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Adunsky, A., R. Levy, et al. (2003). "The unfavorable nature of preoperative delirium in
elderly hip fractured patients." Archives of Gerontology & Geriatrics 36(1): 67-74.
The onset of delirium is frequent in elderly patients who sustain hip fractures. The
purpose of this study was to characterize different patterns of preoperative and
postoperative delirium, to study factors associated with preoperative delirium and
to evaluate the possible different outcome of these patients. This retrospective
study comprised 281 elderly patients with hip fractures undergoing surgical
fixation. Data collection included age, sex, length of stay, type of fracture,
cognitive status by mini mental state examination (MMSE), assessment of
possible delirium by the confusion assessment method (CAM) and functional
outcome assessed by functional independence measure (FIM). A database
search was conducted to identify whether delirium onset occurred prior to or
following surgery. About 31% of the total sample developed delirium. Delirious
patients tended to be more disabled (P = 0.03) and cognitively impaired (P =
0.018), compared with non-delirious patients. Most delirious cases (53%) had
their onset in the preoperative period. Patients with preoperative delirium were
older (P = 0.03), had a lower prefracture mobility (P < 0.01), impaired cognition
(P = 0.04) and showed an adverse functional outcome in terms of FIM score.
Regression analysis showed that prefracture dementia, prefracture mobility and
low MMSE scores were strongly associated with higher probability of having
preoperative delirium, with no additional effect of other variables. It is concluded
that preoperative delirium should be viewed as a separate entity with unfavorable
nature and adverse outcome. Careful preventive measures and better treating
strategies should be employed to avoid this clinical condition.
Akechi, T., A. Kugaya, et al. (1999). "Suicidal thoughts in cancer patients: clinical
experience in psycho-oncology." Psychiatry & Clinical Neurosciences 53(5): 569-73.
Because cancer is a life-threatening illness, its impact on the patient's emotional
well-being, such as suicidal thoughts, has become a significant problem in public
health as well as in clinical oncology. Factors such as the pain and hopelessness
are suggested as making cancer patients more vulnerable to suicide. On the
other hand, euthanasia and physician-assisted suicide are now important
medical and social issues all over the world. However, little is known about the
relationship between the characteristics of cancer patients and suicidal thoughts.
The present study investigated the characteristics of patients who were referred
to the Psychiatry Division, National Cancer Center Hospital East, due to risk of
suicide or suicide attempts. Fourteen patients were referred, representing 3.9%
of all consultations. Most of these patients suffered from advanced cancer and
poor physical functioning. The most frequent psychiatric diagnosis was mood
disorder (57%), and the next was delirium (29%). In patients with mood disorders
(8 cases), suicidal thoughts disappeared after psychiatric treatment in 5 cases,
but not in 3 cases. Those three patients survived a significantly shorter time than
the others after psychiatric consultation. These empirical data might indicate that
most suicidal thoughts experienced by cancer patients are not rational, and a
careful evaluation, including psychiatric assessment, should be conducted in
such patients.
Alamanni, F., A. Parolari, et al. (2001). "Centrifugal pump and reduction of neurological
risk in adult cardiac surgery." Journal of Extra-Corporeal Technology 33(1): 4-9.
This study was performed to assess if the kind of pump used for CPB (roller vs.
centrifugal) can influence neurological outcomes of adult cardiac surgery
patients. Between 1994 and 1998, 3438 patients underwent coronary and/or
valve surgery at our hospital; of these, 1805 (52.5%) underwent surgery with the
use of a centrifugal pump, and 1633 (47.5%) were operated with a roller pump.
The effect of the type of the pump and of common preoperative and
intraoperative risk factors for five different neurological outcomes (permanent
neurological deficit, coma, delirium, transient neurological deficit, overall
neurological complications) were assessed with univariate and multivariate
analyses in the whole patients population, in patients > or = 75 years old and in
patients with histories of previous neurological events. Centrifugal pump use was
the only protective factor for perioperative permanent neurological deficit in
multivariable models developed for the whole patient population and for patients
> or = 75 years old. In addition, it resulted as the only protective factor for
perioperative coma occurrence in multivariable models developed for patients >
or = 75 years old, and for patients with histories of previous neurological events.
The use of the centrifugal pump provided a risk reduction for the considered
events ranging from 23 to 84%. Centrifugal pump use can be helpful in reducing
the occurrence of some of the most feared neurological complications of adult
cardiac surgery patients.
Anderson, S. D. and R. A. Hewko (2003). "Studying delirium.[comment]." CMAJ
Canadian Medical Association Journal 168(5): 541; author reply 541-2.
Bekker, A. Y. and E. J. Weeks (2003). "Cognitive function after anaesthesia in the
elderly." Best Practice & Research Clinical Anaesthesiology 17(2): 259-72.
Despite advances in peri operative care, a significant percentage of elderly
patients experience transient post operative delirium and/or long-term postoperative cognitive dysfunction (POCD). This chapter reviews the aetiology,
clinical features, preventive strategies and treatment of these syndromes. Preoperative, intra-operative, and post-operative risk factors for delirium and POCD
following cardiac and non-cardiac surgery are discussed. It is most likely that the
aetiology of delirium and POCD is multifactorial and may include factors such as
age, decreased pre-operative cognitive function, general health status and,
possibly, intra-operative events. Currently there is no single therapy that can be
recommended for treating post-operative cognitive deterioration. Primary
prevention of delirium and POCD is probably the most effective treatment
strategy. Several large clinical trials show the effectiveness of multicomponent
intervention protocols that are designed to target well-documented risk factors in
order to reduce the incidence of post-operative delirium and, possibly, POCD in
the elderly. [References: 70]
Bitsch, M., N. Foss, et al. (2004). "Pathogenesis of and management strategies for
postoperative delirium after hip fracture: a review.[see comment]." Acta Orthopaedica
Scandinavica 75(4): 378-89.
BACKGROUND: Postoperative delirium is a frequent and serious complication in
elderly patients following operation for hip fracture, leading to an increased risk of
complications. The pathophysiological mechanisms are unresolved, but probably
multifactorial. The purpose of this review is to summarize current knowledge
about the pathogenesis of postoperative delirium with a view to finding strategies
for prevention and management. METHOD: We conducted an Internet search
through the Medline database (1966-March 2003) and supplemented it with a
manual search. We included 12 studies which specifically discussed pathogenic
factors or interventions against postoperative delirium following operation for hip
fracture. RESULTS: 1,823 patients were included with an average incidence of
delirium of 35%. We concentrated on pre-, intra-, and postoperative risk factors.
Only advanced age and dementia met our fixed criterion of "strong evidence" for
a significant association. Hence, from the studies that we reviewed we were
unable to find intraoperative or postoperative factors with "strong evidence" for a
significant association with delirium. INTERPRETATION: Postoperative delirium
is a serious complication. The pathophysiology leading to delirium after hip
fracture surgery still remains to be clarified and no single drug or surgical
regimen has proven to be preventive. This calls for more detailed investigations
of the differential role of different pathogenic mechanisms, as well as an
aggressive multimodal approach to enhance recovery and reduce morbidity, as
has proven to be successful in a variety of elective surgical procedures. Such
multimodal interventional studies represent a major task for orthopedic
departments in collaboration with anesthesiologists, geriatricians,
physiotherapists and nursing staff. Copyright 2004 Taylor & Francis [References:
53]
Ble, A., G. Zuliani, et al. (2001). "Cystocerebral syndrome: a case report and literature
review." Aging-Clinical & Experimental Research 13(4): 339-42.
Delirium is a frequent cause of hospitalization in the elderly patient, and can be
sustained by several factors, which are not always evident. In 1990 Blackburn
and Dunn described a clinical picture characterized by the presence of acute
urinary retention presenting as delirium, and named it "cystocerebral syndrome".
In 1991 Liem and Carter advanced a possible pathophysiological explanation for
this phenomenon, suggesting that adrenergic tension might increase in the
central nervous system when micturition cannot occur at the usual threshold. The
consequent increase in catecholamines level might produce delirium. We report
the case of a very old subject with delirium and acute urinary retention,
suggestive of the "cystocerebral syndrome", in order to call the attention of
geriatricians to acute urinary retention as a possible precipitating factor of
delirium. [References: 11]
Bobba, R. and E. Arsura (2004). "Cognitive decline in an elderly hospitalized patient
with primary leptomeningeal melanomatosis." Southern Medical Journal 97(11): 111820.
Delirium is one of the most common disorders in hospitalized patients. The
authors present the case of an elderly male patient with postoperative cognitive
decline that did not resolve with the conventional treatment. The diagnosis was
only established on autopsy. A 75-year-old man was evaluated after a fall. Initial
evaluation revealed voluntary guarding in the right epigastric region, and free air
was detected under the right hemidiaphragm on abdominal radiography. An
exploratory laparotomy revealed a perforation that had apparently sealed off.
After surgery, he had initial improvement toward baseline; however, after several
days, his postoperative course was complicated by a progressive deterioration in
mental status, recurrent seizures, and aspiration pneumonia. Computed
tomographic scan of the brain showed communicating hydrocephalus.
Examination of the cerebrospinal fluid revealed an elevated opening pressure
and elevated protein. His mental status continued to deteriorate, and he died.
Autopsy revealed the pathologic diagnosis of primary leptomeningeal
melanomatosis.
Bogardus, S. T., Jr., M. M. Desai, et al. (2003). "The effects of a targeted
multicomponent delirium intervention on postdischarge outcomes for hospitalized older
adults." American Journal of Medicine 114(5): 383-90.
PURPOSE: We sought to determine whether a multicomponent hospital-based
intervention targeted toward risk factors for delirium had any effect on patient
outcomes 6 months later. METHODS: We studied 705 patients aged 70 years or
older who had been enrolled in a controlled trial of a multicomponent intervention
at an academic medical center and who survived for at least 6 months after
hospitalization. Outcomes included self-rated health, functional status,
incontinence, depression, cognitive status, delirium, home health visits,
homemaker visits, rehospitalization, and nursing home placement. RESULTS:
Overall, there were no differences between the intervention and control groups
for any of the 10 outcomes, except that incontinence was slightly less common in
the intervention group (30% [103/344] vs. 37% [132/354], P = 0.02). Among highrisk patients, those in the intervention group had better self-rated health (among
those with poor/bad self-rated health at baseline, P <0.001) and better functional
status (among those with baseline functional impairment, P <0.001). There were
no effects in the other six high-risk subgroups, including cognitive and behavioral
outcomes (Folstein Mini-Mental State Examination, Geriatric Depression Scale,
incontinence, and delirium) and health care utilization. CONCLUSION: In the
group as a whole, we were unable to identify a lasting beneficial effect of the
multicomponent intervention, although further efforts to identify appropriate
subgroups for targeted interventions may be worthwhile. Other strategies are
needed after hospital discharge to deter deterioration in susceptible elderly
people. Copyright 2003 by Excerpta Medica Inc.
Bohner, H., T. C. Hummel, et al. (2003). "Predicting delirium after vascular surgery: a
model based on pre- and intraoperative data." Annals of Surgery 238(1): 149-56.
OBJECTIVE: The aim of the study was to determine pre- and intraoperative risk
factors for the development of postoperative delirium among patients undergoing
aortic, carotid, and peripheral vascular surgery to predict the risk for
postoperative delirium. SUMMARY BACKGROUND DATA: Although
postoperative delirium after vascular surgery is a frequent complication and is
associated with the need for more inpatient hospital care and longer length of
hospital stay, little is known about risk factors for delirium in patients undergoing
vascular surgery. METHODS: Pre-, intra-, and postoperative data were
prospectively collected, including the first 7 postoperative days with daily followup by a surgeon and a psychiatrist of 153 patients undergoing elective vascular
surgery. Delirium (Diagnostic and statistical Manual of Mental Disorders IV) was
diagnosed by the psychiatrist. Multivariate linear logistic regression and a cross
validation analysis were performed to find a set of parameters to predict
postoperative delirium. RESULTS: Sixty patients (39.2%) developed
postoperative delirium. The best set of predictors included the absence of
supraaortic occlusive disease and hypercholesterinemia, history of a major
amputation, age over 65 years, a body size of less than 170 cm, preoperative
psychiatric parameters and intraoperative parameters correlated to increased
blood loss. The combination of these parameters allows the estimation of an
individual patients' risk for postoperative delirium already at the end of vascular
surgery with an overall accuracy of 69.9%. CONCLUSIONS: Postoperative
delirium after vascular surgery is a frequent complication. A model based on preand intraoperative somatic and psychiatric risk factors allows prediction of the
patient's risk for developing postoperative delirium.
