abnormal MRI results. RESULTS: Of 253
patients who had MRIs, 38 (15%) incurred some degree of treatment
modification as a result of MRI findings, including 6 patients in whom MRI
identified a medical condition that became the focus of treatment. Six indications
appeared most likely to prompt clinicians to obtain MRIs. Because pertinent
results were associated with each of these indications, statistical evaluation did
not reveal significant differences in their predictive values (chi(2) = 4.32, df = 5, p
=.505). CONCLUSIONS: Unlike prior studies showing no value to screening
radioimaging, this study shows MRI can be a useful screening test among
patients suspected of having organic psychiatric disorders and that the common
indications for MRI employed at one institution were predictive.
Estfan, B., T. Yavuzsen, et al. (2005). "Development of opioid-induced delirium while on
olanzapine: a two-case report." Journal of Pain & Symptom Management 29(4): 330-2.
Fann, J. R., C. M. Alfano, et al. (2005). "Clinical presentation of delirium in patients
undergoing hematopoietic stem cell transplantation." Cancer 103(4): 810-20.
BACKGROUND: Delirium is common in patients undergoing hematopoietic stem
cell transplantation (HSCT) and is associated with considerable morbidity and
excess mortality in diverse patient samples. Although delirium can be treated
successfully, it is largely undiagnosed. Understanding the clinical presentation of
delirium may help improve the recognition of delirium in these patients. In the
current study, the authors investigated the clinical presentation of delirium in
HSCT patients, including the time course of these symptoms and comorbid
affective distress, fatigue, and pain. METHODS: Ninety patients ages 22-62
years were recruited prior to undergoing their first allogeneic or autologous
HSCT. Delirium, distress, and pain symptom assessments were conducted
prospectively 3 times per week from pretransplantation through Day 30
posttransplantation. RESULTS: Delirium episodes occurred in 50% of patients
and lasted approximately 10 days, with peak severity at the end of the second
week posttransplantation. Factor analysis revealed three groups of delirium
symptoms representing psychosis-behavior, cognition, and mood-consciousness.
Delirium episodes were characterized by rapid onset of psychomotor and sleepwake cycle disturbance that persisted and cognitive symptoms that continued to
worsen throughout much of the episode. Rises in psychosis-behavior and
cognitive symptoms predated the start of delirium episodes by approximately 4
days. Affective distress and fatigue were common and appeared to be
associated most with psychosis-behavioral delirium symptoms. CONCLUSIONS:
The results describe in detail the clinical presentation of delirium in patients
undergoing HSCT. Affective distress and fatigue commonly were associated with
delirium. These findings may aid clinicians in improving the recognition and
treatment of delirium in this population and avoiding further morbidity and
potential mortality. Copyright (c) 2005 American Cancer Society.
Fayers, P. M., M. J. Hjermstad, et al. (2005). "Which mini-mental state exam items can
be used to screen for delirium and cognitive impairment?" Journal of Pain & Symptom
Management 30(1): 41-50.
Cognitive impairment is common in palliative care patients, but it is frequently
undetected. The clinical consequence is that psychiatric states such as delirium,
which often present with cognitive impairment, are inadequately treated. A short
and simple questionnaire for screening of cognitive impairment is required for
these patients, in order to proceed with more advanced testing if necessary. In
this study, we explored the results from two samples of patients (n=290 and
n=217) who had completed the Mini-Mental State Examination (MMSE). Cases
of cognitive impairment are considered indicated by an MMSE score of less than
24 of the total 30. We found that caseness could be fairly accurately screened by
using four of the original 20 MMSE items, and that a six-item questionnaire
further greatly improved the discrimination.
Fick, D. M., A. M. Kolanowski, et al. (2005). "Delirium superimposed on dementia in a
community-dwelling managed care population: a 3-year retrospective study of
occurrence, costs, and utilization." Journals of Gerontology Series A-Biological
Sciences & Medical Sciences 60(6): 748-53.
BACKGROUND: Dementia is a growing public health problem and a welldescribed risk factor for delirium. Yet little is known about delirium superimposed
on dementia in community-dwelling populations. The purpose of this study was to
examine the 3-year occurrence, healthcare utilization, and costs associated with
delirium superimposed on dementia in community-dwelling persons. METHODS:
We used a 3-year cross-sectional, retrospective design with an administrative
database from a large managed care organization. Four individually matched
samples of 699 individuals each were selected for comparison purposes: delirium
superimposed on dementia (DSD), dementia alone, delirium alone, and a control
group with neither delirium nor dementia. The occurrence rate of DSD was
calculated by measuring those individuals with a dementia diagnosis that were
also coded with an International Classification of Diseases, Ninth Edition Clinical
Modification (ICD-9 CM) code for delirium or delirium with dementia. RESULTS:
Of the total sample of 76,688 persons aged 65 years or older in the managed
care organization, 7347 (10%) were coded as having dementia, and an additional
763 (1%) as having delirium alone. Among the 7347 with dementia, 976 (13%)
had DSD, representing 1.3% of the total sample. After log transformation of total
costs and adjustment for multiple covariates, the adjusted mean total health care
costs remained significantly higher for the DSD group than for all other groups.
CONCLUSIONS: This study is the first to report the occurrence rate of DSD in a
community-dwelling population, and to demonstrate the substantial health care
costs and utilization associated with DSD.
Formiga, F., E. Marcos, et al. (2005). "[Acute confusional syndrome in elderly patients
hospitalized due to medical condition]." Revista Clinica Espanola 205(10): 484-8.
INTRODUCTION: Delirium or acute confusional syndrome (ACS) is a frequent
problem during hospitalization of elderly patients. We study the appearance of
delirium and its characteristics in patients admitted to an internal medicine
service. METHODS: Prospective study of 148 patients over 64 years admitted
due to medical condition (non-surgical) in the internal medicine service of the
University Hospital of Bellvitge. Functionality was quantified with the Barthel
index (BI) and comorbidity with the Charlson index (CI). The Confusional
Assessment Method was used for the diagnosis of the ACS. RESULTS: Seventyseven (77) (52%) of the 148 patients were women, with a mean age of 78.5
years. The CI was 2.2. Mean of previous BI was 81.7. Mortality during admission
was 8% (12 patients). A total of 42.5% of the patients (63) had ACS (30%
prevalent). It was hyperactive in 68%, hypoactive in 16% and mixed in 16%. In
38% of the patients, the ACS had morning predominance and 62% it appeared
after the evening. Advanced age was the only significant differences between
patients with or without ACS (p < 0.001). There were no significant differences in
the ACS percentage between patients who survived or who died (p = 0.36).
CONCLUSIONS: Frequency of appearance of the confusional picture is high in
patients admitted to acute hospitals, it being more frequent in the elderly.
Measures to prevent the confusional picture in elderly patients who are
hospitalized should be increased.
Freter, S. H., M. J. Dunbar, et al. (2005). "Predicting post-operative delirium in elective
orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument." Age & Ageing
34(2): 169-71.
Freter, S. H., J. George, et al. (2005). "Prediction of delirium in fractured neck of femur
as part of routine preoperative nursing care." Age & Ageing 34(4): 387-8.
Gagnon, B., G. Low, et al. (2005). "Methylphenidate hydrochloride improves cognitive
function in patients with advanced cancer and hypoactive delirium: a prospective clinical
study." Journal of Psychiatry & Neuroscience 30(2): 100-7.
OBJECTIVE: To investigate the clinical improvement observed in patients with
advanced cancer and hypoactive delirium after the administration of
methylphenidate hydrochloride. METHODS: Fourteen patients with advanced
cancer and hypoactive delirium were seen between March 1999 and August
2000 at the Palliative Care Day Hospital and the inpatient Tertiary Palliative Care
Unit of Montreal General Hospital, Montreal. They were chosen for inclusion in a
prospective clinical study on the basis of (1) cognitive failure documented by the
Mini-Mental State Examination (MMSE), (2) sleep-wake pattern disturbances, (3)
psychomotor retardation, (4) absence of delusions or hallucinations, and (5)
absence of an underlying cause to explain the delirium. All patients were treated
with methylphenidate, and changes in their cognitive function were measured
using the MMSE. RESULTS: All 14 patients showed improvement in their
cognitive function as documented by the MMSE. The median pretreatment
MMSE score (maximum score 30) was 21 (mean 20.9, standard deviation [SD]
4.9), which improved to a median of 27 (mean 24.9, SD 4.7) after the first dose of
methylphenidate (p < 0.001, matched, paired Wilcoxon signed rank test). One
patient died before reaching a stable dose of methylphenidate. In the other 13
patients, the median MMSE score further improved to 28 (mean 27.8, SD 2.4) (p
= 0.02 compared with the median MMSE score documented 1 hour after the first
dose of methylphenidate). All patients showed an improvement in psychomotor
activities. CONCLUSIONS: Hypoactive delirium that cannot be explained by an
underlying cause (metabolic or drug-induced) in patients with advanced cancer
appears to be a specific syndrome that could be improved by the administration
of methylphenidate.
Gandhi, G. Y., G. A. Nuttall, et al. (2005). "Intraoperative hyperglycemia and
perioperative outcomes in cardiac surgery patients." Mayo Clinic Proceedings 80(7):
862-6.
OBJECTIVE: To estimate the magnitude of association between intraoperative
hyperglycemia and perioperative outcomes in patients who underwent cardiac
surgery. PATIENTS AND METHODS: We conducted a retrospective
observational study of consecutive adult patients who underwent cardiac surgery
between June 10, 2002, and August 30, 2002, at the Mayo Clinic, a tertiary care
center in Rochester, Minn. The primary independent variable was the mean
intraoperative glucose concentration. The primary end point was a composite of
death and infectious (sternal wound, urinary tract, sepsis), neurologic (stroke,
coma, delirium), renal (acute renal failure), cardiac (new-onset atrial fibrillation,
heart block, cardiac arrest), and pulmonary (prolonged pulmonary ventilation,
pneumonia) complications developing within 30 days after cardiac surgery.
RESULTS: Among 409 patients who underwent cardiac surgery, those
experiencing a primary end point were more likely to be male and older, have
diabetes mellitus, undergo coronary artery bypass grafting, and receive insulin
during surgery (P< or =.05 for all comparisons). Atrial fibrillation (n=105),
prolonged pulmonary ventilation (n=53), delirium (n=22), and urinary tract
infection (n=16) were the most common complications. The initial, mean, and
maximal intraoperative glucose concentrations were significantly higher in
patients experiencing the primary end point (P<.01 for all comparisons). In
multivariable analyses, mean and maximal glucose levels remained significantly
associated with outcomes after adjusting for potentially confounding variables,
including postoperative glucose concentration. Logistic regression analyses
indicated that a 20-mg/dL increase in the mean intraoperative glucose level was
associated with an increase of more than 30% in outcomes (adjusted odds ratio,
1.34; 95% confidence Interval, 1.10-1.62). CONCLUSION: Intraoperative
hyperglycemia is an independent risk factor for complications, including death,
after cardiac surgery.
Gaudreau, J. D., P. Gagnon, et al. (2005). "Impact on delirium detection of using a
sensitive instrument integrated into clinical practice." General Hospital Psychiatry 27(3):
194-9.
Early symptoms of delirium often go unnoticed. The Nursing Delirium Screening
Scale (Nu-DESC) is a recently developed short, accurate and sensitive 24-h
screening instrument. The Nu-DESC is more sensitive than the instrument from
which it was derived, the Confusion Rating Scale (CRS). This study examined
the impact on delirium detection of using the Nu-DESC over the CRS in 134
consecutive oncology patients. Expected false-negative rate (FNR) reductions at
different delirium prevalence rates when using the Nu-DESC compared to the
CRS and the number needed to screen (NNS) by the Nu-DESC were calculated.
Kaplan-Meier survival analyses were used to study Nu-DESC-CRS divergences
in delirium status and length of delirium-free survival. Ninety-nine patients were
negative for delirium according to both tests. Of the remaining 35 patients, 16
had identical Nu-DESC-CRS delirium status and delirium-free survival, whereas
19 were detected later by the CRS (mean, 4.8 days). Among the 19 patients, 6
were still CRS negative upon hospital discharge. Integrating a continuous and
sensitive delirium assessment instrument into usual care can facilitate its
recognition, since more cases of delirium are diagnosed and patients are
detected earlier.
Gaudreau, J. D., P. Gagnon, et al. (2005). "Psychoactive medications and risk of
delirium in hospitalized cancer patients." Journal of Clinical Oncology 23(27): 6712-8.
PURPOSE: Psychoactive medications are biologically plausible and potentially
modifiable risk factors of delirium. To date, however, research findings are
inconsistent regarding their association with delirium. The association between
exposure to anticholinergics, benzodiazepines, corticosteroids, and opioids and
the risk of delirium was studied. PATIENTS AND METHODS: A total of 261
hospitalized cancer patients were followed up with repeated assessments by
using the Nursing Delirium Screening Scale for up to 4 weeks for incident
delirium. Detailed exposure to psychoactive medications was documented daily.
