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BIBLIOGRAPHIE SUR LE DELIRIUM (MEDLINE,CURRENT CONTENTS, COCHRANE) 2005 Par ordre alphabétique d’auteur 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]