Bourgeois, J. A. and D. M. Hilty (2005). "Prolonged delirium managed with risperidone."
Psychosomatics 46(1): 90-1.
Brauer, C., R. S. Morrison, et al. (2000). "The cause of delirium in patients with hip
fracture." Archives of Internal Medicine 160(12): 1856-60.
OBJECTIVES: To ascertain the most common causes of delirium, to establish
the initiation and timing of delirium, and to determine the duration of delirium in
patients with hip fracture. METHODS: Five hundred seventy-one (88%) of 650
patients with hip fracture admitted to 4 New York City hospitals were
prospectively interviewed on a daily basis, 5 days a week, with the Confusion
Assessment Method for the presence of delirium. The patients were enrolled
within 48 hours of admission. Their medical charts and the data collected by the
study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.)
reviewed the case summaries independently and assigned a cause based on a
previously developed classification system, estimated the onset of the delirious
episode, and determined whether the delirium had cleared, improved, or
persisted at discharge. Subsequently, discrepancies in cause, timing of initiation,
and mental status on discharge between the 2 physicians reviewers were
discussed until consensus was reached. RESULTS: The prevalence of delirium
was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of
episodes were assigned a definite cause, 20% a probable cause, 11% a possible
cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight
(53%) of 54 subjects developed delirium after surgery. The delirium had cleared
or improved in 40 (74%) of 54 subjects at the time of discharge. CONCLUSIONS:
Delirium in patients with hip fracture appears to be a different syndrome from that
observed in patients who are otherwise medically ill; it also appears to follow a
different clinical course. These results have important implications for the
management of delirium in patients with hip fracture.
Breitbart, W., C. Gibson, et al. (2002). "The delirium experience: delirium recall and
delirium-related distress in hospitalized patients with cancer, their spouses/caregivers,
and their nurses." Psychosomatics 43(3): 183-94.
We conducted a systematic examination of the experience of delirium in a
sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria
for delirium and were rated with the Memorial Delirium Assessment Scale as a
measure of delirium severity, phenomenology, and resolution. Of the 154
patients assessed, 101 had complete resolution of their delirium and were
administered the Delirium Experience Questionnaire (DEQ-a face-valid measure
that assesses delirium recall and distress related to the delirium episode).
Spouse/caregivers and primary nurses were also administered the DEQ to
assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients
recalled their delirium experience. Logistic-regression analysis demonstrated that
short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR =
11.3), and the presence of perceptual disturbances (OR = 6.9) were significant
predictors of delirium recall. Mean delirium-related distress levels (on a 0-4
numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium,
3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis
demonstrated that the presence of delusions (OR = 7.9) was the most significant
predictor of patient distress. Patients with "hypoactive" delirium were just as
distressed as patients with "hyperactive" delirium. Karnofsky Performance Status
(OR = 9.1) was the most significant predictor of spouse/caregiver distress.
Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR
=3.6) were the most significant predictors of nurse distress. In conclusion, a
majority of patients with delirium recall their delirium as highly distressing.
Delirium is also a highly distressing experience for spouses/caregivers and
nurses who are caring for delirious patients. Prompt recognition and treatment of
delirium is critically important to reduce suffering and distress.
Breitbart, W., A. Tremblay, et al. (2002). "An open trial of olanzapine for the treatment of
delirium in hospitalized cancer patients." Psychosomatics 43(3): 175-82.
We conducted an open, prospective trial of olanzapine for the treatment of
delirium in a sample of 79 hospitalized cancer patients. Patients all met DSM-IV
criteria for a diagnosis of delirium and were rated systematically with the
Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity,
phenomenology, and resolution, over the course of a 7-day treatment period.
Sociodemographic and medical variables and measures of physical performance
status and drug-related side effects were collected. Fifty-seven patients (76%)
had complete resolution of their delirium on olanzapine therapy. No patients
experienced extrapyramidal side effects; however, 30% experienced sedation
(usually not severe enough to interrupt treatment). Several factors were found to
be significantly associated with poorer response to olanzapine treatment for
delirium, including age >70 years, history of dementia, central nervous system
spread of cancer and hypoxia as delirium etiologies, "hypoactive" delirium, and
delirium of "severe" intensity (i.e., MDAS >23). A logistic-regression model
suggests that age >70 years is the most powerful predictor of poorer response to
olanzapine treatment for delirium (odds ratio, 171.5). Olanzapine appears to be a
clinically efficacious and safe drug for the treatment of the symptoms of delirium
in the hospitalized medically ill.
Bucerius, J., J. F. Gummert, et al. (2004). "Predictors of delirium after cardiac surgery
delirium: effect of beating-heart (off-pump) surgery.[see comment]." Journal of Thoracic
& Cardiovascular Surgery 127(1): 57-64.
BACKGROUND: Despite improved outcomes after cardiac operations,
postoperative delirium remains a common complication that is associated with
increased morbidity and prolonged hospital stay. METHODS: Univariate and
multivariate predictors of postoperative delirium were determined from
prospectively gathered data on 16,184 patients undergoing cardiac operations
with cardiopulmonary bypass (conventional, n = 14,342) and without
cardiopulmonary bypass (beating-heart surgery, n = 1847) between April 1996
and August 2001. Delirium was defined as a transient mental syndrome of acute
onset characterized by global impairment of cognitive functions, a reduced level
of consciousness, attentional abnormalities, increased or decreased
psychomotor activity, and a disordered sleep-wake cycle. RESULTS: The overall
prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related
risk factors and treatment variables, 35 were highly associated with postoperative
delirium by univariate analysis. Stepwise logistic regression revealed the
following variables as independent predictors of delirium: history of
cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes
mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic
shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours
or more, and a high perioperative transfusion requirement. Two variables were
identified as having a significant protective effect against postoperative delirium:
beating-heart surgery and younger patient age. CONCLUSIONS: Postoperative
delirium is a common complication in cardiac operations. The increased use of
beating-heart surgery without cardiopulmonary bypass may lead to a lower
prevalence of this complication and thus improve patient outcomes.
Burns, S. M. (2003). "Delirium during emergence from anesthesia: a case study."
Critical Care Nurse 23(1): 66-9.
Caeiro, L., J. M. Ferro, et al. (2004). "Delirium in the first days of acute stroke." Journal
of Neurology 251(2): 171-8.
BACKGROUND AND PURPOSE: Delirium is an acute, transient disorder of
cognition and consciousness with fluctuating intensity. The aim of this study was
to investigate the presence and the risk factors for delirium in the first days after
stroke onset. PATIENTS AND METHODS: We assessed delirium prospectively
in a sample of 218 consecutive patients (mean age 57 years) with an acute (</=
4 days) stroke (28 subarachnoid haemorrhages, 48 intracerebral haemorrhages,
142 cerebral infarcts) and in a control group of 50 patients with acute coronary
syndromes with the Delirium Rating Scale (DRS) (cut-off score >/= 10).
RESULTS: 29 (13%) acute stroke patients (mean DRS score = 13.2, SD = 2.3)
and only one (2 %) acute coronary patient had delirium (chi(2) = 5.2, p = 0.02). In
nine patients delirium was secondary to stroke without any additional cause, in
10 patients there were also medical complications and in the remaining 10 there
were multiple potential causes for delirium. Delirium was more frequent after
hemispherical than after brainstem/cerebellum strokes (p = 0.02). No other
statistically significant associations with stroke locations were found. Medical
complications (OR = 4.3; 95% CI = 1.8 to 10.2), neglect (OR = 3.5; 95% CI = 1.3
to 9.2), intracerebral haemorrhage (OR = 3.1; 95% CI = 1.3 to 7.5) and age >/=
65 (OR = 2.4; 95% CI = 1.0 to 5.8) were independent factors to the development
of delirium in stroke patients. CONCLUSION: Delirium was more frequent in
stroke than in coronary acute patients. Among stroke patients, delirium was most
frequent in older patients, in those with neglect, with medical complications and
with intracerebral haemorrhages. These findings indicated that delirium in acute
stroke patients 1) is not a non-specific consequence of acute disease and
hospitalisation and 2) is secondary to hemisphere brain damage and to metabolic
disturbances due to medical complications.
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.
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.
Clayer, M. and J. Bruckner (2000). "Occult hypoxia after femoral neck fracture and
elective hip surgery." Clinical Orthopaedics & Related Research(370): 265-71.
The incidence of hypoxia after femoral neck and total hip arthroplasty was
investigated. In addition, the incidence of preoperative and postoperative delirium
was assessed. Oxygen saturation and mental status were tested before and after
surgery in patients undergoing surgery for a femoral neck fracture or total hip
arthroplasty. Hypoxia was present before surgery in five of 50 patients who
underwent total hip replacement and 17 of 50 patients with femoral neck
fractures. On Day 1 after surgery, 20 patients who underwent total hip
replacement and 36 with femoral neck fractures had hypoxia; on Day 3 after
surgery, 12 patients who underwent total hip replacement and 17 with femoral
neck fractures had hypoxia. Respiratory recovery was quicker in patients after
total hip replacement with 39 who recovered by Day 3 after surgery, compared
with 31 patients with femoral neck fractures. Preoperatively, patients with femoral
neck fracture had significantly lower mental test scores than did patients who had
undergone total hip replacement, and this continued on Day 1 after surgery.
However, by Day 3 after surgery, there was no significant difference between the
groups. Although the scores for the patients with femoral neck fractures were
lower, delirium developed in only three patients with total hip replacements and
six patients with femoral neck fracture. Hypoxia after hip surgery, particularly
after femoral neck fracture, is common. The incidence of delirium was much
lower than reported previously, and it is suggested that supplemental oxygen,
when indicated and monitored by pulse oximetry, was the cause for the reduction
in delirium.
Cobb, J. L., M. J. Glantz, et al. (2000). "Delirium in patients with cancer at the end of
life." Cancer Practice 8(4): 172-7.
PURPOSE: Delirium is a common and distressing syndrome seen in patients
with advanced cancer. Behavioral manifestations of delirium, such as agitation,
may result in medical intervention, stress to family caregivers, and inpatient
hospice admission. The purpose of this study was to examine the frequency,
characteristics, and presumed causes of delirium in patients with advanced
cancer. DESCRIPTION OF STUDY: Records of all patients with cancer who
were admitted to an inpatient hospice facility in 1995 were reviewed
retrospectively (N = 210). Patients were classified as delirious based on the
clinical judgment of the admitting physician. RESULTS: Delirium was the third
most common reason for admission (20%). Male gender (P =.04) and the
presence of a primary or metastatic brain tumor (P =.03) were significant risk
factors for delirium, while advanced age and primary or metastatic liver, lung, or
bone cancer were not. Resolution of the agitation, the most disruptive symptom
of delirium, occurred in 69% of patients before death or discharge. CLINICAL
IMPLICATIONS: Delirium is common in hospice patients with cancer and is an
important cause of family distress and increased cost of care. The recognition of
early clinical signs and predisposing factors should facilitate prompt diagnosis.
Appropriate intervention is usually successful in alleviating the most distressing
symptoms of delirium.
Cole, M. G., J. McCusker, et al. (2002). "Symptoms of delirium among elderly medical
inpatients with or without dementia." Journal of Neuropsychiatry & Clinical
Neurosciences 14(2): 167-75.
This study examined the frequencies of the 10 symptoms of delirium identified in
DSM-III-R among patients with delirium (DSM-III-R criteria) who did or did not
have dementia. The prevalence of each symptom, the numbers of symptoms,
and the combinations of symptoms were determined among 322 elderly medical
inpatients classified into one of four groups: delirium and dementia (n=128),
delirium only (n=40), dementia only (n=94), or neither (n=60). Symptoms were
assessed at the time of diagnosis and independently (by use of a different scale)
within 24 hours of diagnosis. Delirium appeared to be phenomenologically similar
among patients with and those without dementia, although patients with
dementia had more psychomotor agitation at the time of diagnosis and more
disorganized thinking and disorientation at the second assessment. [References:
30]
Contin, A. M., J. Perez-Jara, et al. (2005). "Postoperative delirium after elective
orthopedic surgery." International Journal of Geriatric Psychiatry 20(6): 595-7.