Strengths of association with delirium were expressed as hazard ratios (HRs) in
univariate and multivariate analyses by using Cox regression models. All
medication variables were coded as time-dependent covariates. Whenever
possible, exposure was computed by using cumulative daily doses in
equivalents; dichotomous cutoffs were determined. RESULTS: During follow-up
(mean, 8.6 days), 43 patients became delirious (16.5%). Delirium was associated
with a history of delirium and the presence of hepatic metastases at admission.
Analysis of the effect of medications was performed adjusting for these factors.
Patients exposed to daily doses of benzodiazepines above 2 mg (HR, 2.04; 95%
CI, 1.05 to 3.97), above 15 mg of corticosteroids (HR, 2.67; 95% CI, 1.18 to
6.03), or above 90 mg of opioids (HR, 2.12; 95% CI, 1.09 to 4.13) had increases
in the risks for delirium. We did not observe associations between
anticholinergics and risk for delirium. CONCLUSION: Exposure to opioids,
corticosteroids, and benzodiazepines is independently associated with an
increased risk of delirium in hospitalized cancer patients.
Gaudreau, J. D., P. Gagnon, et al. (2005). "Fast, systematic, and continuous delirium
assessment in hospitalized patients: the nursing delirium screening scale." Journal of
Pain & Symptom Management 29(4): 368-75.
Because no rigorously validated, simple yet accurate continuous delirium
assessment instrument exists, we developed the Nursing Delirium Screening
Scale (Nu-DESC). The Nu-DESC is an observational five-item scale that can be
completed quickly. To test the validity of the Nu-DESC, 146 consecutive
hospitalized patients from a prospective cohort study were continuously
assessed for delirium symptoms by bedside nurses using the Nu-DESC.
Psychometric properties of Nu-DESC screening were established using 59
blinded Confusion Assessment Method (CAM) ratings made by research nurses
and psychiatrists. DSM-IV criteria and the Memorial Delirium Assessment Scale
(MDAS) were rated along with CAM assessments. Analysis of these data
showed that the Nu-DESC is psychometrically valid and has a sensitivity and
specificity of 85.7% and 86.8%, respectively. These values are comparable to
those of the MDAS, a longer instrument. Nu-DESC and DSM-IV sensitivities
were similar. The Nu-DESC appears to be well-suited for widespread clinical use
in busy oncology inpatient settings and shows promise as a research instrument.
Gonzalez, M., J. de Pablo, et al. (2005). "Delirium: A predictor of mortality in the
elderly." European Journal of Psychiatry 19(3): 165-171.
The frequency of delirium in elderly inpatients is high, resulting in poor hospital
outcomes. The objective of this study is to assess whether delirium is an
independent predictor for mortality over a three-month period. Methods:
Prospective, observational study in a cohort of 17 1 inpatients aged over 65
years. Presence of delirium and/or dementia, severity of delirium and incapacity
due to illness were assessed at baseline using DSM-IV diagnostic criteria, the
Confusion Assessment Method (CAM), the MMSE. the Delirium Rating Scale
(DRS) and the Karnofsky Performance Status (KPS). Mortality rates were
evaluated over a three-month follow-up period after enrollment. Kaplan-Meier
survival curves were constructed and the adjusted effect of a set of covariates
was evaluated with the Cox multiple regression analysis. Results: By 3 months
after enrollment, 34.4% of the patients with delirium died, compared with 16.5%
of those without delirium. The survival analysis shows a statistically significant
difference between the two groups (log-rank = 11.92; d.f. = 1; P = 0.0006). After
adjustment for covariates, delirium was found to be independently associated
with higher mortality. Conclusions: Delirium was found to be an independent
marker for mortality in older medical patients over a three-month follow-up.
[References: 23]
Goodchild, J. H. and M. Donaldson (2005). "Hallucinations and delirium in the dental
office following triazolam administration." Anesthesia Progress 52(1): 17-20.
A rare and unusual case of hallucinations following triazolam administration is
reported. A review of the literature suggests that hallucinations following
triazolam are rare; this is the first report of such a reaction when triazolam was
used for oral conscious sedation in dentistry. A discussion of dental implications
follows with emphasis on complete medical history evaluation before
administering oral sedatives. We conclude that the proper selection of oral
sedation candidates, coupled with recognition and management of adverse
events, is essential. [References: 15]
Gotor, P., J. I. Gonzalez-Montalvo, et al. (2005). "[Delirium on hospitalized aged hip
fracture patients]." Medicina Clinica 125(12): 477-8; author reply 478-9.
Gray-Vickrey, P. (2005). "Acute delirium." Nursing 35(8): 88.
Gupta, N., P. Sharma, et al. (2005). "Effectiveness of risperidone in delirium." Canadian
Journal of Psychiatry - Revue Canadienne de Psychiatrie 50(1): 75.
Hakko, E., B. Mete, et al. (2005). "Levofloxacin-induced delirium." Clinical Neurology &
Neurosurgery 107(2): 158-9.
Harmon, D., N. Eustace, et al. (2005). "Plasma concentrations of nitric oxide products
and cognitive dysfunction following coronary artery bypass surgery." European Journal
of Anaesthesiology 22(4): 269-76.
BACKGROUND AND OBJECTIVE: Prospective longitudinal studies now indicate
that cognitive dysfunction following coronary artery bypass surgery (CABG) is
both common and persistent. This dysfunction is due in part to the inflammatory
response and cerebral ischaemia-reperfusion, with nitric oxide (NO) as an
important mediator of both. We hypothesized that a clinically significant
association exists between plasma concentrations of nitrate/nitrite (NO3-/NO2-)
and cognitive dysfunction after CABG. METHODS: Cognitive assessment was
performed on 36 adult patients the day before CABG, on the fourth postoperative
day and 3 months postoperatively. Patient spouses (n = 10) were also studied.
RESULTS: A new cognitive deficit was present in 22/36 (62%) 4 days
postoperatively and in 16/35 (49%) of patients, 3 months postoperatively.
Patients who had cognitive dysfunction 3 months postoperatively were more
likely to have cognitive dysfunction and increased plasma NO3-/NO2concentrations compared to the non-deficit group preoperatively (22.6 (9.2) vs.
27.6 (8.4)) (P = 0.002). Plasma NOx (NO3- plus NO2-) concentrations were
greater in patients with cognitive dysfunction 3 months postoperatively, 2 h (24.2
(6.3) vs. 19.1 (5.2)) (P = 0.002), and 12 h postoperatively (24.8 (7.6) vs. 18.8
(5.6)) (P = 0.001). There was, however, a time course similarity in NOx
elevations for both deficit and non-deficit groups. CONCLUSIONS: Perioperative
plasma NOx concentrations do not serve as an effective biomarker of cognitive
deficit after CABG.
Hastings, S. N. and M. T. Heflin (2005). "A systematic review of interventions to improve
outcomes for elders discharged from the emergency department." Academic
Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
12(10): 978-86.
OBJECTIVES: To evaluate the evidence for interventions designed to improve
outcomes for elders discharged from the emergency department (ED).
METHODS: The study was a systematic review of English-language articles
indexed in MEDLINE and CINAHL (1966-2005) with 1) key words "geriatric,"
"older adults," or "seniors," or 2) Medical Subject Heading (MeSH) terms
"Geriatrics" or "Health Services for the Aged" AND key word "emergency," or 3)
MeSH terms "Emergencies," "Emergency Service, Hospital," or "Emergency
Treatment." Bibliographies of the retrieved articles were reviewed for additional
references, and the authors consulted with content experts to identify relevant
unpublished work. Patients of interest were community-dwelling elder patients
discharged home from the ED. Data were abstracted from selected articles by
the authors. Studies with interventions limited to patients with a single
presentation or diagnosis (falls, delirium, etc.) or delivered only to patients who
would have otherwise been hospitalized were not included. RESULTS: Of 669
citations, 27 studies (reported in 33 articles) met study criteria and were
reviewed; six randomized controlled trials (RCTs), two nonrandomized clinical
trials, and 19 observational studies or program descriptions. Three of four RCTs
designed to measure functional outcomes showed a reduction in functional
decline in the intervention group. The trials that resulted in functional benefits
enrolled high-risk patients and included geriatric nursing assessment and homebased services as part of the intervention. Results of trials to decrease health
service utilization rates following an ED visit were mixed. CONCLUSIONS: A
significant number of programs to improve outcomes for elders discharged from
the ED exist, but few have been systematically examined. Development of
interventions to improve the care of elder patients following ED visits requires
further research into system and patient-centered factors that impact health care
delivery in this situation.
Head, B. and A. Faul (2005). "Terminal restlessness as perceived by hospice
professionals." American Journal of Hospice & Palliative Care 22(4): 277-82.
Any hospice professional can identify the syndrome known as terminal
restlessness, and all would agree that it is extremely distressing to patients as
well as their families and caregivers. Often, caregivers cannot ameliorate the
anguish many patients experience at life's end. Many clinicians assert that the
causes are physical resulting from medication toxicity, organ shutdown and the
associated metabolic changes, pain, urinary or fecal retention, dyspnea and
related hypoxia, and sepsis. Yet, many also credit psychosocial and spiritual
distress as precipitating factors. The purposes of this study were twofold: to
compare the perceptions of practicing hospice clinicians with the literature related
to terminal restlessness, and to determine if their experience with terminal
restlessness agreed with the components of the one established scale for
terminal restlessness found in the literature. In general, the study findings
corresponded to the literature in regards to frequency, definition, causes, and
behavioral manifestations of terminal restlessness. The clinicians in the study
supported the impact of psychosocial and spiritual causes of terminal
restlessness and defined the phenomenon in terms of time period; emotional,
physical, and spiritual distress; changes in consciousness; and increased activity.
However, the study did not support the inclusion of impaired consciousness and
withdrawal as comprised in the terminal restlessness scale.
Hori, K., Y. Funaba, et al. (2005). "Assessment of pharmacological toxicity using serum
anticholinergic activity in a patient with dementia." Psychiatry & Clinical Neurosciences
59(4): 508-510.
Huffman, J. C. and G. L. Fricchione (2005). "Hypercalcemic delirium associated with
hyperparathyroidism and a vitamin D analog." General Hospital Psychiatry 27(5): 374-6.
Inouye, S. K., L. Leo-Summers, et al. (2005). "A chart-based method for identification of
delirium: validation compared with interviewer ratings using the confusion assessment
method." Journal of the American Geriatrics Society 53(2): 312-8.
OBJECTIVES: To validate a chart-based method for identification of delirium and
compare it with direct interviewer assessment using the Confusion Assessment
Method (CAM). DESIGN: Prospective validation study. SETTING: Teaching
hospital. PARTICIPANTS: Nine hundred nineteen older hospitalized patients.
MEASUREMENTS: A chart-based instrument for identification of delirium was
created and compared with the reference standard interviewer ratings, which
used direct cognitive assessment to complete the CAM for delirium. Trained
nurse chart abstractors were blinded to all interview data, including cognitive and
CAM ratings. Factors influencing the correct identification of delirium in the chart
were examined. RESULTS: Delirium was present in 115 (12.5%) patients
according to the CAM. Sensitivity of the chart-based instrument was 74%,
specificity was 83%, and likelihood ratio for a positive result was 4.4. Overall
agreement between chart and interviewer ratings was 82%, kappa=0.41. By
contrast, using International Classification of Diseases, Ninth Revision, Clinical
Modification, administrative codes, the sensitivity for delirium was 3%, and
specificity was 99%. Independent factors associated with incorrect chart
identification of delirium were dementia, severe illness, and high baseline
delirium risk. With all three factors present, the chart instrument was three times
more likely to identify patients incorrectly than with none of the factors present.
CONCLUSION: A chart-based instrument for delirium, which should be useful for
patient safety and quality-improvement programs in older persons, was validated.
Because of potential misclassification, the chart-based instrument is not
recommended for individual patient care or diagnostic purposes.
Kalisvaart, K. J., J. F. de Jonghe, et al. (2005). "Haloperidol prophylaxis for elderly hipsurgery patients at risk for delirium: a randomized placebo-controlled study." Journal of
the American Geriatrics Society 53(10): 1658-66.
OBJECTIVES: To study the effectiveness of haloperidol prophylaxis on
incidence, severity, and duration of postoperative delirium in elderly hip-surgery
patients at risk for delirium. DESIGN: Randomized, double-blind, placebocontrolled trial. SETTING: Large medical school-affiliated general hospital in
Alkmaar, The Netherlands. PARTICIPANTS: A total of 430 hip-surgery patients
aged 70 and older at risk for postoperative delirium. INTERVENTION:
Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up
to 3 days postoperatively. Proactive geriatric consultation was provided for all
randomized patients. MEASUREMENTS: The primary outcome was the
incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, and Confusion Assessment Method criteria).