Culp, K. R., B. Wakefield, et al. (2004). "Bioelectrical impedance analysis and other
hydration parameters as risk factors for delirium in rural nursing home residents.[see
comment]." Journals of Gerontology Series A-Biological Sciences & Medical Sciences
59(8): 813-7.
BACKGROUND: The study investigators conducted a vigorous screening
protocol for delirium in rural long-term care (LTC) facilities for a period of 28 days
focusing on Bioelectrical Impedance Analysis (BIA) and other hydration
parameters as risk factors. METHODS: A two-stage cluster sampling procedure
was used to randomly select participants (n = 313) from 13 LTC facilities located
in southeastern Iowa, stratified on facility bed size. BIA was used to estimate
intracellular water (ICW), extracellular water (ECW), and total body water (TBW)
on four occasions--baseline and follow-up days 7, 14, and 28. Volume estimates
were calculated as a percent of body weight (%WT). Serum electrolytes and
hematology were also measured. Delirium was measured with four strict criteria:
a NEECHAM Confusion Scale score < 25, Vigilance "A" score > 2, a Mini-Mental
Status Examination < baseline, and a positive Confusion Assessment Method
score. RESULTS: There were n = 69 delirium cases (22.0%). Blood urea
nitrogen/creatinine ratios greater than 21:1 (odds ratio = 1.76, 95% confidence
interval 1.02-3.06). No significant risk for delirium was associated with ICW,
ECW, or TBW as a percent of body weight. CONCLUSIONS: Some changes
were observed with a slight decrease in ICW between day 7 and day 14 of
follow-up that tended to follow an increase in delirium events, but in general the
BIA measures did not predict delirium events. Copyright 2004 The Gerontological
Society of America
Dai, Y. T., M. F. Lou, et al. (2000). "Risk factors and incidence of postoperative delirium
in elderly Chinese patients." Gerontology 46(1): 28-35.
OBJECTIVES: To investigate the incidence of postoperative delirium among
elderly patients and to examine the interrelationship between basic vulnerability
and precipitating factors for delirium. DESIGN AND METHODS: This was a
prospective cohort study. Data were collected in a tertiary medical center in
Taipei, Taiwan. From the 1st to the 5th postoperative day, nurses assessed
patients using a confusion-screening tool. Patients with signs of delirium were
closely examined for changes in behavior and cognitive status and vital signs,
and laboratory data were collected to further validate the organic etiology of
delirium. Patients were finally diagnosed according to the DSM-IV criteria in
consensus meetings. SUBJECTS: Seven hundred and one elderly patients, that
were admitted consecutively for elective orthopedic or urologic surgery, were
enrolled in this study. All subjects met the following criteria: (1) 65 years of age or
older; (2) able to communicate orally in Chinese, and (3) not unconscious,
delirious, deaf, or aphasic upon admission. RESULTS: The overall incidence of
delirium among these subjects was 5.1%. Logistic regression analysis identified
that older age and preexisting cognitive impairment were vulnerability factors,
and that the use of psychoactive drugs was a precipitating factor for delirium.
Patients with both basic vulnerability and the precipitating factor had a 56-fold
increased probability of delirium (0.28 vs. 0.005 in comparison with those who did
not exhibit these factors). CONCLUSION: Few risk factors of postoperative
delirium in the older Chinese sample were identified. The only modifiable risk
factor appears to be the use of psychoactive drugs.
Daines, P. A. "Pain management at the end of life in a patient with renal failure." Cannt
Journal 14(2): 20-3.
Literature indicates that an essential element of a 'good' death is the absence of
pain. Achieving a pain-free death for the patient who discontinues dialysis is a
goal shared by patient, family and care providers. Pain management at end of life
can be challenging, especially in the setting of renal failure. Aspects of
assessment and pharmacological management of pain in the dying patient are
explored through the use of a case study. Through investment in ongoing
relationships with their patients, and striving to build knowledge and skills in pain
management, nephrology nurses promote excellence in end-of-life patient care.
[References: 24]
Dolan, M. M., W. G. Hawkes, et al. (2000). "Delirium on hospital admission in aged hip
fracture patients: prediction of mortality and 2-year functional outcomes.[see comment]."
Journals of Gerontology Series A-Biological Sciences & Medical Sciences 55(9): M52734.
BACKGROUND: Hip fracture patients are at increased risk of confusion or
delirium due to the trauma associated with the injury and the rapid progression to
hospitalization and surgery, in addition to the pain and loss of function
experienced. Hip fracture patients who develop delirium may require longer
hospital stays, are more often discharged to long-term care, and have a generally
poor prognosis for returning home or regaining function in activities of daily living
(ADL). METHODS: The present study examines the impact of delirium present
on hospital admission in a sample of 682 non-demented, aged hip fracture
patients residing in the community at the time of their fracture. In-hospital
assessments designed to assess both prefracture and postfracture functioning,
as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were
obtained from participants. RESULTS: Analyses indicate that baseline or
admission delirium is an important prognostic predictor of poor long-term
outcomes in persons without known cognitive impairment, after controlling for
age, gender, race, comorbidity, and functional status. Delirium at admission (i.e.,
prior to surgery) was associated with poorer functioning in physical, cognitive,
and affective domains at 6 months postfracture and slower rates of recovery.
Impairment and delays in recovery may be further exacerbated by increased
depressive symptoms in confused patients over time. Delirium on hospital
admission was not a significant predictor of mortality after adjustment for
confounding factors. CONCLUSIONS: The present findings further emphasize
the significance of immediate detection and treatment of delirium in hip fracture
patients to ameliorate the short and long-term effects of acute confusion on
functional outcomes.
Duppils, G. S. and K. Wikblad (2004). "Cognitive function and health-related quality of
life after delirium in connection with hip surgery. A six-month follow-up." Orthopaedic
Nursing 23(3): 195-203.
NEED: Delirium is a serious psychiatric disorder, and elderly patients who
undergo hip surgery are at higher risk for delirium development. PURPOSE: The
purpose was to compare change in cognitive function and health-related quality
of life 6 months after hip surgery in patients who experienced postoperative
delirium with those who did not. SAMPLE: A total of 115 patients 75 years or
older were included. MEASURES: Screening for delirium was done using the
Diagnostic and Statistical Manual, 4th ed criteria. Cognitive function was
measured with the Mini Mental State Examination and health-related quality of
life with the SF-36. RESULTS: Of the 115 patients, 32 became delirious during
hospital stay (D group), whereas the remaining patients did not (NonD group).
Both D and NonD groups scored lower on the Mini Mental State Examination at
follow-up than during hospital stay, but the deterioration was significantly greater
in the D group. At follow-up, health-related quality of life was improved in patients
who were destined for hip replacement surgery but unchanged or impaired for
those with hip fracture. Delirium onset in connection with hip fracture lowered the
health-related quality of life even more. At follow-up, low cognitive function
correlated with lower scoring in physical function. Greater knowledge about
delirious patients' vulnerable positions related to lower cognition and life quality
can improve rehabilitation and support for these patients.
Edelstein, D. M., G. B. Aharonoff, et al. (2004). "Effect of postoperative delirium on
outcome after hip fracture." Clinical Orthopaedics & Related Research(422): 195-200.
Nine-hundred twenty-one community-dwelling patients 65 years of age or older,
who sustained an operatively treated hip fracture from July 1, 1987 to June 30,
1998 were followed up for the development of postoperative delirium. The
outcomes examined in the current study were postoperative complication rates,
in-hospital mortality, hospital length of stay, hospital discharge status, 1-year
mortality rate, place of residence, recovery of ambulatory ability, and activities of
daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with
postoperative delirium. Patients who had delirium develop were more likely to be
male, have a history of mild dementia, and have had surgery under general
anesthesia. Patients who had postoperative delirium develop had a significantly
longer length of hospitalization. They also had significantly higher rates of
mortality at 1 year, were less likely to recover their prefracture level of
ambulation, and were more likely to show a decline in level of independence in
basic activities of daily living at the 1-year followup. There was no difference in
the rate of postoperative complications, in-hospital mortality, discharge
residence, and recovery of instrumental activities of daily living at 1 year.
Edlund, A., M. Lundstrom, et al. (2001). "Delirium before and after operation for femoral
neck fracture." Journal of the American Geriatrics Society 49(10): 1335-40.
OBJECTIVES: The aim of this study was to investigate the differences between
preoperative and postoperative delirium regarding predisposing, precipitating
factors and outcome in older patients admitted to hospital with femoral neck
fractures. DESIGN: A prospective clinical assessment of patients treated for
femoral neck fractures. SETTING: Department of orthopedic surgery at Umea
University Hospital, Sweden. PARTICIPANTS: One hundred one patients, age
65 and older admitted to the hospital for treatment of femoral neck fractures.
MEASUREMENTS: The Organic Brain Syndrome (OBS) Scale. RESULTS:
Thirty patients (29.7%) were delirious before surgery and another 19 (18.8%)
developed delirium postoperatively. Of those who were delirious preoperatively,
all but one remained delirious postoperatively. The majority of those delirious
before surgery were demented, had been treated with drugs with anticholinergic
properties (mainly neuroleptics), had had previous episodes of delirium, and had
fallen indoors. Patients who developed postoperative delirium had perioperative
falls in blood pressure and had more postoperative complications such as
infections. Male patients were more often delirious both preoperatively and
postoperatively. Patients with preoperative delirium were more often discharged
to institutional care and had poorer walking ability both on discharge and after 6
months than did patients with postoperative delirium only. CONCLUSIONS:
Because preoperative and postoperative delirium are associated with different
risk factors it is necessary to devise different strategies for their prevention.
Edlund, A., M. Lundstrom, et al. (1999). "Clinical profile of delirium in patients treated for
femoral neck fractures." Dementia & Geriatric Cognitive Disorders 10(5): 325-9.
The incidence of delirium, its predisposing factors, clinical profile, associated
symptoms and consequences were investigated in 54 consecutive patients, 19
men and 35 women, mean age 77.1 years, admitted to an 'ortho-geriatric unit'
with femoral neck fractures. The incidence of postoperative delirium was 15/54
(27.8%) and a logistic regression model found that dementia and a prolonged
waiting time for the operation increased the risk of postoperative delirium.
Delirium during the night was most common but in 5 patients the delirium was
worst in the morning. Patients with delirium suffered more anxiety, depressed
mood, emotionalism, delusions and hallucinations. A larger proportion of patients
with delirium could not return to their previous dwelling, and a larger proportion of
delirious patients were either dead, wheelchair-bound or bedridden at the 6month follow-up (p < 0.005). The conclusion is that delirium is common and has a
serious impact on the outcome after hip fracture surgery.
Eriksson, S. (1999). "Social and environmental contributants to delirium in the elderly."
Dementia & Geriatric Cognitive Disorders 10(5): 350-2.
Even if the mechanisms and etiology of delirium still require further clarification,
this article works on the assumption that delirium is caused by stress factors
acting on the brain to such an extent that the brain can no longer cope.
Therefore, social and environmental factors involving high levels of stress will
cause delirium in the elderly. The influence of these factors is obviously very
complex with several potential interacting mechanisms between different factors.
Since studies on this subject are limited to certain aspects of the complex topic
discussed, only narrowly focussed systematic knowledge on this topic is
available. However, it can be concluded that hospital admission for example is an
important risk factor for developing delirium.
Fann, J. R. (2002). "Neurological effects of psychopharmacological agents." Seminars
in Clinical Neuropsychiatry 7(3): 196-205.
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.
Fann, J. R., S. Roth-Roemer, et al. (2002). "Delirium in patients undergoing
hematopoietic stem cell transplantation." Cancer 95(9): 1971-81.
BACKGROUND: Delirium is common in patients with malignant disease and is
associated with significant morbidity. Studies have not examined the
epidemiology of delirium in patients undergoing hematopoietic stem cell
transplantation (HSCT). The objectives of this study were to determine the
prevalence, incidence, severity, and duration of delirium in the acute phase of
HSCT and to determine the pretransplantation risk factors for the occurrence and
severity of delirium during this period. METHODS: Ninety adult patients with
malignancies who were admitted to the Fred Hutchinson Cancer Research
Center for their first HSCT were assessed prospectively from 1 week
pretransplantation to 30 days posttransplantation. Delirium occurrence using the
Delirium Rating Scale (DRS) and severity using the Memorial Delirium
Assessment Scale (MDAS) were assessed three times per week.