Secondary outcomes were the severity of delirium (Delirium Rating Scale,
revised version-98 (DRS-R-98)), the duration of delirium, and the length of
hospital stay. RESULTS: The overall incidence of postoperative delirium was
15.8%. The percentage of patients with postoperative delirium in the haloperidol
and placebo treatment condition was 15.1% and 16.5%, respectively (relative
risk=0.91, 95% confidence interval (CI)=0.6-1.3); the mean highest DRS-R-98
score+/-standard deviation was 14.4+/-3.4 and 18.4+/-4.3, respectively (mean
difference 4.0, 95% CI=2.0-5.8; P<.001); delirium duration was 5.4 versus 11.8
days, respectively (mean difference 6.4 days, 95% CI=4.0-8.0; P<.001); and the
mean number of days in the hospital was 17.1+/-11.1 and 22.6+/-16.7,
respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). No
haloperidol-related side effects were noted. CONCLUSION: Low-dose
haloperidol prophylactic treatment demonstrated no efficacy in reducing the
incidence of postoperative delirium. It did have a positive effect on the severity
and duration of delirium. Moreover, haloperidol reduced the number of days
patients stayed in the hospital, and the therapy was well tolerated.
Kato, D., C. Kawanishi, et al. (2005). "Delirium resolving upon switching from
risperidone to quetiapine: implication of CYP2D6 genotype." Psychosomatics 46(4):
374-5.
Khosravi, A., C. A. Skrabal, et al. (2005). "Evaluation of coated oxygenators in
cardiopulmonary-bypass systems and their impact on neurocognitive function."
Perfusion 20(5): 249-54.
INTRODUCTION: Coronary artery bypass graft surgery (CABG) using
cardiopulmonary bypass (CPB) is assumed to be associated with a decline of
neurocognitive functions. This study was designed to analyse the neurocognitive
function of patients with coronary heart disease before and after CABG and to
determine possible protective effects of oxygenator surface coating on
neurological outcome. METHODS: Forty patients scheduled for selective CABG
were prospectively randomized into two groups of 20 patients each according to
the type of hollow-fibre membrane oxygenator used. Non-coated oxygenators
(Group A) were compared to phosphorylcholine (PC)coated oxygenators (Group
B). A battery of six neurological tests was administered preoperatively, 7-10 days
and 4-6 months after surgery. RESULTS: One patient of Group A suffered from a
perioperative stroke and died on postoperative day 3, presumably because of
sudden heart failure. Two patients of Group A (10%) developed a symptomatic
transitory delirious psychotic syndrome (STPT) on postoperative days 3 and 5.
None of the patients of Group B had perioperative complications. The test
analysis revealed a trend of declined neurocognitive function early after CABG,
but did not show any difference in neurocognitive outcome between the two
groups. DISCUSSION: PC coating of the oxygenators did not show any
significant benefit on neurocognitive function after CABG using CPB.
King, P., P. Devichand, et al. (2005). "Dementia of acute onset in the Canadian Study of
Health and Aging." International Psychogeriatrics 17(3): 451-459.
Background: Although most people with dementia experience an insidious onset
of symptoms, in some cases onset can be acute. The importance of acute onset
is unclear. Some reports suggest that it portends a worse course. Methods: We
performed a secondary analysis of the clinical examination cohort (n = 2914) of
the Canadian Study of Health and Aging (CSHA). We defined "acute onset of
dementia" from the Cambridge Examination for Mental Disorders in the Elderly
(CAMDEX) questionnaire, conducted with an informant. People with dementia of
acute onset were compared to those with dementia of insidious onset for
development of adverse outcomes of death and institutionalization over 5 years.
Results: Of the 1132 people who had dementia, 130 (11.5%) met criteria for
acute onset. Compared with gradual-onset dementia patients, those with acuteonset dementia were more often men (42% vs. 30%, p < 0.05), resided in nursing
homes (75% vs. 63%, p < 0.05), had vascular risk factors (72% vs. 47%, p <
0.05), and a Hachinski Ischemia Scale (HIS) score >= 7 (64% vs. 19%, p < 0.05).
More patients with dementia of acute onset than gradual onset were diagnosed
with vascular dementia (55% vs. 13%;p < 0.05). Adjusted hazard ratios (HRs) for
survival and institutionalization in the acute-onset group were 0.93 [95%
confidence interval (CI) 0.7-1.2] and 0.76 (95% CI 0.4-1.3), respectively,
compared with the gradual-onset group. Conclusions: People with acute-onset
dementia had more vascular risk factors than those with gradual-onset dementia
across all dementia diagnoses, and lower risks of institutionalization but worse
survival. Routine inquiry about the onset of dementia might help to better clarify
prognoses in patients with dementia. [References: 28]
Korak-Leiter, M., R. Likar, et al. (2005). "Withdrawal following sufentanil/propofol and
sufentanil/midazolam. Sedation in surgical ICU patients: correlation with central nervous
parameters and endogenous opioids." Intensive Care Medicine 31(3): 380-7.
PURPOSE: Patients in the ICU after long-term administration of an
opioid/hypnotic often develop delirium. To assess the nature of this phenomenon,
patients in a surgical ICU following ventilatory support and sedation with an
opioid/hypnotic/sedative were studied. METHODOLOGY: Following
sufentanil/midazolam (group 1; n =14) or sufentanil/propofol (group 2; n =15)
sedation, patients were evaluated for changes in mean arterial blood pressure
and heart rate, the activity of the central nervous system (sensory evoked
potentials, spectral edge frequency of EEG), and the endogenous opioids plasma
concentrations (beta-endorphin, met-enkephalin). Data obtained were correlated
with the individual intensities of withdrawal symptoms 6-, 12-, and 24 h following
sedation. RESULTS: Following a mean duration of ventilation of 7.7 days (+/-3.6
SD) in groups 1 and 3.5 (+/-1.7 SD) in group 2, withdrawal intensities peaked
within the 6th hour after cessation. Plasma beta-endorphin and met-enkephalin
levels were low during sedation, and only the sufentanil/midazolam group
demonstrated a postinhibitory overshoot. Withdrawal symptom intensities
demonstrated an inverse correlation with beta-endorphin and met-enkephalin
levels, a direct linear correlation with amplitude height of the evoked potential,
and blood pressure and heart rate changes. Withdrawal intensities did not
correlate with EEG power spectral edge frequency. CONCLUSION: The
endorphinergic system is suppressed when a potent exogenous opioid like
sufentanil is given over a long period of time. Following sedation, abstinence
symptoms seem to be related to postinhibitory increased endorphin synthesis.
This is mostly seen in the combination of sufentanil/midazolam. In addition, an
increase in the amplitude of the sensory-evoked potential suggests a
postinhibitory excitatory state within the nociceptive system.
Korevaar, J. C., B. C. van Munster, et al. (2005). "Risk factors for delirium in acutely
admitted elderly patients: a prospective cohort study." BMC Geriatrics 5(1): 6.
BACKGROUND: Delirium is a neuropsychiatric syndrome frequently observed in
elderly hospitalised patients and can be found in any medical condition. Due to
the severe consequences, early recognition of delirium is important in order to
start treatment in time. Despite the high incidence rate, the occurrence of
delirium is not always identified as such. Knowledge of potential risk factors is
important. The aim of the current study is to determine factors associated with
the occurrence of a prevalent delirium among elderly patients acutely admitted to
an internal medicine ward. METHODS: All consecutive patients of 65 years and
over acutely admitted to the Department of Internal Medicine of the Academic
Medical Centre, Amsterdam, a university hospital, were asked to participate. The
presence of delirium was determined within 48 hrs after admission by an
experienced geriatrician. RESULTS: In total, 126 patients were included, 29%
had a prevalent delirium after acute admission. Compared to patients without
delirium, patients with delirium were older, more often were cognitively and
physically impaired, more often were admitted due to water and electrolyte
disturbances, and were less often admitted due to malignancy or gastrointestinal
bleeding. Independent risk factors for having a prevalent delirium after acute
admission were premorbid cognitive impairment, functional impairment, an
elevated urea nitrogen level, and the number of leucocytes. CONCLUSIONS: In
this study, the most important independent risk factors for a prevalent delirium
after acute admission were cognitive and physical impairment, and a high serum
urea nitrogen concentration. These observations might contribute to an earlier
identification and treatment of delirium in acutely admitted elderly patients.
Kulh, M. A., V. A. Mumford, et al. (2005). "Management of delirium: a clinical
governance approach." Australian Health Review 29(2): 246-52.
This study assessed the management of delirium in the Acute Care of the Elderly
unit (ACE) at a tertiary referral hospital as a case study of the application of
clinical governance principles. The environment was found to be supportive of
ongoing clinical governance activities, both in clinical organisation of work
processes and orientation of management. However, patient involvement,
dissemination and use of clinical pathways, performance measurement and
feedback, and maintaining stability of care are areas requiring further
development. Although there is a clinical governance strategy in place at the
policy level, this has not always filtered through to the level of clinical work.
Lee, V. (2005). "Confusion: geriatric self-learning module." MEDSURG Nursing 14(1):
38-41.
The Geriatric Resource Nurse Model is used at the University of Virginia to
improve the competency of staff in caring for older adults. Eight self-learning
educational modules were developed to address common concerns in
hospitalized elders. The Confusion. Geriatric Self-Learning Module is published
here, along with a post-test. This is the third in a four-part publication of selflearning modules.
Leentjens, A. F. G. and R. C. van der Mast (2005). "Delirium in elderly people: an
update." Current Opinion in Psychiatry 18(3): 325-330.
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.
[References: 55]
Leslie, D. L., Y. Zhang, et al. (2005). "Premature death associated with delirium at 1year follow-up." Archives of Internal Medicine 165(14): 1657-62.
BACKGROUND: While previous studies have demonstrated the increased
mortality risk associated with delirium, little is known about the mortality time
course. The objective of this study is to estimate the fraction of a year of life lost
associated with delirium at 1-year follow-up. METHODS: Hospitalized patients 70
years and older who participated in a previous controlled clinical trial of a delirium
prevention intervention at an academic medical center from March 25, 1995,
through March 18, 1998, were followed up for 1 year after discharge, and
patients who died were identified, along with the date of death. The adjusted
number of days survived were estimated using a 2-step regression model
approach and compared across patients who developed delirium during
hospitalization and those who did not develop delirium. RESULTS: After
adjusting for pertinent covariates (age, sex, functional status, and comorbidity),
patients with delirium survived 274 days, compared with 321 days for patients
without delirium, representing a difference of 13% of a year (hazard ratio, 1.62;
P<.001). Results were confirmed with a separate binomial regression analysis.
CONCLUSIONS: Patients who experienced delirium during hospitalization had a
62% increased risk of mortality and lost an average of 13% of a year of life
compared with patients without delirium. Although delirium is an acute condition,
it is associated with multiple long-term sequelae that extend beyond the hospital
setting, including premature mortality.
Levenson, J. L., J. Collins, et al. (2005). "Images in psychosomatic medicine: the clockdrawing test." Psychosomatics 46(1): 77-8.
Liptzin, B., A. Laki, et al. (2005). "Donepezil in the prevention and treatment of postsurgical delirium." American Journal of Geriatric Psychiatry 13(12): 1100-6.
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, doubleblind, 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, nurseobservation 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.
Loran, D. B., B. R. Hyde, et al. (2005). "Perioperative management of special
populations: The geriatric patient." Surgical Clinics of North America 85(6): 1259-+.
Americans over age 65 represent the fastest growing segment of the United
States population. As a result, the demographic landscape of America is
changing. Knowledge of aged physiology is necessary to construct a risk-benefit
analysis tailored for each patient to improve perioperative outcomes and lower
the morbidity and mortality rates among the elderly. Benefit estimates should
account for a patient's life expectancy and quality of life before and after surgery.
With aging, baseline functions of almost every organ system undergo
progressive decline resulting in a decreased physiologic reserve and ability to
compensate for stress. Pain control, postoperative cognitive dysfunction, end-oflife issues, and realistic expectations after surgery are paramount issues
throughout the perioperative period. [References: 33]
Lotrich, F. E., J. Rosen, et al. (2005). "Dextromethorphan-induced delirium and possible
methadone interaction." American Journal Geriatric Pharmacotherapy 3(1): 17-20.
INTRODUCTION: Dextromethorphan is a commonly used antitussive agent that
can be purchased over the counter. It is metabolized primarily by the cytochrome
P450 (CYP) 2D6 isozyme. Methadone has been found to inhibit CYP2D6,
indicating a potential for interaction with dextromethorphan. CASE SUMMARY:
An 83-year-old woman was evaluated for delirium, hypersomnia, confusion,
lethargy, impaired concentration, and poor food intake. Symptoms resolved soon
after discontinuing dextromethorphan. DISCUSSION: Vulnerability to delirium
was potentially caused by coadministration of methadone, which can inhibit the
CYP2D6 isozyme. CONCLUSION: Evaluation of delirium should include close
investigation of the patient's medications for potential interactions with
dextromethorphan.
Lundstrom, M., A. Edlund, et al. (2005). "A multifactorial intervention program reduces
the duration of delirium, length of hospitalization, and mortality in delirious patients."
Journal of the American Geriatrics Society 53(4): 622-8.
OBJECTIVES: To investigate whether an education program and a
reorganization of nursing and medical care improved the outcome for older
delirious patients. DESIGN: Prospective intervention study. SETTING:
Department of General Internal Medicine, Sundsvall Hospital, Sweden.
PARTICIPANTS: Four hundred patients, aged 70 and older, consecutively
admitted to an intervention or a control ward. INTERVENTION: The intervention
consisted of staff education focusing on the assessment, prevention, and
treatment of delirium and on caregiver-patient interaction. Reorganization from a
task-allocation care system to a patient-allocation system with individualized
care. MEASUREMENTS: The patients were assessed using the Organic Brain
Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7
after admission. Delirium was diagnosed according to Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: Delirium was
equally common on the day of admission at the two wards, but fewer patients
remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62,
59.7%, P=.001). The mean length of hospital stay+/-standard deviation was
significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs
13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs
20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and
nine in the control ward died during hospitalization (P=.03). CONCLUSION: This
study shows that a multifactorial intervention program reduces the duration of
delirium, length of hospital stay, and mortality in delirious patients.
Macleod, A. D. (2005). "Psychogenic delirium?[comment]." Palliative Medicine 19(2):
170-1.
Marcantonio, E. R., D. K. Kiely, et al. (2005). "Outcomes of older people admitted to
postacute facilities with delirium." Journal of the American Geriatrics Society 53(6): 9639.
OBJECTIVES: To compare outcomes of patients admitted to postacute skilled
nursing facilities with delirium, subsyndromal delirium, and no delirium. DESIGN:
Observational cohort study. SETTING: Seven skilled nursing facilities that
specialize in postacute care within a single metropolitan region. PARTICIPANTS:
Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and
older who underwent mental status testing within 5 days of admission to the
participating facilities. Subjects who met full Confusion Assessment Method
(CAM) criteria were classified as delirious, those with one or more CAM criteria
were classified as having subsyndromal delirium, and those with no CAM
features were classified as having no delirium. All subjects with delirium and with
available medical records were included. A random subset of subjects with no
delirium and subsyndromal delirium with available medical records was included.
MEASUREMENTS: The medical records of all subjects underwent a structured
review by trained research nurses who were masked to the subjects' initial
delirium status. Records were reviewed for the development of new
complications within the postacute setting and to determine whether the subjects
were discharged within 30 days and, if so, the discharge destination. The
National Death Index was used to assess 6-month mortality. RESULTS: Subjects
with delirium were more likely to experience one or more complications than
subjects with no delirium (73% vs 41%, P <.01). Within 30 days of postacute
admission, subjects with delirium were more than twice as likely to be
rehospitalized (30% vs 13%), and less than half as likely to be discharged to the
community (30% vs 73%) than subjects without delirium (differences P <.01).
Subjects with subsyndromal delirium had outcomes intermediate between those
with and without delirium. Finally, subjects admitted to the postacute setting with
delirium experienced a 6-month mortality rate of 25.0%, compared with 5.7% in
subjects admitted without delirium. Subjects with subsyndromal delirium had a 6month mortality rate of 18.3%. CONCLUSION: Patients admitted to postacute
skilled nursing facilities with delirium are more likely to experience complications,
rehospitalization, and death than patients without delirium. These findings
support the need for improved case finding and management of delirium in
postacute care.
McGory, M. L., P. G. Shekelle, et al. (2005). "Developing quality indicators for elderly
patients undergoing abdominal operations." Journal of the American College of
Surgeons 201(6): 870-83.
BACKGROUND: Although the expanding and aging population will likely
increase demand for surgical services, surgeons and other providers must
develop strategies to optimize care. We sought to develop process-based quality
indicators for elderly patients undergoing abdominal operations to identify
necessary and meaningful ways to improve care in this cohort. STUDY DESIGN:
Through structured interviews with thought leaders and systematic reviews of the
literature, we identified candidate quality indicators addressing perioperative care
in elderly patients undergoing abdominal operations. Using a modification of the
RAND/UCLA Appropriateness Methodology, an expert panel of physicians in
surgery, geriatrics, anesthesia, internal, and rehabilitation medicine formally rated
and discussed the indicators. RESULTS: Eighty-nine candidate indicators were
identified and categorized into seven domains: comorbidity assessment (eg,
cardiopulmonary disease), elderly issues (eg, cognition), medication use (eg,
polypharmacy), patient-to-provider discussions (eg, life-sustaining preferences),
intraoperative care (eg, preventing hypothermia), postoperative management
(eg, preventing delirium), and discharge planning (eg, home health care). Of the
89 candidate indicators, 76 were rated as valid by the expert panel. Importantly,
the majority of indicators rated as valid address processes of care not routinely
performed in younger surgical populations. CONCLUSIONS: Attention to the
quality of surgical care in elderly patients is of great importance because of the
increasing numbers of elderly undergoing operations. This project used a
validated methodology to identify and rate process measures to achieve highquality perioperative care for elderly surgical patients. This is the first time quality
indicators have been developed in this regard.
McNicoll, L., M. A. Pisani, et al. (2005). "Detection of delirium in the intensive care unit:
comparison of confusion assessment method for the intensive care unit with confusion
assessment method ratings." Journal of the American Geriatrics Society 53(3): 495-500.
OBJECTIVES: To compare the Confusion Assessment Method (CAM) and CAM
for the Intensive Care Unit (CAM-ICU) methods for detecting delirium in alert,
nonintubated older ICU patients. DESIGN: Comparison study. SETTING:
Fourteen-bed medical ICU of an 800-bed university teaching hospital.
PARTICIPANTS: Twenty-two patients aged 65 and older admitted to the ICU.
MEASUREMENTS: Two blinded, trained clinician-researchers who had
undergone interrater reliability testing interviewed patients separately, usually
within 10 minutes of each other (up to 120 minutes). Each researcher examined
patients for the four key CAM criteria: acuteness, inattention, disorganized
thinking, and altered level of consciousness. One researcher used the CAM
method with the Mini-Mental State Examination and Digit Span; the other
researcher used the CAM-ICU method with nonverbal cognitive and attention
tasks. RESULTS: Rates of delirium were 68% according to CAM and 50%
according CAM-ICU. Comparing the two methods, agreement was 82%, with a
kappa of 0.64. Using the CAM as the reference standard, the CAM-ICU had a
sensitivity of 73% (95% confidence interval (CI)=60-86) and specificity of 100%
(95% CI=56-100). There were four false-negative ratings using the CAM-ICU.
Reasons for disparate results were that the CAM used more-detailed cognitive
testing that detected more deficits (3 patients) and the time elapsed (90 minutes)
between ratings in one patient with markedly fluctuating symptoms.
CONCLUSION: CAM and CAM-ICU agreement was moderately high. Although
the CAM-ICU is recommended for ICU patients because of its brevity and ease
of use, the standard CAM method may detect more subtle cases of delirium in
nonintubated, verbal ICU patients.
Merchant, R. A., K. L. Lui, et al. (2005). "The relationship between postoperative
complications and outcomes after hip fracture surgery." Annals of the Academy of
Medicine, Singapore 34(2): 163-8.
INTRODUCTION: We studied the prevalence of postoperative complications in a
series of consecutive patients who received surgery for hip fractures in a major
public hospital in Singapore. We also studied the predictors for the occurrence of
complications and the impact of these complications on patient outcomes.
MATERIALS AND METHODS: A retrospective chart review of patients admitted
with hip fracture, from March to November 2001, was carried out. Patients were
classified as having postoperative complications if they developed any of the
following conditions after surgery: dislocation of prosthesis, deep vein
thrombosis, postoperative confusion, foot drop, stroke, cardiac arrhythmias or
acute myocardial infarctions, urinary retention, urinary tract infection, pneumonia,
wound infection and incident pressure sores. RESULTS: Of the 180 patients
studied, 60 developed postoperative complications. Significant predictors of
complications after logistic regression included being of female gender [odds
ratio (OR), 2.79; 95% confidence interval (CI), 1.13 to 6.89] and pre-fracture
mobility status (OR for independent ambulators 0.45; 95% CI, 0.23 to 0.87), but
not the age of the patients. Postoperative complications significantly affected the
length of stay within the acute hospital (beta coefficient, 6.42; 95% CI, 2.55 to
10.29), but were not associated with a decline in mobility status at 3 months postfracture, eventual discharge destination or readmission within 1 year.
CONCLUSION: Postoperative complications are common after surgery for hip
fractures and result in significantly longer hospitalisation periods. Significant
predictors for such complications include being of female gender and pre-fracture
mobility. Age, in itself, does not result in a higher risk of complications and should
not preclude older hip fracture patients from surgical management.
Micek, S. T., N. J. Anand, et al. (2005). "Delirium as detected by the CAM-ICU predicts
restraint use among mechanically ventilated medical patients.[see comment]." Critical
Care Medicine 33(6): 1260-5.
OBJECTIVE: The first goal of this investigation was to identify individuals with
delirium defined by the Confusion Assessment Method for the Intensive Care
Unit (CAM-ICU) among medical patients with respiratory failure. Our second goal
was to compare clinical interventions including use of continuous sedation
infusions, the number of ventilator-free days, ICU length of stay, hospital
mortality, and use of physical restraints in mechanically ventilated patients with
and without delirium. DESIGN: A prospective, single-center, observational cohort
study. SETTING: The medical intensive care unit (19 beds) of an urban teaching
hospital. PATIENTS: Adult, intubated, and mechanically ventilated patients.
INTERVENTIONS: Daily evaluation with the CAM-ICU, outcomes assessment,
and prospective data collection. MEASUREMENTS AND MAIN RESULTS:
Among 93 patients evaluated using the CAM-ICU, 44 patients (47%) developed
delirium (CAM-ICU+) for >/=1 day while in the intensive care unit. Twenty-two
patients (24%) had no episodes of delirium recorded (CAM-ICU-), and 27 (29%)
remained comatose until extubation or death. A statistically greater number of
patients with delirium (CAM-ICU+) received continuous infusions of midazolam
(59% vs. 32%, p <.05) or fentanyl (57% vs. 32%, p <.05) and physical soft-limb
restraints (77% vs. 50%, p <.05) compared with patients without delirium (CAMICU-). CONCLUSIONS: The identification of delirium using the CAM-ICU was
associated with greater use of continuous sedation infusions and physical
restraints. Additional studies are required to determine how the use of these
specific interventions influences the occurrence and the natural history of
delirium among critically ill patients.
Milbrandt, E. B. and D. C. Angus (2005). "Potential mechanisms and markers of critical
illness-associated cognitive dysfunction." Current Opinion in Critical Care 11(4): 355359.
Purpose of review To review the current understanding of the potential
mechanisms of critical illness-associated cognitive dysfunction and to provide
insight into markers that could be used to evaluate the influence of specific
mechanisms in individual patients. Recent findings Cognitive dysfunction is
common in critically ill patients, not only during the acute illness but also long
after it's resolution. Several pathophysiological mechanisms are thought to
underlie critical illness-associated cognitive dysfunction, including
neurotransmitter abnormalities and occult diffuse brain injury. Markers that could
be used to evaluate the influence of specific mechanisms individual patients
include serum anticholinergic activity, certain brain proteins, and tissue sodium
concentration determination by way of high-reolution three-dimensional magnetic
resonance imaging. Summary Although recent advances in this area are exciting,
they are still too immature to influence patient care. Additional research is
needed to provide a better understanding of the relative contribution of specific
mechanisms to the development of critical illness-associated cognitive
dysfunction and to determine whether these mechanisms might be amenable to
treatment or prevention. [References: 62]
Milbrandt, E. B., A. Kersten, et al. (2005). "Haloperidol use is associated with lower
hospital mortality in mechanically ventilated patients.[see comment]." Critical Care
Medicine 33(1): 226-9; discussion 263-5.
OBJECTIVE: To determine whether haloperidol use is associated with lower
mortality in mechanically ventilated patients. DESIGN: Retrospective cohort
analysis. SETTING: A large tertiary care academic medical center. PATIENTS: A
total of 989 patients mechanically ventilated for >48 hrs. MEASUREMENTS AND
MAIN RESULTS: We compared differences in hospital mortality between
patients who received haloperidol within 2 days of initiation of mechanical
ventilation and those who never received haloperidol. Despite similar baseline
characteristics, patients treated with haloperidol had significantly lower hospital
mortality compared with those who never received haloperidol (20.5% vs. 36.1%;
p =.004). The lower associated mortality persisted after adjusting for age,
comorbidity, severity of illness, degree of organ dysfunction, admitting diagnosis,
and other potential confounders. CONCLUSIONS: Haloperidol was associated
with significantly lower hospital mortality. These findings could have enormous
implications for critically ill patients. Because of their observational nature and the
potential risks associated with haloperidol use, they require confirmation in a
randomized, controlled trial before being applied to routine patient care.