Pretransplantation risk factors were assessed by patient self-report, charts, and
computerized records. RESULTS: The cumulative posttransplantation incidence
of delirium events (DRS score > 12) was 66 (73%), and the incidence of delirium
episodes (DRS score > 12 for 2 of 3 consecutive assessments) was 45 (50%).
The mean +/- standard deviation duration of delirium episodes was 4.8 +/- 2.8
assessments (approximately 10 days). Pretransplantation risk factors for having
a delirium episode were lower cognitive functioning (Trailmaking B test [a
standardized test of visual conceptual and visuomotor tracking and cognitive
flexibility]; P = 0.0008), higher blood urea nitrogen (P = 0.002), higher alkaline
phosphatase (P = 0.008), lower physical functioning (SF-12 [self report
questionnaire that is a general measure of functioning]; P = 0.03), and higher
magnesium (P = 0.03). Pretransplantation risk factors for higher delirium severity
scores were higher creatinine (P < 0.0001), the presence of total body irradiation
(P = 0.0001), higher magnesium (P = 0.0003), lower Mini-Mental State
Examination score (P = 0.002), malignancy diagnosis category (P = 0.002),
female gender (P = 0.008), higher alkaline phosphatase (P = 0.02), older age (P
= 0.03), and prior alcohol or drug abuse (P = 0.046). CONCLUSIONS: Half of
patients who undergo HSCT experience a delirium episode during the 4 weeks
posttransplantation. Pretransplantation risk factors can assist in identifying
patients who are more likely to develop delirium posttransplantation. Copyright
2002 American Cancer Society.
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, P., C. Charbonneau, et al. (2002). "Delirium in advanced cancer: a
psychoeducational intervention for family caregivers." Journal of Palliative Care 18(4):
253-61.
Delirium, a global brain dysfunction, develops frequently in advanced cancer. It is
a leading source of distress for family caregivers. Following recommendations
from palliative care professionals and caregivers for terminally ill cancer patients,
a psychoeducational intervention was implemented in a palliative care hospice to
help family caregivers cope with delirium and, eventually, to contribute to early
detection. Prior to receiving information on delirium, the majority of the family
caregivers did not know what it was or that it could be treated. Few knew that
patients in terminal care could become delirious. For caregivers, receiving the
intervention increased their confidence they were making good decisions, and
the majority felt that all family caregivers should be informed on the risk of
delirium (p < 0.009). A specific intervention on delirium, tailored to the needs of
the family caregivers, seems beneficial for caregivers and for patients.
Galanakis, P., H. Bickel, et al. (2001). "Acute confusional state in the elderly following
hip surgery: incidence, risk factors and complications." International Journal of Geriatric
Psychiatry 16(4): 349-55.
OBJECTIVE: To determine incidence and risk factors for the development of
postoperative acute confusional state (ACS) in the elderly. DESIGN: A
prospective cohort study. SETTING: University hospital. PATIENTS: One
hundred and five consecutive patients without ACS at baseline who underwent
hip surgery because of hip fracture or elective hip replacement. All patients were
60 years or older. MEASUREMENTS: All patients underwent preoperative and
daily postoperative evaluation by a research psychiatrist. Standardized
instruments were used for cognitive screening, baseline assessment of
depression, screening for alcohol abuse, comorbidity, and functional status. ACS
was diagnosed by using the Confusion Assessment Method (CAM). Additional
medical data were taken from patients' charts and anaesthetic records.
RESULTS: Postoperative ACS developed in 23.8% of the study sample, in
40.5% of the hip fracture group and in 14.7% of the hip joint replacement group.
The prevalence was highest between postoperative days 2 and 5. Multiple
logistic regression analysis demonstrated the following risk factors of ACS:
higher age (OR = 1.14, 95% CI 1.07-1.22), prior cognitive impairment as
measured by Mini-Mental State Examination (OR = 1.32 for each point less, 95%
CI 1.06-1.64), depression (OR = 3.67, 95% CI 1.12-12.02), low educational level
(OR = 3.59, 95% CI 1.14-11.25), and preoperative abnormal sodium (OR = 4.32,
95% CI 1.01-18.38). Other risk factors showing statistically significant differences
in the univariate analyses were: living in nursing home, vision or hearing
impairment, higher comorbidity, regular use of psychotropic drugs before
admission, fracture on admission, preoperative leucocytosis. A considerable
proportion of patients with ACS showed self-destructive behaviour
postoperatively, whereas self-destructive behaviour was not observed among
non-delirious patients. CONCLUSIONS: ACS is common among elderly hip
surgery patients. The occurrence of ACS is influenced by several predisposing
and precipitating factors. Further knowledge of these risk factors will contribute to
the early identification of high risk patients and to the development of preventive
measures. Copyright 2001 John Wiley & Sons, Ltd.
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.
George, J. and K. Rockwood (2004). "Dehydration and delirium--not a simple
relationship.[comment]." Journals of Gerontology Series A-Biological Sciences &
Medical Sciences 59(8): 811-2.
Gerrah, R., Y. Abramovitch, et al. (2001). "Traumatic memory: a cause for postoperative
delirium--a diagnostic dilemma." Israel Medical Association Journal: Imaj 3(11): 858-9.
Goy, E. and L. Ganzini "End-of-life care in geriatric psychiatry." Clinics in Geriatric
Medicine 19(4): 841-56.
Depression, anxiety and delirium are relatively common during the final stages of
terminal disease, and each can profoundly impact the quality of those last days
for both patient and involved family. In this article the authors review the
assessment and treatment of each syndrome in the context of palliative care for
older adults. Treatment of mental disorders at the end of life warrants special
consideration due to the need to balance the benefits of treatment against the
potential burden of the intervention, especially those that might worsen quality of
life. Dementia and the complications of depression and behavioral disturbance
within dementia are also discussed. Finally, caregivers of dying patients are
vulnerable to stress, depression, grief, and complicated bereavement.
Interventions for caregivers who are debilitated by these states are briefly
summarized. [References: 113]
Granberg Axell, A. I., C. W. Malmros, et al. (2002). "Intensive care unit
syndrome/delirium is associated with anemia, drug therapy and duration of ventilation
treatment." Acta Anaesthesiologica Scandinavica 46(6): 726-31.
BACKGROUND: We have performed a prospective qualitative investigation of
the ICU syndrome/delirium; the main parts of which have recently been
published. The aim of the present study was to explore the relationship between
the ICU syndrome/delirium and age, gender, length of ventilator treatment, length
of stay and severity of disease, as well as factors related to arterial oxygenation
and the amount of drugs used for sedation/analgesia. METHODS: Nineteen
mechanically ventilated patients who had stayed in the ICU for more than 36 h
were closely observed during their stay, and interviewed in depth twice after
discharge. Demographic, administrative and medical data were collected as a
part of the observation study. RESULTS: Patients with severe delirium had
significantly lower hemoglobin concentrations than those with moderate or no
delirium (P=0.033). Patients suffering from severe delirium spent significantly
longer time on the ventilator and at the ICU, and were treated with significantly
higher daily doses of both fentanyl (P=0.011) and midazolam (P=0.011) in
comparison with those reporting only moderate or no symptoms of delirium.
There were no significant differences in the Therapeutic Intervention Scoring
System scores, reflecting the degree of illness, between patients with and without
delirium. CONCLUSION: The development of the ICU syndrome/delirium seems
to be associated with decreased hemoglobin concentrations and extended times
on the ventilator. Prolonged ICU stays and treatment with higher doses of
sedatives and opioids in patients with delirium appear to be secondary
phenomena rather than causes.
Grega, M. A., L. M. Borowicz, et al. (2003). "Impact of single clamp versus double clamp
technique on neurologic outcome." Annals of Thoracic Surgery 75(5): 1387-91.
BACKGROUND: Atherosclerotic disease of the aorta has been identified as a
risk factor for neurologic complications following coronary artery bypass grafting
(CABG) due to the use of aortic clamping and manipulation. We reviewed a
change from double clamp to single clamp technique to determine its impact on
neurologic outcomes. METHODS: Patients undergoing isolated CABG by a
single surgeon were identified as having double clamp technique (DCT) (aortic
cross clamp + sidebiting clamp) or single clamp technique (SCT) (aortic cross
clamp only). Data were collected by study personnel and clinicians to determine
stroke and neurologic injury (confusion, delirium, seizure, altered mental status,
and agitation) outcomes for 461 patients. RESULTS: Two hundred seventy-two
patients had DCT and 189 patients had SCT performed. There were no
differences in mean age, previous stroke, hypertension, or diabetes.
Intraoperatively, patients with SCT had shorter bypass times (115 minutes vs 128
minutes, p = 0.001), longer aortic cross clamp time (89 minutes vs 80 minutes, p
= 0.001), fewer coronary grafts (2.8 vs 3.1, p = 0.001), and had higher mean
arterial blood pressure on cardiopulmonary bypass (76 mm Hg vs 69 mm Hg, p =
0.001). Postoperatively, the SCT group had fewer strokes (1.1% vs 2.9%, NS),
and neurologic injuries (3.2% vs 9.6%, p = 0.008). By multivariate analysis, the
factors that were related to neurologic injury were DCT (p = 0.04), age (p =
0.001), and number of coronary grafts (p = 0.03). CONCLUSIONS: This
experience suggests that the use of the SCT may be important in reducing
neurologic injury following CABG.
Guerini, F., C. Bellwald, et al. (2002). "An unusual case of spontaneous and remitting
functional decline in an elderly man: is "functional delirium" a clinical entity?" AgingClinical & Experimental Research 14(3): 221-2.
Gustafson, Y. (2004). "Postoperative delirium--a challenge for the orthopedic
team.[comment]." Acta Orthopaedica Scandinavica 75(4): 375-7.
Henry, M. (2002). "Descending into delirium.[see comment]." American Journal of
Nursing 102(3): 49-56; quiz 57.
Hix, J. K., W. E. Braun, et al. (2004). "Delirium in a renal transplant recipient associated
with BK virus in the cerebrospinal fluid." Transplantation 78(9): 1407-8.
Hughes, A. (2001). "Recognising the causes of delirium in older people." Nursing Times
97(33): 32-3.
Ignatavicius, D. (1999). "Resolving the delirium dilemma." Nursing 29(10): 41-6; quiz
N289.
Inouye, S. K. (2000). "Prevention of delirium in hospitalized older patients: risk factors
and targeted intervention strategies." Annals of Medicine 32(4): 257-63.
Delirium is a common, costly, and potentially devastating condition for
hospitalized older patients. Delirium is a multifactorial syndrome, involving the
inter-relationship between patient vulnerability, or predisposing factors at
admission, and noxious insults or precipitating factors during hospitalization.
Through a series of studies, we first identified significant predisposing factors for
delirium, including vision impairment, severe illness, cognitive impairment, and
dehydration. Subsequently, significant precipitating factors were identified,
including physical restraint use, malnutrition, adding more than three drugs,
bladder catheter use, and any iatrogenic event. Through targeting preventive
strategies towards six identified risk factors in a controlled clinical trial, we were
successful in the primary prevention of delirium. In 852 subjects, the incidence of
delirium was significantly reduced in the intervention group compared with usual
care (9.9% vs 15.0%, matched odds ratio: 0.60; 95% confidence interval: 0.390.92). The total number of days and episodes of delirium were also significantly
reduced in the intervention group. Based on this work, evidence-based
recommendations for delirium prevention are proposed. While not all cases of
delirium will be preventable with this approach, unifying medical and
epidemiological approaches to delirium represents a key advance essential to
reducing the high morbidity and mortality associated with delirium in the older
population.
Inouye, S. K. (2001). "Delirium after hip fracture: to be or not to be?[see
comment][comment]." Journal of the American Geriatrics Society 49(5): 678-9.
Inouye, S. K. (2004). "A practical program for preventing delirium in hospitalized elderly
patients." Cleveland Clinic Journal of Medicine 71(11): 890-6.
Delirium in hospitalized elderly patients is common and often unrecognized
(especially the hypoactive type), and can lead to serious complications. A
systematic program can improve the rate of recognition of this problem and
decrease its incidence, and is cost-effective. [References: 25]
Inouye, S. K., M. D. Foreman, et al. (2001). "Nurses' recognition of delirium and its
symptoms: comparison of nurse and researcher ratings." Archives of Internal Medicine
161(20): 2467-73.
BACKGROUND: Nurses play a key role in recognition of delirium, yet delirium is
often unrecognized by nurses. Our goals were to compare nurse ratings for
delirium using the Confusion Assessment Method based on routine clinical
observations with researcher ratings based on cognitive testing and to identify
factors associated with underrecognition by nurses. METHODS: In a prospective
study, 797 patients 70 years and older underwent 2721 paired delirium ratings by
nurses and researchers. Patient-related factors associated with underrecognition
of delirium by nurses were examined. RESULTS: Delirium occurred in 239 (9%)
of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in
only 19% of observations and 31% of patients compared with researchers.
Sensitivities of nurses' ratings for delirium and its key features were generally low
(15%-31%); however, specificities were high (91%-99%). Nearly all
disagreements between nurse and researcher ratings were because of
underrecognition of delirium by the nurses. Four independent risk factors for
underrecognition by nurses were identified: hypoactive delirium (adjusted odds
ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older
(OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and
dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses
increased with the number of risk factors present from 2% (0 risk factors) to 6%
(1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P(trend)<.001).
Patients with 3 or 4 risk factors had a 20-fold risk for underrecognition of delirium
by nurses. CONCLUSIONS: Nurses often missed delirium when present, but
rarely identified delirium when absent. Recognition of delirium can be enhanced
with education of nurses in delirium features, cognitive assessment, and factors
associated with poor recognition.
Johnson-Greene, D., K. M. Adams, et al. (2002). "Relationship between
neuropsychological and emotional functioning in severe chronic alcoholism." Clinical
Neuropsychologist 16(3): 300-9.
Previous studies of patients with severe chronic alcoholism have shown a high
prevalence of emotional distress such as anxiety and depression, and
neuropsychological impairments such as executive deficits, but few have
examined the relationship between these disorders. We addressed this issue in
51 abstinent patients with histories of severe chronic alcoholism utilizing the
Minnesota Multiphasic Personality Inventory (MMPI) and the Halstead-Reitan
Neuropsychological Test Battery (HRNTB). Applying factor analysis to the MMPI
clinical and validity scales, we derived four dimensions accounting for 78% of the
available variance. We found that Factor 1, which loaded on most clinical scales
of the MMPI, was significantly correlated (p <.01) with performance on the
Halstead Category Test (HCT), a measure of executive functioning. Further,
group analysis with MANOVA using HCT (impaired and nonimpaired) as the
independent variable revealed a significant main effect for Factor 1 (p <.004),
which was maintained and strengthened when age and education were
controlled as covariates (p <.001). The results suggest a relationship between
emotional distress and executive functioning as measured by the HCT, reflecting
differing facets of frontal lobe dysfunction common to cognitive and affective
domains in patients with severe chronic alcoholism.
Justic, M. (2000). "Does "ICU psychosis" really exist?[see comment]." Critical Care
Nurse 20(3): 28-37; quiz 38-9.
In summary, ICU psychosis does not develop in all patients. Instead, many
patients are at risk for hypoactive, hyperactive, or mixed hypoactive and
hyperactive delirium. Prevention of delirium should always be foremost, including
recognition of patients at high risk, minimal use of causative medications, and
treatment of physiological conditions that are often unrelated to a patient's
admitting diagnosis. When prevention fails, early diagnosis and treatment can
make a marked difference in patients' outcomes. The potential adverse outcomes
of delirium are well documented. These include increased mortality; increased
length of stay; reduced level of functioning in the elderly, which often leads to
placement in a nursing home; and stress response syndrome after
hospitalization. The value of nursing in preventing delirium is evident when
nurses apply their knowledge of potential causes and develop strategies to avoid
these causes in their patients. Nurses provide early detection and coordinate with
other members of the healthcare team to initiate a plan of care that includes
prompt treatment of delirium to reduce the signs and symptoms, duration, and
potential adverse sequelae of this disorder. Nursing interventions are designed to
enhance patients' cognitive status, sense of security, safety, and comfort. Nurses
are instrumental in providing appropriate choices, doses, and administration of
medications and in recognizing side effects. Use of medications ordered to treat
delirium is often left to nurses' discretion because the orders specify that the
drugs should be given as needed. Finally, nurses are the ones who recognize the
need for additional assistance via psychiatric consultations or for more intensive
observation and management of patients to ensure quality care. [References: 48]
Kobayashi, K., M. Higashima, et al. (2004). "Severe delirium due to basal forebrain
vascular lesion and efficacy of donepezil." Progress in Neuro-Psychopharmacology &
Biological Psychiatry 28(7): 1189-94.
A severe intractable delirium caused by the basal forebrain vascular lesion and
its dramatic recovery after donepezil administration were reported. A 68-year-old
man had suffered for a month from delirium of mixed type caused by the right
basal forebrain vascular lesion after surgery for craniopharyngioma. Magnetic
resonance imaging (MRI) showed hemorrhagic infarcts in the head of the right
caudate nucleus and the right basal forebrain of the medial septal nucleus,
diagonal band of Broca and nucleus basalis of Meynert. He had been treated
with anti-psychotics, anti-depressants and hypnotics, which resulted in little
improvement. Donepezil administration dramatically improved his intractable
delirium at the 19th post-donepezil administration day, but this was followed by
amnestic symptoms. Clinical correlates of delirium with the basal forebrain lesion
and efficacy of donepezil support the hypocholinergic theory of delirium.
Kung, S., P. S. Mueller, et al. (2002). "Delirium resulting from paraneoplastic limbic
encephalitis caused by Hodgkin's disease." Psychosomatics 43(6): 498-501.
Kunimatsu, T., T. Misaki, et al. (2004). "Postoperative mental disorder following
prolonged oral surgery." Journal of Oral Science 46(2): 71-4.
A prolonged period of oral surgery is a potential risk factor of postoperative
mental disorders although no such report has been published to date. We
retrospectively studied perioperative features in 36 patients who underwent
prolonged (10 hours or more) of oral surgery. Patients were categorized as predelirium (Pre-D) when they manifested 1 or 2 symptoms and delirium (D) when
they showed more than 2 symptoms, according to the modified International
Classification of Diseases, 10th edition. Of the 36 patients who returned to a
normal mental state without drug therapy, 13 were classified as D and 14 were
Pre-D. A number of patients had moderate complications preoperatively, and
massive hemorrhaging occurred during the operation in some Pre-D and D
patients. Age was greater in D (62.0 +/- 9.9 years) than in Pre-D (56.0 +/- 13.8
years) patients. Propofol-based general anesthesia was most commonly
employed. The time prior to appearance of pre-delirium was significantly shorter
in D (30.0 +/- 16.7 hours) than in Pre-D (55.0 +/- 35.0 hours) group patients. Our
results indicate that, in general, patients predisposed to postoperative mental
disorders have moderate complications preoperatively, are generally older than
50-years-old, receive propofol-based general anesthesia and/or experience a
massive hemorrhage during the operation.
Lawlor, P. G., B. Gagnon, et al. (2000). "Occurrence, causes, and outcome of delirium
in patients with advanced cancer: a prospective study.[see comment]." Archives of
Internal Medicine 160(6): 786-94.
CONTEXT: Delirium impedes communication and contributes to symptom
distress in patients with advanced cancer. There are few prospective data on the
reversal of delirium in this population. OBJECTIVES: To evaluate the occurrence,
precipitating factors, and reversibility of delirium in patients with advanced
cancer. DESIGN: Prospective serial assessment in a consecutive cohort of 113
patients with advanced cancer. Precipitating factors were examined using
standardized criteria; 104 patients met eligibility criteria. SETTING: Acute
palliative care unit in a university-affiliated teaching hospital. MAIN OUTCOME
MEASURES: Delirium occurrence and reversal rates, duration, and patient
survival. Strengths of association of various precipitating factors with reversal
were expressed as hazard ratios (HRs) in univariate and multivariate analyses.
RESULTS: On admission, delirium was diagnosed in 44 patients (42%), and of
the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred
in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%)
of the 52 deaths. In univariate analysis, psychoactive medications, predominantly
opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration
(HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic
encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44;
95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate
analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic
encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR,
0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium
had poorer survival rates than controls (P<.001). CONCLUSIONS: Delirium is a
frequent, multifactorial complication in advanced cancer.Despite its terminal
presentation in most patients, delirium is reversible in approximately 50% of
episodes. Delirium precipitated by opioids and other psychoactive medications
and dehydration is frequently reversible with change of opioid or dose reduction,
discontinuation of unnecessary psychoactive medication, or hydration,
respectively.
Lewis, M. C. and S. R. Barnett (2004). "Postoperative delirium: the tryptophan
dyregulation model." Medical Hypotheses 63(3): 402-6.
A model previously presented by Uchida in this journal [Med. Hypotheses 53
(1997) 103] described a mechanism for postoperative delirium. It described an
increased level of melatonin resulting in a central "serotonin shortage". This
construct adequately explained only the hypoactive type of delirium. Recently it
has been shown that a reduction in urinary metabolites of melatonin is
associated with hyperactive delirium, whereas urinary metabolites were
increased in the hypoactive variant. These findings suggest that this initial
paradigm requires modification. We propose that both the agitation seen in
hyperactive delirium, and the somnolence associated with the hypoactive form
could be explained by a disturbance of central tryptophan homeostasis. It is
postulated that intervention in the form of melatonin administration may restore
tryptophan levels, and prevent delirium. Copyright 2004 Elsevier Ltd.
Litaker, D., J. Locala, et al. (2001). "Preoperative risk factors for postoperative
delirium.[see comment]." General Hospital Psychiatry 23(2): 84-9.
The objective of this article was to estimate the incidence of delirium in a sample
of patients undergoing elective surgery and to identify the preoperative factors
most closely associated with developing this complication. Consecutive patients
(n=500) underwent a full preoperative medical evaluation including assessment
of cognitive and functional status. Daily evaluation on postoperative days 1
through 4 included medical record review and direct standardized patient
interviews. Logistic regression was used to explore the associations between
preoperative factors and postoperative delirium. Delirium was detected in 57
(11.4%) patients. Univariate factors associated with delirium included age> or
=70 years (RR=3.1 [1.75,5.55]), preexisting cognitive impairment (RR=3.1 [1.73,
5.43]), greater preoperative functional limitations (RR=1.57 [1.27, 1.94]), and a
history of prior delirium (RR 4.1 [1.98 to 8.27]. Adjusting for other factors,
previous delirium (OR=4.08 [1.85, 9.0]), age> or =70 years (OR=3.2 [1.6, 6.0],
and preexisting cognitive impairment (OR=2.16 [1.15, 4.0] remained predictive of
delirium. Patients' perceptions that alcohol had affected their health (OR=6.53
[1.58 to 28.1]) and use of narcotic analgesics just prior to admission (OR=2.7
[1.37 to 5.3]) were also significantly associated with delirium postoperatively.
Several easily obtained preoperative clinical factors can be used to identify
patients at risk for postoperative delirium. This approach, when combined with
specialized delirium teams using established guidelines, may be more effective in
targeting patients at risk, thus reducing the number of episodes and days of
delirium.
Ljubisavljevic, V. and B. Kelly (2003). "Risk factors for development of delirium among
oncology patients." General Hospital Psychiatry 25(5): 345-52.
To determine the occurrence of delirium in oncology inpatients and to identify
and evaluate admission characteristics associated with the development of
delirium during inpatient admission, a prospective observational study was
conducted of 113 patients with a total of 145 admissions with histological
diagnosis of cancer admitted to the oncology unit over a period of ten weeks. At
the point of inpatient admission, all patients were assessed for the presence of
potential risk factors for development of delirium. During the index admission
patients were assessed daily for the presence of delirium using the Confusion
Assessment Method. Delirium was confirmed by clinician assessment. Delirium
developed in 26 of 145 admissions (18%) and 32 episodes of delirium were
recorded with 6 patients having 2 episodes of delirium during the index
admission. Delirium occurred on average 3.3 days into the admission. The
average duration of an episode of delirium was 2.1 day. Four patients with
delirium (15%) died. All other cases of delirium were reversed. Factors
significantly associated with development of delirium on multivariate analysis
were: advanced age, cognitive impairment, low albumin level, bone metastases,
and the presence of hematological malignancy. Hospital inpatient admission was
significantly longer in delirium group (mean: 8.8 days vs 4.5 days in nondelirium
group, P<.01). Delirium among hospitalized oncology patients is a common
condition. Identification of risk factors to delirium at the time of inpatient
admission can be used to recognize those patients at the greatest risk and may
aid prevention, early detection and treatment.