Milisen, K., M. D. Foreman, et al. (2005). "Psychometric properties of the Flemish
translation of the NEECHAM Confusion Scale." BMC Psychiatry 5(1): 16.
BACKGROUND: Determination of a patient's cognitive status by use of a valid
and reliable screening instrument is of major importance as early recognition and
accurate diagnosis of delirium is necessary for effective management. This study
determined the reliability, validity and diagnostic value of the Flemish translation
of the NEECHAM Confusion Scale. METHODS: A sample of 54 elderly hip
fracture patients with a mean age of 80.9 years (SD = 7.85) were included. To
test the psychometric properties of the NEECHAM Confusion Scale, performance
on the NEECHAM was compared to the Confusion Assessment Method (CAM)
and the Mini-Mental State Examination (MMSE), by using aggregated data based
on 5 data collection measurement points (repeated measures). The CAM and
MMSE served as gold standards. RESULTS: The alpha coefficient for the total
NEECHAM score was high (0.88). Principal components analysis yielded a twocomponent solution accounting for 70.8% of the total variance. High correlations
were found between the total NEECHAM scores and total MMSE (0.75) and total
CAM severity scores (-0.73), respectively. Diagnostic values using the CAM
algorithm as gold standard showed 76.9% sensitivity, 64.6% specificity, 13.5%
positive and 97.5% negative predictive values, respectively. CONCLUSION: This
validation of the Flemish version of the NEECHAM Confusion Scale adds to
previous evidence suggesting that this scale holds promise as a valuable
screening instrument for delirium in clinical practice. Further validation studies in
diverse clinical populations; however, are needed.
Minden, S. L., L. A. Carbone, et al. (2005). "Predictors and outcomes of delirium."
General Hospital Psychiatry 27(3): 209-14.
OBJECTIVES: To determine factors associated with the occurrence of delirium
among patients undergoing surgical repair of abdominal aortic aneurysm (AAA).
METHODS: The sample included all consenting patients who underwent AAA
repair during a 12-month period. Before surgery, daily while in hospital, and at 1
and 6 months after surgery, we assessed patients' mood, mental status and
functional status. We compared delirious and nondelirious patients for severity of
preoperative depressive symptoms, length of hospital stay and mortality. The
effects of delirium on postoperative functional status were assessed in
conjunction with postoperative depressive symptoms using regression models.
RESULTS: The sample of 35 patients was primarily male and elderly; onequarter had three or more medical conditions; and eight (23%) developed
delirium after surgery. Postoperative delirium was significantly associated with
preoperative depressive symptoms, alcohol use and cognitive impairment as well
as with longer lengths of stay and poorer functional status at 1 and 6 months
after surgery. CONCLUSION: Identification and treatment of patients with
depressive symptoms, alcohol use and cognitive impairment prior to AAA surgery
could reduce the incidence of postoperative delirium and the prolonged hospital
stays and impaired functional status associated with it. Surgeons should consider
using simple screening instruments before surgery to identify patients at risk and
referring them for psychiatric evaluation and treatment. They should also
consider including psychiatrists early in the care of high-risk patients to improve
detection of and early intervention for delirium.
Morita, T., C. Takigawa, et al. (2005). "Opioid rotation from morphine to fentanyl in
delirious cancer patients: an open-label trial." Journal of Pain & Symptom Management
30(1): 96-103.
Although recent studies suggest that opioid rotation could be an effective
treatment strategy for morphine-induced delirium, there have been no
prospective studies to investigate the treatment effects of opioid rotation using
fentanyl. The primary aim of this study was to clarify the efficacy of opioid rotation
from morphine to fentanyl in symptom palliation of morphine-induced delirium.
Twenty-one consecutive cancer patients with morphine-induced delirium
underwent opioid rotation to fentanyl. Physicians recorded the symptom severity
of delirium (the Memorial Delirium Assessment Scale, MDAS), pain, and other
symptoms (categorical verbal scale from 0: none to 3: severe) and the Schedule
for Team Assessment Scale (STAS) (from 0: none to 4: extreme); and
performance status at the time of study enrollment and three and seven days
after. Of 21 patients recruited, one patient did not complete the study. In the
remaining 20 patients, morphine was substituted with transdermal fentanyl in 9
patients and parenteral fentanyl in 11 patients. Total opioid dose increased from
64 mg oral morphine equivalent/day (Day 0) to 98 mg/day (Day 7), and the
median increase in total opioid dose was 42%. Treatment success, defined as an
MDAS score below 10 and pain score of 2 or less, was obtained in 13 patients on
Day 3 and 18 patients on Day 7. The mean MDAS score significantly decreased
from 14 (Day 0) to 6.4 and 3.6 (Days 3 and 7, respectively, P < 0.001). Pain
scores significantly decreased from 2.2 (Day 0) to 1.3 and 1.1 on the categorical
verbal scale (Days 3 and 7, respectively, P < 0.001); from 2.6 (Day 0) to 1.6 and
1.3 on the STAS (Days 3 and 7, respectively, P < 0.001). Symptom scores of dry
mouth, nausea, and vomiting significantly decreased, and performance status
significantly improved. Opioid rotation from morphine to fentanyl may be effective
in alleviating delirium and pain in cancer patients with morphine-induced delirium.
Nakasato, Y., J. Servat, et al. (2005). "Delirium in the older hospitalized patient." Journal
- Oklahoma State Medical Association 98(3): 113-6.
Naughton, B. J., S. Saltzman, et al. (2005). "A multifactorial intervention to reduce
prevalence of delirium and shorten hospital length of stay." Journal of the American
Geriatrics Society 53(1): 18-23.
OBJECTIVES: To improve outcomes for cognitively impaired and delirious older
adults. DESIGN: Pretest, posttest. SETTING: A university-affiliated hospital.
PARTICIPANTS: Physicians and nurses in the emergency department (ED) and
on an acute geriatric unit (AGU). INTERVENTION: Multifactorial and targeted to
the processes of care for cognitively impaired and delirious older adults admitted
to medicine service from the ED. MEASUREMENTS: Prevalence of delirium,
admission to AGU, psychotropic medication use, hospital length of stay.
RESULTS: Patient characteristics did not differ between baseline and the two
outcome cohorts 4 and 9 months postintervention. Prevalence of delirium was
40.9% at baseline, 22.7% at 4 months (P<.002), and 19.1% at 9 months
(P<.001). More delirious patients were admitted to the AGU than to non-AGU
units at 4 months (P<.01) and 9 months (P<.01). Postintervention medication use
in the hospital differed from baseline. Antidepressant use was greater at 4
months (P<.05). Benzodiazepine and antihistamine use were lower at 9 months
(P>.01). Antidepressant and neuroleptic use were higher (P<.02) and
antihistamine use was lower (P<.02) at 4 months on the AGU than for the
baseline group. Benzodiazepine (P<.01) and antihistamine (P<.05) use were
lower at 9 months. Each case of delirium prevented saved a mean of 3.42
hospital days. CONCLUSION: A multifactorial intervention designed to reduce
delirium in older adults was associated with improved psychotropic medication
use, less delirium, and hospital savings.
O'Hanlon, D. (2005). "Incidence of delirium in very old patients after surgery for hip
fracture." American Journal of Geriatric Psychiatry 13(1): 81; author reply 81.
O'Keeffe, S. T., E. C. Mulkerrin, et al. (2005). "Use of serial Mini-Mental State
Examinations to diagnose and monitor delirium in elderly hospital patients." Journal of
the American Geriatrics Society 53(5): 867-70.
OBJECTIVES: To determine the responsiveness of serial Mini-Mental State
Examinations (MMSEs) for the diagnosis and monitoring of delirium in elderly
hospital patients. DESIGN: Prospective study. SETTING: University teaching
hospital. PARTICIPANTS: One hundred sixty-five people admitted to an acute
geriatric service. MEASUREMENTS: Subjects were assessed using the MMSE
and the Confusion Assessment Method on hospital Days 1 and 6. Changes in
scores were compared between patients who remained free of delirium (n=124)
and those who by Day 6 had developed delirium (n=14) or had resolution of
delirium present on admission (n=22). RESULTS: A number of measures of
responsiveness confirmed that serial MMSE scores were responsive to
resolution and to development of delirium. A fall of 2 or more points on the
MMSE was the best determinant for detecting development of delirium (93%
sensitivity, 90% specificity, positive likelihood ratio (LR)=8.9 (95% confidence
interval (CI)=5.2-15.1) and negative LR=0.08 95% CI=0.01-0.53)). A rise of 3 or
more points was the best determinant for detecting resolution of delirium (77%
sensitivity, 75% specificity, positive LR=3.1 (95% CI=2.1-4.5) and negative
LR=0.30 (95% CI=0.14-0.66)). CONCLUSION: The MMSE is responsive to
short-term changes in cognitive function in elderly patients. Serial MMSE tests
should be helpful in monitoring the development and resolution of delirium in this
population.
Olin, K., M. Eriksdotter-Jonhagen, et al. (2005). "Postoperative delirium in elderly
patients after major abdominal surgery." British Journal of Surgery 92(12): 1559-64.
BACKGROUND: The aim of this study was to investigate the occurrence of
postoperative delirium (POD) in elderly patients undergoing major abdominal
surgery and to identify factors associated with delirium in this population.
METHODS: Data were collected prospectively from 51 patients aged 65 years or
more. Delirium was diagnosed by the Confusion Assessment Method and from
the medical records. The Mini Mental State Examination (MMSE) was used to
identify cognitive impairment. RESULTS: POD occurred in 26 of 51 patients.
Delirium lasted for 1-2 days in 14 patients (short POD group) and 3 days or more
in 12 patients (long POD group). The latter patients had significantly greater
intraoperative blood loss and intravenous fluid infusion, a higher rate of
postoperative complications, a lower MMSE score on postoperative day 4 and a
longer hospital stay than patients without POD. Patients in the short POD group
were significantly older than those in the long POD group and those who did not
develop delirium. CONCLUSION: Approximately half of the elderly patients in this
study developed POD. Bleeding was found to be an important risk factor for
delirium. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by
John Wiley & Sons, Ltd.
Olofsson, B., M. Lundstrom, et al. (2005). "Delirium is associated with poor rehabilitation
outcome in elderly patients treated for femoral neck fractures." Scandinavian Journal of
Caring Sciences 19(2): 119-27.
The aim of this study was to describe risk factors for delirium and the impact of
delirium on the rehabilitation outcome for patients operated for femoral neck
fractures. Sixty-one patients, aged 70 years or older, consecutively admitted to
the Department of Orthopaedic Surgery at Umea University Hospital, Sweden for
femoral neck fractures were assessed and interviewed during hospitalization and
at follow up 4 months after surgery. Delirium occurred in 38 (62%) patients and
those who developed delirium were more often demented and/or depressed.
Patients with delirium were longer hospitalized and they were more dependent in
their activity of daily living (ADL) on discharge and after 4 months. They had
poorer psychological well-being and more medical complications than the
nondelirious. A large proportion of the patients who developed delirium did not
regain their previous walking ability and could not return to their prefracture living
accommodation. Delirium after hip fracture surgery is very common especially
among patients with dementia or depression. This study shows that delirium has
a serious impact on the rehabilitation outcome from both short- and long-term
perspectives. Because delirium can be prevented and treated, it is important to
improve the care of elderly patients with hip fractures.
Onen, S. H., F. Onen, et al. (2005). "Alcohol abuse and dependence in elderly
emergency department patients." Archives of Gerontology & Geriatrics 41(2): 191-200.
Although elderly people are particularly vulnerable to the adverse effects of
alcohol, alcohol use disorders in late life have received relatively little attention in
the literature. Our objectives were to assess the prevalence of alcohol use
disorders (abuse and dependence), the medical profile and psychosocial
characteristics in elderly people visiting emergency department (ED). A cohort of
2405 patients aged over 60 who came to the ED of a university hospital during a
3-month period was studied. Alcohol use disorder diagnosis (DSM-IV), medical
profile and social characteristics were collected from retrospective review of
patient files. The data derived from 128 patients (mean age, 69.8+/-6.8 years;
87% males) with alcohol use disorders and 128 non-alcoholic controls. The
prevalence of current alcohol use disorder was 5.3%. The most common current
alcohol-induced disorders were alcohol intoxication and alcohol-induced mood
disorder. Social factors associated with alcohol use disorders were being
homeless, living alone, being divorced and never married. Falls and delirium
were frequent ED admission circumstances in elderly drinkers. Drinkers more
commonly presented with gastrointestinal disorders. In conclusion, alcohol use
disorders among older patients admitted in ED are common and occur more
frequently among men. Falls and delirium are the main ED admission
circumstances in elderly drinkers. Alcohol use disorders are also associated with
gastrointestinal problems.