Marcantonio, E., T. Ta, et al. (2002). "Delirium severity and psychomotor types: their
relationship with outcomes after hip fracture repair." Journal of the American Geriatrics
Society 50(5): 850-7.
OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as
a measure of delirium severity in a cohort of patients aged 65 and older; to
examine the association between severity of delirium and patient outcomes; and
to examine the association between psychomotor variants of delirium and each
of those outcomes. DESIGN: Prospective assessment of sample. SETTING:
Hospital. PARTICIPANTS: One hundred twenty-two older patients (mean age +/standard deviation = 79 +/- 8) who had undergone acute hip fracture surgery.
MEASUREMENTS: We used standardized instruments to assess prefracture
activities of daily living (ADLs), ambulatory status, cognition, and living situation.
Postoperatively, each patient was interviewed daily. Delirium was diagnosed
using the Confusion Assessment Method (CAM), and delirium severity was
measured using the MDAS. The MDAS was also used to categorize the
psychomotor types of delirium into "purely hypoactive" or "any hyperactivity."
Telephone or face-to-face interviews were conducted at 1 and 6 months to
assess survival, ADL function, ambulatory status, and living situation. RESULTS:
Of 122 patients, 40% developed CAM-defined delirium. Delirious patients had
higher average MDAS scores than nondelirious patients (11.7 vs 2.4, P <.0001).
We used the median of the average MDAS score to classify patients into mild or
severe delirium. Severe delirium was generally associated with worse outcomes
than was mild delirium, and the associations reached statistical significance for
nursing home placement or death at 6 months (52% vs 17%, P =.009).
Additionally, patients who did not meet full CAM criteria for delirium experienced
worse outcomes if they had some symptoms of delirium than if they had no or
few symptoms (nursing home placement or death at 6 months: 27% vs 0%, P
=.001). Surprisingly, these patients with subsyndromal delirium who did not fulfill
CAM criteria for delirium but demonstrated significant delirium symptoms, had
outcomes similar to or worse than those with mild CAM-defined delirium. Pure
hypoactive delirium accounted for 71% (34/48) of cases and was less severe
than was delirium with any hyperactivity (average MDAS score 10.6 vs 14.8, P
=.007). In our cohort, patients with pure hypoactive delirium had better outcomes
than did those with any hyperactivity (nursing home placement or death at 1
month: 32% vs 79%, P =.003); this difference persisted after adjusting for
severity. CONCLUSION: In this study of delirium in older hip fracture patients,
the MDAS, a continuous severity measure, was a useful adjunct to the CAM, a
dichotomous diagnostic measure. In patients with CAM-defined delirium, severe
delirium was generally associated with worse outcomes than was mild delirium.
In patients who did not fulfill CAM criteria, subsyndromal delirium was associated
with worse outcomes than having few or no symptoms of delirium. Patients with
subsyndromal delirium had outcomes similar to patients with mild delirium,
suggesting that a dichotomous approach to diagnosis and management may be
inappropriate. Pure hypoactive delirium was more common than delirium with
any hyperactive features, tended to be milder, and was associated with better
outcomes even after adjusting for severity. Future studies should confirm our
preliminary associations and examine whether treatment to reduce the severity of
delirium symptoms can improve outcomes after hip fracture repair.
Marcantonio, E. R., J. M. Flacker, et al. (2000). "Delirium is independently associated
with poor functional recovery after hip fracture." Journal of the American Geriatrics
Society 48(6): 618-24.
OBJECTIVE: To evaluate the role of delirium in the natural history of functional
recovery after hip fracture surgery, independent of prefracture status. DESIGN:
Prospective cohort study. SETTING: Orthopedic surgery service at a large
academic tertiary hospital, with follow-up extending into rehabilitation hospitals,
nursing homes, and the community. PARTICIPANTS: One hundred twenty-six
consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women)
admitted emergently for surgical repair of hip fracture. MEASUREMENTS:
Detailed assessment at enrollment to ascertain prefracture status through
interviews with the patient and designated proxy and review of the medical
record. Interviews included administration of standardized instruments (Activities
of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom
Interview) and assessment of ambulation, and prefracture living situation.
Medical comorbidity, the nature of the hip fracture, and the surgical repair were
obtained from the medical record. All subjects underwent daily interviews for the
duration of the hospitalization, including the Mini-Mental State Examination and
Delirium Symptom Interview, and delirium was diagnosed using the Confusion
Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6
months after fracture, and underwent interviews similar to those at enrollment to
determine death, persistent delirium, decline in ADL function, decline in
ambulation, or new nursing home placement. RESULTS: Delirium occurred in
52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge,
15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or
older, and those with prefracture cognitive impairment, ADL functional
impairment, and high medical comorbidity were more likely to develop delirium.
However, after adjusting for these factors, delirium was still significantly
associated with outcomes indicative of poor functional recovery 1 month after hip
fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI),
1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new
nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium
persisted at 1 month had worse outcomes than those whose delirium had
resolved. CONCLUSIONS: Delirium is common, persistent, and independently
associated with poor functional recovery 1 month after hip fracture even after
adjusting for prefracture frailty. Further research is necessary to identify the
mechanisms by which delirium contributes to poor functional recovery, and to
determine whether interventions designed to prevent or reduce delirium can
improve recovery after hip fracture.
Marshall, M. C. and M. D. Soucy (2003). "Delirium in the intensive care unit." Critical
Care Nursing Quarterly 26(3): 172-8.
Delirium in the intensive care unit (ICU) is a complex, common, and problematic
condition that interferes with healing and recovery. It leads to higher morbidity
and mortality and extended hospital stays. The aging population older than 65,
and more likely to develop delirium, is the fastest growing population in the
United States and is increasingly seen in the ICU. Delirium is often unrecognized
and misdiagnosed, which leads to mistreatment or lack of appropriate treatment.
This article discusses the definition of delirium, pathogenesis, clinical practice
guidelines, newer assessment tools for ICU, and nursing interventions directed
toward prevention and early identification of delirium. [References: 30]
McCusker, J., M. Cole, et al. (2001). "Environmental risk factors for delirium in
hospitalized older people." Journal of the American Geriatrics Society 49(10): 1327-34.
OBJECTIVES: To evaluate the relationship of environmental risk factors in
hospitals to changes over time in delirium symptom severity scores. DESIGN:
Observational prospective clinical study with repeated measurements, several
times during the first week of hospitalization and then weekly during
hospitalization. SETTING: University-affiliated general community hospital.
PARTICIPANTS: Four hundred forty-four patients age 65 and older admitted to
the medical wards: 326 with delirium and 118 without delirium. Patients with prior
cognitive impairment were oversampled. MEASUREMENTS: The severity of
delirium symptoms was measured with the Delirium Index, a scale developed
and validated by our group, based on the Confusion Assessment Method.
Potential environmental risk factors assessed included isolation, hospital unit,
room changes, levels of sensory stimulation, aids to orientation, and presence of
medical (e.g., intravenous) or physical restraints. RESULTS: Controlling for initial
severity of delirium and patient characteristics, variables significantly related to
an increase in delirium severity scores included hospital unit (intensive care or
long-term care unit), number of room changes, absence of a clock or watch,
absence of reading glasses, presence of a family member, and presence of
medical or physical restraints. CONCLUSION: The associations of intensive care
and medical and physical restraints with severity of delirium symptoms may be
due to uncontrolled confounding by indication. However, the other factors
identified suggest potentially modifiable risk factors for symptoms of delirium in
hospitalized older people.
McMullin, N. and J. Queen (2004). "A construction worker with recent confusion,
disorientation, and somnolence." Cleveland Clinic Journal of Medicine 71(10): 809-14.
McNicoll, L., M. A. Pisani, et al. (2003). "Delirium in the intensive care unit: occurrence
and clinical course in older patients." Journal of the American Geriatrics Society 51(5):
591-8.
OBJECTIVES: To describe the occurrence of delirium in a cohort of older
medical intensive care unit (ICU) patients and its short-term duration in the
hospital and to determine the association between preexisting dementia and the
occurrence of delirium. DESIGN: Prospective cohort study. SETTING: Fourteenbed medical ICU of an 800-bed university teaching hospital. PARTICIPANTS:
One hundred eighteen consecutive patients aged 65 and older admitted to the
ICU. MEASUREMENTS: Baseline characteristics were obtained through
surrogate interviews and medical chart review. Dementia was determined using
two validated surrogate-rated instruments. Delirium was assessed daily in the
ICU using the Confusion Assessment Method (CAM) for the ICU (CAM-ICU).
After discharge from the ICU, patients were followed for up to 7 days using the
CAM. RESULTS: Delirium was present in 37 of 118 (31%) patients on admission.
Only 45 patients had a normal mental status on admission, of whom 14 (31%)
became delirious during their hospital stay. In the post-ICU period, delirium
occurred in 40% of patients. Almost half of patients with delirium in the ICU had
persistent delirium in the post-ICU period. Overall, 83 of 118 (70%) had delirium
during hospitalization. Stupor or coma occurred in 44% of the patients overall,
and 89% of survivors of stupor/coma progressed to delirium. Patients with
dementia were 40% more likely to be delirious (relative risk = 1.4, 95%
confidence interval = 1.1-1.7), even after controlling for comorbidity, baseline
functional status, severity of illness, and invasive procedures. CONCLUSION:
Delirium is a frequent complication in older ICU patients and often persists
beyond their ICU stay. Delirium in older ICU persons is a dynamic and complex
process. Dementia is an important predisposing risk factor for the development of
delirium in this population during and after the ICU stay.
Meagher, D. J. (2001). "Delirium: optimising management.[see comment]." BMJ
322(7279): 144-9.
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.
Milisen, K., M. D. Foreman, et al. (2001). "A nurse-led interdisciplinary intervention
program for delirium in elderly hip-fracture patients.[see comment]." Journal of the
American Geriatrics Society 49(5): 523-32.
OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary
intervention program for delirium on the incidence and course (severity and
duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and
length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective
before/after design (sequential design). SETTING: The emergency room and two
traumatological units of an academic medical center located in an urban area in
Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females,
median age = 82, interquartile range (IQR) = 13) and another 60 patients in a
usual care/nonintervention cohort (80% females, median age = 80, IQR = 12).
INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive
screening, (3) consultative services by a delirium resource nurse, a geriatric
nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain
protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as
measured by the Confusion Assessment Method (CAM). Severity of delirium was
assessed using a variant of the CAM. Cognitive and functional status were
measured by the Mini-Mental State Examination (MMSE) (including subscales of
memory, linguistic ability, concentration, and psychomotor executive skills) and
the Katz Index of activities of daily living (ADLs), respectively. RESULTS:
Although there was no significant effect on the incidence of delirium (23.3% in
the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was
shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention
cohort. Further, clinically higher cognitive functioning was observed for the
delirious patients in the intervention cohort compared with the nonintervention
cohort. Additionally, a trend toward decreased length of stay postoperatively was
noted for the delirious patients in the intervention cohort. Despite these positive
intervention effects, no effect on ADL rehabilitation was found. Results for risk of
mortality were inconclusive. CONCLUSIONS: This study demonstrated the
beneficial effects of an intervention program focusing on early recognition and
treatment of delirium in older hip-fracture patients and confirms the reversibility of
the syndrome in view of the delirium's duration and severity.
Milisen, K., M. D. Foreman, et al. (2002). "Documentation of delirium in elderly patients
with hip fracture.[see comment]." Journal of Gerontological Nursing 28(11): 23-9.
This study determined the accuracy of diagnosis and documentation of delirium
in the medical and nursing records of 55 elderly patients with hip fracture (mean
age = 78.4, SD = 8.4). These records were reviewed retrospectively on a
patient's discharge for diagnosis of delirium, and for description of clinical
indicators or symptoms of delirium. Additionally, all patients were monitored by
one of the research members on days 1, 3, 5, 8, and 12 postoperatively for signs
of delirium, as measured by the Confusion Assessment Method (CAM).
Clinicians were blinded to the purpose of the study. According to the CAM
criteria, the incidence of delirium was 14.5% on postoperative Day 1; 9.1% on
postoperative Day 3; 10.9% on postoperative Day 5; 7.7% on postoperative Day
8; and 5.6% on postoperative Day 12. For those same days, no formal diagnosis
of delirium or a description of clinical indicators was found in the medical records.
In the nursing records, a false-positive documentation of 8.5%, 4%, 4.1%, 4.2%,
and 5.9%, respectively was noted. False-negative documentation was found in
87.5%, 80%, 66.7%, 75%, and 50% of the cases on the respective days.
Documentation of essential symptoms--namely onset and course of the
syndrome--and disturbances in consciousness, attention, and cognition, were
seldom or never found in the nursing records. However, behaviors of the
hyperactive variant of delirium and which are known to interfere with nursing care
were documented more often (e.g., 13.4% restless, 10.3% fidget with materials,
7.2% annoying behavior). Both medical and nursing records showed poor
documentation and under-diagnosis of delirium. However, a correct diagnosis
and early recognition of delirium may enhance the management of this
syndrome.
Milisen, K., E. Steeman, et al. (2004). "Early detection and prevention of delirium in
older patients with cancer." European Journal of Cancer Care 13(5): 494-500.
Delirium poses a common and multifactorial complication in older patients with
cancer. Delirium independently contributes to poorer clinical outcomes and
impedes communication between patients with cancer, their family and health
care providers. Because of its clinical impact and potential reversibility, efforts for
prevention, early recognition or prompt treatment are critical. However, nurses
and other health care providers often fail to recognize delirium or misattribute its
symptoms to dementia, depression or old age. Yet, failure to determine an
individual's risk for delirium can initiate the cascade of negative events causing
additional distress for patients, family and health care providers alike. Therefore,
parameters for determining an individual's risk for delirium and guidelines for the
routine and systematic assessment of cognitive functioning are provided to form
a basis for the prompt and accurate diagnosis of delirium. Guidelines for the
prevention and treatment of delirium are also discussed.
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.
Moretti, R., P. Torre, et al. (2004). "Cholinesterase inhibition as a possible therapy for
delirium in vascular dementia: a controlled, open 24-month study of 246 patients."
American Journal of Alzheimer's Disease & Other Dementias 19(6): 333-9.
The goal of this study was to determine whether rivastigmine, a dual inhibitor of
acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), has any effect
on delirium in vascular dementia (VaD). The results from this follow-up study
suggest that although delirium is frequent in elderly, cognitively impaired patients,
it might not be a simple consequence of acute disease and hospitalization.
Rather, delirium can be secondary to brain damage and to metabolic
disturbances. According to the Lewy body dementia model, delirium could be
induced by a lack of acetylcholine in the brain. Rivastigmine may help reduce the
frequency of delirium episodes and help shorten their duration. Additional studies
are required to better define the causes of delirium, which currently has no
definitive treatment.
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.
Morita, T., Y. Tei, et al. (2003). "Impaired communication capacity and agitated delirium
in the final week of terminally ill cancer patients: prevalence and identification of
research focus." Journal of Pain & Symptom Management 26(3): 827-34.
The maintenance of intellectual activity is an important area in the "good death"
concept. To clarify the communication capacity levels of terminally ill cancer
patients in their final week, and to identify factors contributing to the development
of communication capacity impairment and agitated delirium, a retrospective
study was performed on 284 consecutive hospice inpatients. The data were
collected by chart review, and two independent raters measured the degree of
communication capacity and agitation in the last week, using multiple items from
the Memorial Delirium Assessment Scale, the Communication Capacity Scale,
and the Agitation Distress Scale. The percentages of patients who could achieve
complex communication were 43%, 28%, and 13% at 5 days, 3 days, and 1 day
before death, respectively. Agitated delirium was identified in 20%. Patients
receiving opioids at a dose of > or =120 mg oral morphine equivalents/day one
week before death were significantly unable to communicate clearly 3 days
before death (0.48 [0.28-0.84], P=0.011). Male gender and the presence of
icterus were identified as significant contributors to the development of agitated
delirium (odds ratios [95% C.I.]=2.6 [1.4-5.0], P<0.01; 2.4 [1.3-4.4], P< 0.01).
These findings demonstrate that communication capacity impairment and
agitated delirium are frequently observed in terminally ill cancer patients, and are
significantly correlated with a higher dose requirement of opioids and the
presence of icterus. To explore the best management to maintain the intellectual
activity of dying patients, research should focus on a homogeneous sample of
patients receiving high-dose opioids and those with hepatic encephalopathy. In
the meanwhile, clinicians should educate patients and family members about the
nature of the dying process and help facilitate the completion of life purposes
requiring complex mental activities before the latest stages of cancer.
Morita, T., Y. Tei, et al. (2001). "Underlying pathologies and their associations with
clinical features in terminal delirium of cancer patients." Journal of Pain & Symptom
Management 22(6): 997-1006.
Delirium is a common complication in terminally ill cancer patients. Identification
of underlying pathologies and prediction of clinical features may improve effective
symptom alleviation. This study aims to clarify precipitating factors and their
associations with clinical features of terminal delirium. Consecutive hospice
inpatients who developed delirium were prospectively evaluated following a
structured protocol. Among 237 patients followed until death, 245 episodes of
delirium were identified in 213 patients. Precipitating factors for delirium were
disclosed in 93% of the 153 cases in which investigations were completed. Mean
number of etiologies was 1.8 +/- 1.1 per patient, and two or more factors were
recognized in 52%. The main pathologies identified were hepatic failure,
medications, prerenal azotemia, hyperosmolality, hypoxia, disseminated
intravascular coagulation, organic damage to the central nervous system,
infection, and hypercalcemia. Occurrence of hyperactive delirium and the
requirement for symptomatic sedation significantly correlated with hepatic failure,
opioids, and steroids, while dehydration-related pathologies were significantly
associated with hypoactive delirium. Complete recovery was frequently achieved
in cases with medication- and hypercalcemia-induced delirium, whereas a low
remission rate was related to hepatic failure, dehydration, hypoxia, and
disseminated intravascular coagulation. In conclusion, standard examinations
can confirm factors potentially contributing to delirium and thereby predict the
severity of agitation and clinical outcomes.
Morrison, R. S., J. Magaziner, et al. (2003). "Relationship between pain and opioid
analgesics on the development of delirium following hip fracture." Journals of
Gerontology Series A-Biological Sciences & Medical Sciences 58(1): 76-81.
BACKGROUND: Delirium and pain are common following hip fracture. Untreated
pain has been shown to increase the risk of delirium in older adults undergoing
elective surgery. This study was performed to examine the relationship among
pain, analgesics, and other factors on delirium in hip fracture patients.
METHODS: We conducted a prospective cohort study at four New York hospitals
that enrolled 541 patients with hip fracture and without delirium. Delirium was
identified prospectively by patient interview supplemented by medical record
review. Multiple logistic regression was used to identify risk factors. RESULTS:
Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk
factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95%
confidence interval, or CI, 1.8-7.2), abnormal blood pressure (RR 2.3, 95% CI
1.2-4.7), and heart failure (RR 2.9, 95% CI 1.6-5.3). Patients who received less
than 10 mg of parenteral morphine sulfate equivalents per day were more likely
to develop delirium than patients who received more analgesia (RR 5.4, 95% CI
2.4-12.3). Patients who received meperidine were at increased risk of developing
delirium as compared with patients who received other opioid analgesics (RR
2.4, 95% CI 1.3-4.5). In cognitively intact patients, severe pain significantly
increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2). CONCLUSIONS: Using
admission data, clinicians can identify patients at high risk for delirium following
hip fracture. Avoiding opioids or using very low doses of opioids increased the
risk of delirium. Cognitively intact patients with undertreated pain were nine times
more likely to develop delirium than patients whose pain was adequately treated.
Undertreated pain and inadequate analgesia appear to be risk factors for delirium
in frail older adults.
Mussi, C., R. Ferrari, et al. (1999). "Importance of serum anticholinergic activity in the
assessment of elderly patients with delirium." Journal of Geriatric Psychiatry &
Neurology 12(2): 82-6.
To evaluate the importance of serum anticholinergic activity (SAA) in elderly
patients who developed delirium following hospital admission, we performed a
cross-sectional study with consecutively referred inpatients in a university
geriatric medical ward. Sixty-one patients aged 66 to 95 years (mean age:
79.2+/-11.6; 54% females) were recruited. Delirium was assessed by means of
the Confusion Assessment Method, SAA determination, questionnaire for current
drug treatment, past medical history and clinical examination, and blood
chemistries. Patients were divided into two groups according to the absence (N =
49) or the presence (N = 12) of delirium. Delirious patients showed a significantly
higher SAA (23.0 vs 3.9 pmol/mL atropine equivalents, P <.004); they were using
antibiotics (P <.05), neuroleptics (P <.002), barbiturates (P <.004), and
benzodiazepines (P <.005) more frequently. Subjects with delirium were more
likely to have infections and a lower Body Mass Index; they had higher plasma
glucose and creatinine. The multivariate analysis identified SAA and use of
neuroleptics, and benzodiazepines as the most important features independently
associated with delirium. SAA may be a suitable marker for identifying people at
risk of developing delirium. Moreover, neuroleptics and benzodiazepines must be
carefully used in the elderly because of their relationship with the onset of
delirium.
Nakasato, Y., J. Servat, et al. (2005). "Delirium in the older hospitalized patient." Journal
- Oklahoma State Medical Association 98(3): 113-6.
Nishikawa, K., M. Nakayama, et al. (2004). "Recovery characteristics and postoperative delirium after long-duration laparoscope-assisted surgery in elderly patients:
propofol-based vs. sevoflurane-based anesthesia." Acta Anaesthesiologica
Scandinavica 48(2): 162-8.
BACKGROUND: Post-operative mental dysfunction may be an important
problem in elderly patients. This study was designed to compare the effects of
propofol and sevoflurane anesthesia on recovery characteristics and the
incidence of post-operative delirium (POD) in long-duration laparoscopic surgery
for elderly patients. METHODS: Fifty ASA physical status I-II patients over the
age of 65 scheduled for laparoscopic surgery lasting 3 h or more randomly
received propofol (group P, n = 25) or sevoflurane (group S, n = 25) for both
induction and maintenance of general anesthesia. Both groups were combined
with continuous perioperative epidural analgesia. The level of primary
anesthetics was adjusted to maintain changes in mean arterial pressure within
20% of the pre-anesthetic values. The emergence times from anesthesia (eye
opening, extubation, response to command, and orientation) were recorded, and
the occurrence of POD was assessed by the delirium rating scale (DRS) during
the first 3 days after surgery. All patients received oxygen and continuous
epidural analgesia postoperatively. RESULTS: Immediate emergence, i.e. eye
opening and extubation was significantly faster after sevoflurane (P < 0.05).
There was no significant difference between the incidences of POD in the two
groups during the first 3 days after surgery. The scores for DRS on day 2 and 3
after surgery, however, were significantly higher in group P than in group S (P <
0.01). CONCLUSION: Sevoflurane may be preferable to propofol for general
anesthesia in combination with epidural analgesia with respect to less effect on
mental function during the early postoperative period for long-duration
laparoscopic surgery in elderly patients.
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.
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.
Onishi, H., C. Kawanishi, et al. (2004). "Successful treatment of Wernicke
encephalopathy in terminally ill cancer patients: report of 3 cases and review of the
literature." Supportive Care in Cancer 12(8): 604-8.
Although Wernicke encephalopathy has been reported in the oncological
literature, only one terminally ill cancer patient with Wernicke encephalopathy
has been reported. Wernicke encephalopathy, a potentially reversible condition,
may be unrecognized in terminally ill cancer patients. In this communication, we
report three terminally ill cancer patients who developed Wernicke
encephalopathy. Early recognition and subsequent treatment resulted in
successful palliation of delirium. Two of the three patients did not show the
classical triad of Wernicke encephalopathy. Common clinical symptoms were
delirium and poor nutritional status. Intravenous thiamine administration
dramatically improved the symptoms of delirium in all three patients. In terminally
ill cancer patients, clinicians must remain aware of the possibility of Wernicke
encephalopathy when patients with a poor nutritional status present with
unexplained delirium. Early intervention may correct the symptoms and prevent
irreversible brain damage and the quality of life for the patient may improve.