Otter, H., J. Martin, et al. (2005). "Validity and reliability of the DDS for severity of
delirium in the ICU." Neurocritical Care 2(2): 150-8.
INTRODUCTION: Until now, there has been no gold standard for monitoring
delirium in intensive care unit (ICU) patients. In this prospective cohort study, a
new score, the Delirium Detection Score (DDS), for severity of delirium in the ICU
was evaluated. METHODS: After ethical approval and written informed consent,
intensive care doctors and nurses assessed 1073 consecutive patients in
surgical ICUs using the DDS together with the Ramsay Sedation Scale (RSS).
The DDS is composed of eight criteria (orientation, hallucination, agitation,
anxiety, seizures, tremor, paroxysmal sweating, and altered sleep- wake rhythm).
Additionally, intensive care doctors had to document the Sedation-Agitation
Scale (SAS) combined with a defined clinical assessment. For interrater
reliability, pair of evaluators assessed patients in a blinded fashion at the same
time. RESULTS: RSS1 (9%) was associated with a significantly (p < 0.001)
higher DDS than RSS levels 2-6. The DDS increased with the severity of delirium
(p < 0.001). The receiver operating characteristics (ROC) for the differentiation
between no delirium (SAS < 4) and symptoms of delirium at all (SAS 5-7)
showed an area under the curve (AUC) of 0.802 (95% confidential interval (CI):
0.719-0.898; p < 0.001) and 69% sensitivity and 75% specificity was determined.
For reliability, a Cronbach's alpha of 0.667 was calculated. The paired
comparisons revealed an intraclass correlation between 0.642 and 0.758.
CONCLUSION: The DDS demonstrated good validity with excellent sensitivity
and specificity for delirium. The severity of delirium can be more accurately
estimated by the DDS. By its composition of several items, the DDS might help to
start a symptom-guided therapy immediately.
Pandharipande, P., J. Jackson, et al. (2005). "Delirium: acute cognitive dysfunction in
the critically ill." Current Opinion in Critical Care 11(4): 360-368.
Purpose of review The management of sepsis and the multiple organ dysfunction
syndrome has traditionallybeen centered on dysfunction of organs other than the
brain (e.g., heart, lungs, or kidneys), although the brain is one of the most
prevalent organs involved. Recent studies indicate that nonpulmonary acute
organ dysfunction may contribute significantly to mortality and other important
clinical outcomes. Acute confusional states (delerium) occur in 10 to 60% of the
older hospitalized population and in 60 to 80% of patients in the intensive care
unit, yet go unrecognized by the managing physicians and nurses in 32 to 66% of
cases. Delerium is an important independent prognostic determinant of hospital
outcomes, including duration of mechanical ventilation, nursing home placement,
functional decline, and death. Recently, new monitoring instruments have been
validated for monitoring of delerium in noncommunitative patients receiving
mechanical ventilation. Hence, critical care physicians and nurses should
routinely assess their patients for delerium and develop strategies for its
prevention and treatment. Recent findings This state-of-the-art review discusses
in depth the delerium monitoring instruments, the pathophysiology and risk
factors of delerium, its prognostic implications, and strategies (including ongoing
clinical trials) to prevent and treat delerium. Summary Delerium is extremely
common and has significant prognostic implications in critically ill patients.
Routine monitoring and a multimodal approach to prevent or reduce the
prevalence of delerium are of paramount importance. [References: 87]
Papaioannou, A., O. Fraidakis, et al. (2005). "The impact of the type of anaesthesia on
cognitive status and delirium during the first postoperative days in elderly patients."
European Journal of Anaesthesiology 22(7): 492-9.
BACKGROUND AND OBJECTIVES: Postoperative confusion and delirium is a
common complication in the elderly with a poorly understood pathophysiology.
The aim of this study was to examine whether the type of anaesthesia (general
or regional) plays a role in the development of cognitive impairment in elderly
patients during the immediate postoperative period. METHODS: Forty-seven
patients > 60 yr of age and undergoing major surgery were randomly allocated to
receive either regional or general anaesthesia. The mental status of the patients
was assessed preoperatively and during the first three postoperative days with
the Mini Mental State Examination. The incidence of delirium was also examined
during the same period with the use of DSM III criteria. RESULTS: Overall,
during the first three postoperative days, the mean Mini Mental State
Examination score decreased significantly (P < 0.001). However, this decline was
very significant only in patients assigned to receive general anaesthesia (P <
0.001) compared to regional anaesthesia. Nine patients developed delirium but
the type of anaesthesia did not affect its incidence. The only important factor for
the development of delirium was preexisting cardiovascular disease irrespective
of anaesthesia type (P < 0.025). CONCLUSIONS: Elderly patients subjected to
general anaesthesia displayed more frequent cognitive impairment during the
immediate postoperative period in comparison to those who received a regional
technique.
Pierre, J. S. (2005). "Delirium: a process improvement approach to changing prescribing
practices in a community teaching hospital." Journal of Nursing Care Quality 20(3): 24450; quiz 251-2.
An interdisciplinary continuous process improvement team developed an
educational intervention for physicians, nurses, and other healthcare
professionals that focused on the role of medications in the etiology of delirium
among hospitalized patients aged 65 years and older. An analysis of prescribing
practices after the educational intervention revealed a reduction in the use for
57% of the drugs targeted. Other outcomes from this process improvement
methodology are also examined.
Pitkala, K. H., J. V. Laurila, et al. (2005). "Prognostic significance of delirium in frail older
people." Dementia & Geriatric Cognitive Disorders 19(2-3): 158-63.
Our aim was to investigate the long-term prognosis of delirium in the frailest
elderly, and to clarify whether delirium is just a marker of the underlying severe
disease. We used logistic regression analysis to determine the independent
prognostic significance of delirium. A representative sample of 425 patients (> or
= 70 years) in acute geriatric wards and nursing homes were assessed at
baseline and followed up for 2 years. DSM-IV was used for classification. The
prevalence of delirium at baseline was 24.9% (106/425). The prognosis of
delirium was poor: mortality at 1 year was 34.9 vs. 21.6% in nondelirious subjects
(p = 0.006), and at 2 years 58.5 vs. 42.6% (p = 0.005). Among home-dwelling
people at baseline, 54.4% of the delirious vs. 27.9% of others were permanently
institutionalized within 2 years (p < 0.001). In logistic regression analysis, delirium
was an independent predictor for mortality at 1 year (OR 1.86, 95% CI 1.1-3.1),
at 2 years (OR 1.76, 95% CI 1.1-2.8), and for permanent institutionalization (OR
2.45, 95% CI 1.2-4.9). Delirious patients with prior dementia tended to have a
better prognosis than those without.
Pratico, C., D. Quattrone, et al. (2005). "Drugs of anesthesia acting on central
cholinergic system may cause post-operative cognitive dysfunction and delirium."
Medical Hypotheses 65(5): 972-82.
Given the progressive and constant increase of average life expectancy, an
increasing number of elderly patients undergo surgery. After surgery, elderly
patients often exhibit a transient reversible state of cerebral cognitive alterations.
Among these cognitive dysfunctions, a state of delirium may develop. Delirium is
an aetiologically non-specific syndrome characterised by concurrent disturbances
of consciousness and attention, perception, thinking, memory, psychomotor
behaviour and the sleep-wake cycle. Delirium appears to occur in 10-26% of
general medical patients over 65, and is frequently associated with a significant
increase in morbidity and mortality. During hospitalization, mortality rates have
been estimated to be 10-26% of patients who developed post-operative delirium,
and 22-76% during the following months. Over the last few decades, postoperative delirium has been associated with several pre-operative predictor
factors, as well as age (50 years and older), alcohol abuse, poor cognitive and
functional status, electrolyses or glucose abnormalities, and type of surgery. The
uncertain pathogenesis of post-operative cognitive dysfunctions and delirium has
not permitted a causal approach to developing an effective treatment. General
anesthesia affects brain function at all levels, including neuronal membranes,
receptors, ion channels, neurotransmitters, cerebral blood flow and metabolism.
The functional equivalents of these impairments involve mood, memory, and
motor function behavioural changes. These dysfunctions are much more evident
in the occurrence of stress-regulating transmission and in the alteration of intracellular signal transduction systems. In addition, more essential cellular
processes, that play an important role in neurotransmitter synthesis and release,
such as intra-neuronal signal transduction and second messenger system, may
be altered. Keeping in mind the functions of the central muscarinic cholinergic
system and its multiple interactions with drugs of anesthesia, it seems possible to
hypothesize that the inhibition of muscarinic cholinergic receptors could have a
pivotal role in the pathogenesis not only of post-operative delirium but also the
more complex phenomena of post-operative cognitive dysfunction.
Prommer, E. (2005). "Re: Olanzapine-induced delirium.[comment]." Journal of Pain &
Symptom Management 29(2): 119-20.
Pun, B. T., S. M. Gordon, et al. (2005). "Large-scale implementation of sedation and
delirium monitoring in the intensive care unit: a report from two medical centers.[see
comment]." Critical Care Medicine 33(6): 1199-205.
OBJECTIVE: To implement sedation and delirium monitoring via a processimprovement project in accordance with Society of Critical Care Medicine
guidelines and to evaluate the challenges of modifying intensive care unit (ICU)
organizational practice styles. DESIGN: Prospective observational cohort study.
SETTING: The medical ICUs at two institutions: the Vanderbilt University Medical
Center (VUMC) and a community Veterans Affairs hospital (York-VA).
SUBJECTS: Seven hundred eleven patients admitted to the medical ICUs for
>24 hrs and followed over 4,163 days during a 21-month study period.
INTERVENTIONS: Unit-wide nursing documentation was changed to
accommodate a sedation scale (Richmond Agitation-Sedation Scale) and
delirium instrument (Confusion Assessment Method for the ICU). A 20-min
introductory in-service was performed for all ICU nurses, followed by graded,
staged educational interventions at regular intervals. Data were collected daily for
compliance, and randomly 40% of nurses each day were chosen for accuracy
spot-checks by reference raters. An implementation survey questionnaire was
distributed at 6 months. MEASUREMENTS AND MAIN RESULTS: The
implementation project involved 64 nurses (40 at VUMC and 24 at York-VA).
Sedation and delirium monitoring data were recorded for 711 patients (614 at
VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation
Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at
York-VA. Compliance with the Confusion Assessment Method for the ICU was
90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The
Confusion Assessment Method for the ICU was performed more often than
requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of
shifts at York-VA. Overall weighted-kappa between bedside nurses and
references raters for the Richmond Agitation-Sedation Scale were 0.89 (95%
confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval,
0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses
and reference raters using the Confusion Assessment Method for the ICU was
0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence
interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to
implementation were physician buy-in and time. CONCLUSIONS: With minimal
training, the compliance of bedside nurses using sedation and delirium
instruments was excellent. Agreement of data from bedside nurses and a
reference-standard rater was very high for both the sedation scale and the
delirium assessment over the duration of this process-improvement project.
Raivio, M. M., J. V. Laurila, et al. (2005). "Psychotropic medication and stroke
outcome.[comment]." American Journal of Psychiatry 162(5): 1027; author reply 1027-8.
Reischies, F. M., A. H. Neuhaus, et al. (2005). "Electrophysiological and
neuropsychological analysis of a delirious state: the role of the anterior cingulate gyrus."
Psychiatry Research 138(2): 171-81.
Functional neuroimaging studies in humans have provided evidence that a frontal
network including the anterior cingulate cortex (ACC) plays an important role in
attention and awareness. Disturbed attention and awareness are core symptoms
of delirium, but imaging studies of attentional dysfunctions in delirium are lacking.
However, an increase of slow electroencephalographic (EEG) activity (delta,
theta) is a consistent biological finding in delirium. The question whether this slow
activity is related to a disturbance in the frontal attentional network has not yet
been addressed. The delirium after electroconvulsive therapy (ECT) has been
investigated using 32-channel resting EEG before and shortly after ECT in 12
patients with major depressive disorder. During delirium compared with baseline
studies, substantial increases of delta and theta power and a decrease of alpha
power were observed. The decrease of theta activity at the Fz electrode position
in the following 24 h was significantly related to the recovery of awareness and
performance of free recall. Source analysis with Low Resolution Electromagnetic
Tomography (LORETA) indicated that the main generators of the theta excess
during delirium were significantly localized in the anterior cingulate cortex, and
additionally in right fronto-temporal brain areas. The results support the concept
that a disturbance of attention and awareness during delirium is related to a
dysfunction of an attentional network involving the ACC. However, the
localization of the theta excess may reflect some motor dysfunctions as well. This
dysfunction of the ACC was shown for the first time in patients during a delirious
state and may represent an important pathophysiological aspect of delirium.
Rothenhausler, H. B., B. Grieser, et al. (2005). "Psychiatric and psychosocial outcome
of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up
study." General Hospital Psychiatry 27(1): 18-28.
Little is known concerning the natural history of psychiatric morbidity,
postoperative delirium, cognitive decline and health-related quality of life
(HRQOL) in cardiac surgery patients and the impact of neurocognitive
dysfunction on HRQOL after cardiac surgery with cardiopulmonary bypass
(CPB). In a prospective study, we followed up for 1 year 30 of the original 34
patients who had undergone cardiac surgery with CPB. Patients were assessed
preoperatively, before discharge, and at 1 year after surgery with the Structural
Clinical Interview for DSM-IV and a series of neuropsychological tests.
Psychometric scales were administered to evaluate cognitive functioning
(Syndrom Kurztest), depressive symptomatology (Montgomery-Asberg
Depression Rating Scale), posttraumatic stress symptoms (Posttraumatic Stress
Syndrome 10-Questions Inventory) and HRQOL (SF-36 Health Status
Questionnaire). Delirium Rating Scale (DRS) was used daily over the course of
intensive care unit treatment. Postoperative delirium developed in 11 of the 34
patients (mean DRS rating scale score+/-S.D.: 20.36+/-6.22, range: 14-31).
Short-term consequences of cardiac surgery included adjustment disorder with
depressed features (n=11), posttraumatic stress disorder (n=6), major
depression (n=6) and clinically relevant cognitive deficits (n=13). At 12 months,
the severity of depression and anxiety disorders improved and returned to the
preoperative level, and 6 out of the 30 followed-up patients displayed cognitive
deficits. Our patients' HRQOL SF-36 self-reports significantly improved compared
with baseline quality of life data. However, 1-year overall lower cognitive function
scores were associated with lower HRQOL. Cardiac surgery with CPB is
associated with improvements in HRQOL relative to the preoperative period, but
the presence of cardiac surgery-related cognitive decline impairing HRQOL is a
complication for a subgroup of cardiac surgical patients in the long-term
outcome.
Rozzini, R., T. Sabatini, et al. (2005). "Do we need delirium units?[comment]." Journal
of the American Geriatrics Society 53(5): 914-5; author reply 915-6.
Rudolph, J. L., V. L. Babikian, et al. (2005). "Atherosclerosis is associated with delirium
after coronary artery bypass graft surgery." Journal of the American Geriatrics Society
53(3): 462-6.
OBJECTIVES: To investigate whether atherosclerosis of the ascending aorta,
internal carotid arteries, and coronary arteries is predictive of postoperative
delirium in subjects undergoing coronary artery bypass graft (CABG) surgery.
DESIGN: Prospective cohort study. SETTING: Boston Veterans Affairs
Healthcare System. PARTICIPANTS: Thirty-six male veterans undergoing
primary CABG surgery. MEASUREMENTS: Subjects underwent Duplex
ultrasound to assess stenosis in the internal carotid arteries. Information on the
ascending aortic plaque, as assessed by transesophageal echocardiogram, and
the number of coronary vessels bypassed was collected. To create an
atherosclerosis score, the number of atherosclerotic areas was added. A
validated delirium battery was administered to the subjects preoperatively and on
postoperative Days 2 and 5. RESULTS: Fifteen subjects (41.7%) developed
delirium postoperatively. In bivariate analysis, carotid stenosis of 50% or more
(relative risk (RR)=3.5, 95% confidence interval (CI)=1.5-8.1) and moderatesevere ascending aortic plaque (RR=2.9, 95% CI=1.0-8.5) were significantly
associated with the development of delirium. There was a trend toward a
significant association for three or more vessels bypassed (RR=9.6, 95% CI=0.6145.3). After controlling for age, baseline cognition, and medical comorbidity, the
atherosclerosis score was significantly associated with postoperative delirium
(adjusted RR=2.7, 95% CI=1.1-6.8). CONCLUSION: In this preliminary report,
atherosclerosis in the carotid arteries, aorta, and coronary circulation is
associated with the development of delirium after CABG surgery. Further
investigation into atherosclerosis as a risk factor for delirium is warranted.
Santana Santos, F., L. O. Wahlund, et al. (2005). "Incidence, clinical features and
subtypes of delirium in elderly patients treated for hip fractures." Dementia & Geriatric
Cognitive Disorders 20(4): 231-7.
OBJECTIVE: To describe the incidence, risk factors and clinical features
(subtypes) of delirium during the postoperative period after hip fracture surgery in
elderly patients. DESIGN: Prospective study. METHODS: Thirty-four consecutive
patients (9 men and 25 women) were included in this study between June 16 to
July 14, 2003. All patients underwent surgery for a fractured neck of femur and
were pre- and postoperatively cared for at a combined geriatric/orthopedic ward.
ASSESSMENT: The diagnosis of delirium was based on the criteria of the DSMIV and the Confusion Assessment Method Scale. Subtypes of delirium were
classified according to the criteria proposed by Lipowski: hyperactive-hyperalert
(or agitated), hypoactive-hypoalert (somnolent) and mixed delirium. Results:
Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The
development of delirium was associated with the medication midazolam taken
perioperatively. Nine (47%) of the delirious patients had a hyperactive type of
delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed
type. We did not find any association among subtypes of delirium and clinical
features. CONCLUSIONS: Delirium is a common complication in the
postoperative period of elderly patients treated for hip fractures. The use of
midazolam in the perioperative period increased the risk of developing
postoperative delirium. The hyperactive type of delirium was the most common
subtype of delirium. Copyright (c) 2005 S. Karger AG, Basel.
Schoevers, R. A., D. J. Deeg, et al. (2005). "Depression and generalized anxiety
disorder: co-occurrence and longitudinal patterns in elderly patients." American Journal
of Geriatric Psychiatry 13(1): 31-9.
OBJECTIVE: The authors sought to establish the natural course and risk-profile
of depression, generalized anxiety disorder (GAD), and depression with coexisting GAD in later life. METHODS: A total of 2,173 community-living elderly
persons were interviewed at baseline, and at a 3-year follow-up. The course of
"pure" depression, "pure" GAD, and depression with coexisting GAD was studied
in 258 subjects with baseline psychopathology. Authors assessed bivariate and
multivariate relationships between risk factors and course types. The risk-profile
for onset of pure depression, pure GAD, and the mixed condition at follow-up
was studied in 1,915 subjects without baseline psychopathology. RESULTS:
Remission rate at follow-up was 41% for subjects with depression-only, 48% for
pure GAD, and significantly lower (27%) for depression with coexisting GAD. A
pattern of temporal sequencing was established, with anxiety often progressing
to depression or depression with GAD. Onset of pure depression and depression
with co-existing GAD was predicted by loss events, ill health, and functional
disability. Onset of pure GAD, and, more strongly, that of depression with
coexisting GAD, was associated with longstanding, possibly genetic vulnerability.
CONCLUSIONS: In comparison with either depression-only or anxiety-only, the
co-occurrence of these represents more severe and more chronic
psychopathology, associated with longstanding vulnerability. In elderly persons,
GAD often progresses to depression or to the mixed condition. These findings
mostly favor a dimensional, rather than a categorical, classification of anxiety and
depression.
Schubert, C. C., M. Boustani, et al. (2006). "Comorbidity profile of dementia patients in
primary care: Are they sicker?" Journal of the American Geriatrics Society 54(1): 104109.
OBJECTIVES: To compare the medical comorbidity of older patients with and
without dementia in primary care. DESIGN: Cross-sectional study. SETTING:
Wishard Health Services, which includes a university-affiliated, urban public
hospital and seven community-based primary care practice centers in
Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and
older attending seven primary care centers in Indianapolis, Indiana.
MEASUREMENTS: An expert panel diagnosed dementia using International
Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed
using 10 physician-diagnosed chronic comorbid conditions and the Chronic
Disease Score (CDS). RESULTS: Patients with dementia attending primary care
have on average 2.4 chronic conditions and receive 5.1 medications.
Approximately 50% of dementia patients in this setting are exposed to at least
one anticholinergic medication, and 20% are prescribed at least one psychotropic
medication. After adjusting for patients' age, race, and sex, patients with and
without dementia have a similar level of comorbidity (mean number of chronic
medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83).
CONCLUSION: Multiple medical comorbid conditions are common in older adults
with and without dementia in primary care. Despite their cholinergic deficit, a
substantial proportion of patients with dementia are exposed to anticholinergic
medications. Models of care that incorporate this medical complexity are needed
to improve the treatment of dementia in primary care. [References: 35]
Sharma, P. T., F. E. Sieber, et al. (2005). "Recovery room delirium predicts
postoperative delirium after hip-fracture repair." Anesthesia & Analgesia 101(4): 12151220.
In this study, we sought to determine the incidence of recovery room delirium in
elderly patients having hip-fracture repair under general anesthesia and to
discover whether recovery room delirium is associated with continuing
postoperative delirium. In this prospective study, patients undergoing hip-fracture
repair were anesthetized using a standardized protocol. In addition,
postoperative pain management was standardized in both the postoperative
anesthesia care unit and in the hospital ward. The presence of delirium was
determined using the confusion assessment method (CAM) score. Recovery
room delirium was assessed by obtaining a CAM score at 60 min after
discontinuation of isoflurane. Postoperative delirium was assessed by obtaining a
daily CAM score during the postoperative in-hospital recovery period. Fifty
patients consented to the study and 47 patients were included in the analysis
(surgery cancelled postinduction n = 1; nonadherence to protocol n = 2). Average
patient age was 77 +/- 1 (mean +/- SE) yr (range, 56-98 yr). Seventy-seven
percent of the study patients were ASA class III or more. The prevalence of
recovery room delirium was 45%. The prevalence of postoperative delirium was
36%. Recovery room delirium predicted postoperative delirium (P < 0.001,
Fisher's exact test) with a sensitivity of 100% and a specificity of 85%. Analgesic
doses administered in the postoperative anesthesia care unit and ward were
similar in patients with or without postoperative delirium: Results of this study
show that recovery room delirium is a strong predictor of postoperative delirium.
[References: 23]
Shulman, K. I., K. Sykora, et al. (2005). "Incidence of delirium in older adults newly
prescribed lithium or valproate: a population-based cohort study." Journal of Clinical
Psychiatry 66(4): 424-7.
BACKGROUND: The use of lithium carbonate for the treatment of mood
disorders in old age has decreased at a dramatic rate in favor of valproate.
Because of lithium's narrow therapeutic range, neurotoxicity can be an important
complication in lithium therapy and potentially influence prescription patterns.
Therefore, we compared the incidence of delirium in older adults with mood
disorders who were newly dispensed either lithium or valproate. METHOD: Using
4 population-based administrative databases from the province of Ontario,
Canada (the Ontario Drug Benefit program, the Canadian Institute for Health
Information, the Ontario Health Insurance Plan, and the Registered Persons Data
Base), we were able to identify a cohort of mood disorder patients 66 years and
older who were newly dispensed lithium or valproate over an 8-year period
(1993-2001). Measures were taken to ensure that the sample was composed of
mood disorder patients. As a comparator, we included a known deliriogenic drug,
benztropine. The main outcome measure was a new diagnosis of delirium on a
hospitalization record during 1 year of follow-up. RESULTS: Our study cohort
consisted of 2422 new users of lithium and 2918 new users of valproate over an
8-year period. There was no statistically significant difference in the incidence of
delirium between lithium (2.8 per 100 person-years) and valproate (4.1 per 100
person-years). Compared with patients who received lithium, patients who
received benztropine had a significantly higher risk of delirium (p <.001).
CONCLUSION: The incidence of hospitalizations with delirium was similar in
patients treated with lithium and valproate. These findings add to the evidence
suggesting that the shift away from the use of lithium carbonate to manage mood
disorders in older adults is not justified on the basis of concerns of neurotoxicity.
Speciale, S., G. Bellelli, et al. (2005). "Staff training and use of specific protocols for
delirium management.[comment]." Journal of the American Geriatrics Society 53(8):
1445-6.
Tabet, N., S. Hudson, et al. (2005). "An educational intervention can prevent delirium on
acute medical wards." Age & Ageing 34(2): 152-6.
BACKGROUND: Delirium is a common disorder in hospitalised older people and
established cases may have a poor outcome that is not readily improved by
intervention. Prevention of cases through education of medical and nursing staff
has not been fully studied. OBJECTIVES: To test the hypothesis that an
educational package for medical and nursing staff would both reduce the number
of incident cases of delirium and increase recognition of cases of delirium within
an acute medical admissions ward. DESIGN: Single-blind case-control study.
SETTING: Two acute admissions wards in a busy inner-city teaching hospital.
SUBJECTS: 250 acute admissions over the age of 70 years. METHODS: An
educational package for staff on one ward consisting of a 1 hour formal
presentation and group discussion, written management guidelines and follow-up
sessions. The follow-up sessions, which were based on one-to-one and group
discussions, aimed at providing continuous support of staff through emphasising
learning and testing knowledge. Diagnosis and management of some discharged
delirium patients were also discussed to allow staff to learn from previous
experience. The main outcome measures are point prevalence of delirium
established by researchers, and recognition and case-note documentation of
delirium by clinical staff. RESULTS: The point prevalence of delirium was
significantly reduced on the intervention compared to the control ward (9.8%
versus 19.5%, P < 0.05) and clinical staff recognised significantly more delirium
cases that had been detected by research staff on the ward where the
educational package had been delivered. CONCLUSION: A focused and
inexpensive educational programme can decrease the prevalence of delirium
among older inpatients.
Takeuchi, T., E. Matsushima, et al. (2005). "Delirium in inpatients with respiratory
diseases." Psychiatry & Clinical Neurosciences 59(3): 253-8.
The features of delirium in patients being hospitalized due to respiratory diseases
were investigated. From the inpatients in the respiratory medical ward of Tokyo
Metropolitan Hiroo General Hospital over the course of 1 year, the patients who
had delirium were diagnosed by a semistructured interview. The total number of
subjects was 454, and patients with delirium were 43. Various clinical factors
were compared between the delirium group and non-delirium group. In the
delirium group, there were many elderly patients of 70 years or older. Moreover,
there were many patients who had a chronic respiratory disease, patients in
which the respiratory diseases were mutually complicated, and patients in whom
other diseases combined with the respiratory disease in the delirium group.
There were also many patients in the Intensive Care Unit (ICU), and patients with
an endotracheal intubation or extubation. Based on the results of a multiple
logistic regression analysis, for age, ICU accommodation, and endotracheal
intubation, the value of the delirium group was more significant than that of the
non-delirium group. In half of the patients from the delirium group, delirium
developed within 1 week after hospitalization. In the patients who died in the
hospital, however, delirium often developed days after they had been
hospitalized. It was suggested that the later developed delirium had a relation to
the prognosis.
Tuglu, C., E. Erdogan, et al. (2005). "Delirium and extrapyramidal symptoms due to a
lithium-olanzapine combination therapy: A case report." Journal of Korean Medical
Science 20(4): 691-694.
We report an elderly patient who developed severe delirium and extrapyramidal
signs after initiation of lithium-olanzapine combination. On hospital admission,
serum levels of lithium were found to be 3.0 mM/L which were far above toxic
level. Immediate discontinuation of both drugs resulted in complete resolution of
most of the symptoms except for perioral dyskinesia which persisted for three
more months. We critically discussed the differential diagnosis of lithium
intoxication and assessed confounding factors which induce delirium and
extrapyramidal signs related with combination therapy of lithium and olanzapine.
[References: 27]
Vilches, A., I. Singh, et al. (2005). "Delirium in the elderly." Hospital Medicine (London)
66(8): 474-6.
White, S., B. L. Calver, et al. (2005). "Enzymes of drug metabolism during delirium."
Age & Ageing 34(6): 603-8.
BACKGROUND: Delirium is common in ill medical patients. Several drugs and
polypharmacy are recognised risk factors, yet little is known about drug
metabolism in people with delirium. OBJECTIVE: The aim of this study was to
investigate the activities of plasma esterases (drug metabolising enzymes) in
delirium. DESIGN: This was a prospective study of delirium present at time of
hospital admission (community acquired) or developing later (hospital acquired)
in patients admitted as a medical emergency and aged 75 years or over.
METHODS: Following informed consent or assent cognitive screening was
completed on all patients on admission and every 48 hours subsequently.
Delirium was diagnosed by Confusion Assessment Method and DSM IV criteria.
Blood samples were taken on admission and at onset of delirium if this was later.
Four plasma esterase assays were performed spectrophotometrically:
acetylcholinesterase, aspirin esterase, benzoylcholinesterase,
butyrylcholinesterase. RESULTS: 283 patients (71% of eligible) were recruited,
with mean age 82.4 years and 59% female. 27% had community acquired
delirium, 10% developed hospital acquired delirium, 63% never developed
delirium. On admission the mean activities of all four esterase assays were
statistically significantly lower in delirious than non delirious patients. There were
no significant differences on admission in any plasma esterase activity between
patients with hospital and community acquired delirium. In-hospital mortality was
associated with low plasma esterase activities on admission. CONCLUSION:
Plasma esterase activities are suppressed during delirium. These data reinforce
the need for extreme caution with drugs in this vulnerable population.
Wiggins, J. (2005). "Core curriculum in nephrology - Geriatrics." American Journal of
Kidney Diseases 46(1): 147-158.
Wilber, S. T., S. D. Lofgren, et al. (2005). "An evaluation of two screening tools for
cognitive impairment in older emergency department patients." Academic Emergency
Medicine 12(7): 612-616.
Objectives: Screening for cognitive impairment in older emergency department
(ED) patients is recommended to ensure quality care. The Mini-Mental State
Examination (MMSE) may be too long for routine ED use. Briefer alternatives
include the Six-Item Screener (SIS) and the Mini-Cog. The objective of this study
was to describe the test characteristics of the SIS and the Mini-Cog compared
with the MMSE when administered to older ED patients. Methods: This
institutional review board-approved, prospective, randomized study was
performed in a university-affiliated teaching hospital ED. Eligible patients were 65
years and older and able to communicate in English. Patients who were unable
or unwilling to perform testing, who were medically unstable, or who received
medications affecting their mental status were excluded. Patients were
randomized to receive the SIS or the Mini-Cog by the treating emergency
physician. Investigators administered the MMSE 30 minutes later. An SIS score
of <= 4, the Mini-Cog's scoring algorithm, and an MMSE score of <= 23 defined
cognitive impairment. Results: A total of 149 of 188 approached patients were
enrolled; 74 received the SIS and 75 the Mini-Cog. Fifty-five percent were
female, the average age was 75 years, and 23% had an MMSE score of <= 23.
The SIS had a sensitivity of 94% (95% confidence interval [CI] = 73% to 100%)
and a specificity of 86% (95% CI = 74% to 94%). The Mini-Cog had a sensitivity
of 75% (95% CI = 48% to 93%) and a specificity of 85% (95% CI = 73% to 93%).
Conclusions: The SIS, using a cutoff of <= 4 as impaired, is a promising test for
ED use. It is short, easy to administer, and unobtrusive, allowing it to be easily
incorporated into the initial assessment of older ED patients. [References: 17]
Wilson, K., C. Broadhurst, et al. (2005). "Plasma insulin growth factor-1 and incident
delirium in older people." International Journal of Geriatric Psychiatry 20(2): 154-9.
BACKGROUND: A variety of demographic and clinical variables are
acknowledged as risk factors for delirium; a syndrome thought to be mediated by
abnormalities in a wide range of neurotransmitters. However, little research has
been conducted in this field and the role of neuro-immunological factors as a
mechanism of medication has received very little attention. AIMS: To determine if
low base line (on admission) IGF-1 levels (a protective cytokine released by brain
cells in response to insult) is a risk factor for incident delirium in patients aged 75
and over admitted to an acute medical ward. METHOD: Base line demographic
and clinical variables and serum IGF-1 levels were measured in a consecutive
series of 100 non-delirious subjects on inpatient admission. Subjects were
assessed daily regarding the development of delirium during the inpatient
episode. RESULTS: Twelve patients developed incident delirium. IGF-1 (OR:
0.822, CI: 0.69, 0.97, p = 0.027), pre-admission cognitive deterioration (assessed
by IQCODE) (OR; 3.26, CI: 1.18, 9.04, p = 0.023) and depression (GDS four
item: cut-off score > or = 3) (OR; 8.99, CI 1.59,50.76, p = 0.013) were identified
as risk factors for developing subsequent delirium. CONCLUSIONS: Despite the
small size of this study our findings suggest that low, pre-morbid IGF-1 is a risk
factor for subsequent delirium in this population, emphasizing the potential
protective role of this anabolic cytokine and the need for replication of these
findings. 2005 John Wiley & Sons, Ltd.
Wong, C. P., P. K. Chiu, et al. (2005). "Zopiclone withdrawal: an unusual cause of
delirium in the elderly." Age & Ageing 34(5): 526-7.
We report a case of an elderly lady who was admitted for congestive heart
failure. She developed delirium during the course of her hospital stay. Multiple
investigations were performed but were unremarkable. Finally, a diagnosis of
abrupt zopiclone withdrawal causing delirium was made. Zopiclone was resumed
at a lower dose and delirium resolved completely.
Yamagata, K., K. Onizawa, et al. (2005). "Risk factors for postoperative delirium in
patients undergoing head and neck cancer surgery." International Journal of Oral &
Maxillofacial Surgery 34(1): 33-6.
This study was carried out to determine risk factors for delirium after major head
and neck cancer surgery. The postoperative experience of 38 patients who
underwent major head and neck cancer surgery and were managed in the high
care unit was retrospectively examined by reviewing their medical records.
Delirium was defined as confusion and abnormal behavior that interfered with
postoperative recovery. Postoperative delirium occurred in 10 patients (26.3%)
who all had stage IV cancer, flap reconstruction, an operative time of more than
10 h, blood transfusion of more than 4 units or infusion of more than 5000 ml,
which together suggested the risk of delirium increased significantly with
extensive surgery. Delirium occurred less frequently in patients with minor
tranquilizer use for postoperative sleep disorder. Multivariative analyses showed
an operative time of >10 h and no use of minor tranquilizer as significant factors
for increasing the incidence of delirium, with odds ratios (95% confidence
interval) of 11.4 (1.5-83.8) and 9.8 (1.5-66.0), respectively.
Yildizeli, B., O. Ozyurtkan, et al. (2005). "Factors associated with postoperative delirium
after thoracic surgery." Annals of Thoracic Surgery 79(3): 1004-1009.
Background. Postoperative delirium is an acute confusional state characterized
by fluctuating consciousness and is associated with increased morbidity and
mortality. We analyzed the incidence and risk factors of delirium following
thoracic surgery. Methods. All patients (n = 432) who underwent thoracotomy or
sternotomy from 1996 to 2003 were analyzed retrospectively. The diagnosis of
postoperative delirium was based on Diagnostic and Statistical Manual of Mental
Disorders-IV criteria. Results. Postoperative delirium developed in 23 patients
(5.32%) between postoperative days 2 to 12 (mean, 4.4 +/- 2.6 days). There
were 15 males and 8 females, with a mean age of 59.4 years (24 to 77 years).
The delirium group was older (59.4 +/- 14.6 vs 51.3 +/- 15.5 years, p < 0.01) and
had a longer operation time than the nondelirious group (5.34 +/- 1.58 vs 4.38 +/1.6 hours, p = 0.005). Morbidity and mortality rates were not significantly different
between the two groups (56.5% vs 47.1%; 13.0% vs 3.66%, respectively).
Univariate analysis showed that the older age, markedly abnormal postoperative
levels of sodium, potassium, or glucose, sleep deprivation, operation time, and
diabetes mellitus were risk factors (p < 0.05). According to multivariate analyses,
four factors were selected as predictive risk factors: (1) markedly abnormal
postoperative levels of sodium, potassium, or glucose (p = 0.038); (2) sleep
deprivation (p = 0.05); (3) age (p = 0.033); and (4) operation time (p = 0.041).
Conclusions. Postoperative delirium may cause higher morbidity and mortality
rates after thoracic surgery. Close postoperative follow-up and early identification
of predisposing factors such as older age, sleep deprivation, abnormal
postoperative levels of sodium, potassium, or glucose, and longer operation time
can prevent occurrence of postoperative delirium. (C) 2005 by The Society of
Thoracic Surgeons. [References: 28]
Yoshimasu, K., K. Tanaka, et al. (2005). "Relation of surgery, tumor site, and age group
to the loss of reality testing in Japanese patients with malignant tumors: A study of a
hospital-based sample with a consultation-liaison service." Psychiatry & Clinical
Neurosciences 59(3): 259-265.
The relation between surgery and the loss of reality testing (LRT) in Japanese
patients with malignant tumors were examined, taking into account the influence
of the tumor sites and age groups. The patients were comprised of 277 men and
225 women with malignant tumors in Kyushu University Hospital, Fukuoka,
Japan, who underwent a check-up at the Department of Neuropsychiatry for the
first time using the consultation-liaison system. Those with known schizophrenia,
dementia, mental retardation, and paranoid or schizoid (schizotypal) personality
disorder were excluded. Surgery was statistically significantly associated with
LRT in elderly men (&GE; 65 years of age), and in men with malignant tumors of
the digestive organs (odds ratio [OR], 9.7; 95% confidence interval [95% CI], 3.229.3). Even after adjusting for tumor site and age, surgery was statistically
significantly associated with LRT in men (OR, 2.6; 95% CI, 1.4-4.6) and nearly
significantly associated in women (OR, 1.8; 95% CI, 0.9-3.6). There were no
material associations between surgery and LRT in patients with malignant tumors
of sex-specific organs or the head and neck area. The present study showed a
positive relationship between surgery and LRT in Japanese men and women with
malignant tumors. The association was stronger in elderly patients. As for tumor
site, surgery was most strongly associated with an increased risk of LRT in
patients with malignant tumors of the digestive organs. [References: 18]