Paulsen, J. S., R. E. Ready, et al. (2001). "Neuropsychiatric aspects of Huntington's
disease." Journal of Neurology, Neurosurgery & Psychiatry 71(3): 310-4.
OBJECTIVE: Neuropsychiatric symptoms are common in Huntington's disease
and have been considered its presenting manifestation. Research characterising
these symptoms in Huntington's disease is variable, however, encumbered by
limitations within and across studies. Gaining a better understanding of
neuropsychiatric symptoms is essential, as these symptoms have implications for
disease management, prognosis, and quality of life for patients and caregivers.
METHOD: Fifty two patients with Huntington's disease were administered
standardised measures of cognition, psychiatric symptoms, and motor
abnormalities. Patient caregivers were administered the neuropsychiatric
inventory. RESULTS: Ninety eight per cent of the patients exhibited
neuropsychiatric symptoms, the most prevalent being dysphoria, agitation,
irritability, apathy, and anxiety. Symptoms ranged from mild to severe and were
unrelated to dementia and chorea. CONCLUSIONS: Neuropsychiatric symptoms
are prevalent in Huntington's disease and are relatively independent of cognitive
and motor aspects of the disease. Hypothesised links between neuropsychiatric
symptoms of Huntington's disease and frontal-striatal circuitry were explored.
Findings indicate that dimensional measures of neuropsychiatric symptoms are
essential to capture the full range of pathology in Huntington's disease and are
vital to include in a comprehensive assessment of the disease.
Preuss, U. W., G. Koller, et al. (2003). "Alcoholism-related phenotypes and genetic
variants of the CB1 receptor." European Archives of Psychiatry & Clinical Neuroscience
253(6): 275-80.
OBJECTIVE: Neurotransmitter release of GABAergic and glutamatergic neurons
may be significantly influenced by cannabinoid CB1 receptors located at
presynaptic nerve terminals. GABA and glutamate have been reported to be
involved in the pathogenesis of severe alcohol withdrawal-induced seizures and
delirium tremens. The aim of this study is to test the potential influence of a biallelic cannabinoid receptor gene (CNR1) polymorphism (G1359A) on severe
alcohol withdrawal syndromes. METHODS: Based upon a sample size
estimation, 196 subjects meeting DSM IV and ICD10 criteria for alcohol
dependence and 210 non-alcoholic controls were recruited for study. CB1
polymorphisms were determined using polymerase chain reaction (PCR). History
of alcohol withdrawal-induced delirium tremens, seizures and other alcohol
withdrawal-related phenotypes were obtained using the SSAGA (SemiStructured Assessment of Genetics in Alcoholism). Data were corroborated with
information from the inpatients' clinical files. RESULTS: Allele frequencies of the
CNR1 G1359A polymorphism were within the range reported by previous
studies. After correcting for multiple testing, no association of the A- or G-allele of
CNR1 polymorphism with a history of alcohol withdrawal-induced seizures was
detected. In addition, no significant relationships with other alcoholism-related
phenotypes were found. CONCLUSION: This study failed to confirm an earlier
report of a potential role of a CNR1 polymorphism in the pathogenesis of delirium
tremens.
Rahkonen, T., U. Eloniemi-Sulkava, et al. (2001). "Delirium in the non-demented oldest
old in the general population: risk factors and prognosis." International Journal of
Geriatric Psychiatry 16(4): 415-21.
BACKGROUND: The oldest old are prone to develop delirium. Studies into risk
factors for delirium have been carried out predominantly in younger age groups.
The aim of this population-based follow-up study was to investigate the risk
factors for delirium requiring medical attention and subsequent prognosis in the
non-demented general population aged > or = 85 years. METHOD: The study
included the non-demented subjects in the population-based Vantaa 85+ study.
After the 3-year observation period, 199 subjects (91% of those surviving) were
re-examined and their medical records were evaluated for episodes of delirium.
The subjects were followed up with respect to mortality for another 2 years.
RESULTS: During the 3-year observational period, 20 subjects (10%) had been
diagnosed as having had an episode of delirium. A Mini-Mental State
Examination score of < 24 (odds ratio (OR) 3.44, confidence interval (CI = 95%)
1.27-9.32) and high systolic blood pressure (OR 3.08, CI 1.08-8.79) were
identified as independent risk factors for delirium. The association between the
delirium episode and a new diagnosis of dementia was significant (p = 0.001).
The mortality rate was greater among those subjects who experienced delirium
than among subjects without this syndrome (p = 0.008). CONCLUSIONS: Mild
cognitive impairment and high systolic blood pressure were found to be risk
factors for delirium requiring medical attention in the general non-demented
population aged > or = 85 years. The study also highlights the significant
association between delirium and a new dementia diagnosis in this age group.
Copyright 2001 John Wiley & Sons, Ltd.
Rapp, C. G., J. C. Mentes, et al. (2001). "Acute confusion/delirium protocol." Journal of
Gerontological Nursing 27(4): 21-33; quiz 62-3.
This abbreviated version of the Acute Confusion/Delirium Research-Based
protocol provides clinical guidelines for the assessment and management of
acute confusion/delirium in the elderly individual. A screening and ongoing
surveillance program that is based on identified risk factors is recommended to
prevent or minimize episodes of acute confusion in this age group. This protocol
is part of a series of protocols developed to help clinicians use the best evidence
available in the care of older adults.
Roche, V. (2003). "Southwestern Internal Medicine Conference. Etiology and
management of delirium." American Journal of the Medical Sciences 325(1): 20-30.
Delirium has been recognized for the last 3 millennia and is the most common
complication found in hospitalized patients aged 65 and older in the United
States. However, critical basic science and clinical research did not progress until
the DSM III criteria clearly defined delirium 20 years ago. The term delirium then
replaced many nonspecific entities, such as acute confusion state, acute brain
syndrome, metabolic encephalopathy, and toxic psychosis. This review
discusses the epidemiology, risk factors, interventions, causes, management,
and outcomes of delirium. The pathophysiology of delirium has the potential to
radically alter our management of delirium and is a controversial area of
research. [References: 84]
Rolfson, D. B., J. E. McElhaney, et al. (1999). "Incidence and risk factors for delirium
and other adverse outcomes in older adults after coronary artery bypass graft surgery."
Canadian Journal of Cardiology 15(7): 771-6.
OBJECTIVE: To determine the incidence and risk factors for delirium after
coronary artery bypass graft (CABG) surgery. DESIGN: Prospective cohort.
SETTING: Cardiac surgery units of a tertiary care hospital. PARTICIPANTS:
Consecutive patients over age 65 years undergoing elective CABG surgery.
Exclusion criteria included preoperative sensory or language barriers.
INTERVENTIONS: Each patient was assessed within 24 h before surgery for
baseline demographic, medical and functional data. Incident delirium (within four
postoperative days) was diagnosed by a study physician. Nine potential risk
factors for delirium were subjected to univariate and multivariate analysis. MAIN
RESULTS: Of 75 consenting patients, three died during or soon after surgery
and one was still comatose at follow-up. Of the remaining 71 participants, 23
(32%) experienced delirium. Those with delirium were more likely than those
without delirium to have a history of a stroke (21% versus 4%, respectively,
P=0.032) and to have had a longer duration of cardiopulmonary bypass (CPB)
(113 mins versus 95 mins, respectively, P=0.025). A tendency to have
experienced low cardiac output (83% versus 58%, respectively, P=0.061)
postoperatively was also noted. Multivariate analysis confirmed past stroke and
duration of cardiopulmonary bypass as risk factors. CONCLUSIONS: Delirium in
the elderly after CABG surgery is common. Its occurrence may be predisposed
by a history of a stroke and precipitated by a longer duration of CPB.
[References: 36]
Roth, A. J. and R. Modi (2003). "Psychiatric issues in older cancer patients." Critical
Reviews in Oncology-Hematology 48(2): 185-97.
Although many patients are surviving longer than in the past, a cancer diagnosis
may shatter the dream of a dignified old age for elderly patients. Cancer
diagnosis and treatment often produce psychologic stresses resulting from the
actual symptoms of the disease, as well as perceptions of the disease and its
stigma. Concerns related to cancer have particular meaning for aging individuals
who undergo these situations in the context of retirement, widowhood, other
medical disabilities and other losses. Today, patients and families are more
interested in treatment issues, and quality of life, both during and after treatment.
In this article we discuss late life depression, anxiety and delirium as they relate
to elderly patients coping with cancer. [References: 66]
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.
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=0.6-
145.3). 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.
Sakauye, K., T. Berry, et al. (2003). "Postictal delirium after right-unilateral
electroconvulsive therapy caused by non-prototypical hemispheric asymmetry."
American Journal of Geriatric Psychiatry 11(4): 469.
Sandham, J. D. (1999). "Complications of acute anaemia: caused by low packed-cell
volume or by transfusion?" Lancet 354(9182): 883-4.
Sasajima, Y., T. Sasajima, et al. (2000). "Postoperative delirium in patients with chronic
lower limb ischaemia: what are the specific markers?" European Journal of Vascular &
Endovascular Surgery 20(2): 132-7.
OBJECTIVES: we determined the incidence and specific markers of
postoperative delirium in elderly patients with chronic lower limb ischaemia.
PATIENTS AND METHODS: since April, 1995, 110 patients aged 60 years or
older (mean: 71.6+/-6.6 years) who underwent bypass surgery were assessed
regarding aetiological factors of delirium: age, sex, dementia, body-mass index,
hypertension, diabetes, cerebral disease, laboratory test results, severity of limb
ischaemia, type of arterial occlusion, operative time, and blood transfusion.
RESULTS: discriminant analysis showed statistical significance in the following
five variables: age >/=70 years; critical limb ischaemia (and/or ankle pressure
<40 mmHg); dementia; duration of operation >/=7 hours; low serum albumin. The
overall percentage of cases correctly classified was 78.2% (Wilks>>
Lambda=0.695, p<0.001); the standardized regression coefficients of the five
variables were 0.648, 0.500, 0.329, 0.218, and 0.200, respectively. In logistic
regression, the regression coefficients for old age and critical limb ischaemia
were 2.646 (14.1 of odds ratio; 95% confidence interval, 2.7-72.0) and 1.337
(3.8; 1.3-10.9), respectively. CONCLUSIONS: the incidence of postoperative
delirium in elderly patients with chronic lower-limb ischaemia was as high as
42.3%, and an age of over 70 years and critical limb ischaemia were identified as
specific markers, with 14.1 times and 3.8 times the odds of suffering from
delirium after bypass surgery. Copyright 2000 Harcourt Publishers Ltd.
Schneider, F., H. Bohner, et al. (2002). "Risk factors for postoperative delirium in
vascular surgery." General Hospital Psychiatry 24(1): 28-34.
The aim of this study was to identify psychiatric and somatic risk factors
associated with the development, severity and duration of postoperative delirium
after vascular surgery. Forty-seven patients underwent aortic, carotid artery and
peripheral artery surgery. Both, surgeon and psychiatrist, monitored patients
preoperatively with daily follow up. Preoperative psychiatric assessment included
standardized psychopathological scales for the detection of psychiatric
symptoms and cognitive deficits. We diagnosed delirium using DSM IV criteria.
Delirium Rating Scale was used to estimate delirium severity. Surgical
parameters included patient history, diagnoses, medication and laboratory
parameters. A statistical analysis was performed using multivariate regression
analyses to find factors significantly associated with delirium development,
severity, and duration. Thirty-six percent of the patients developed postoperative
delirium after surgery. Comparison of different parameters revealed that
especially preoperative depression symptoms and perioperative
transfusions/infusions had significant predictive value for the development as well
as for the severity of postoperative delirium.
Schofield, I. and J. Dewing (2001). "The care of older people with a delirium in acute
care settings.[see comment]." Nursing Older People 13(1): 21-5; quiz 26.
This article suggests that nurses should play a major part in the screening,
assessment and management of delirium in older people in acute settings.
Schuurmans, M. J., S. A. Duursma, et al. (2001). "Early recognition of delirium: review
of the literature." Journal of Clinical Nursing 10(6): 721-9.
This review focuses on delirium and early recognition of symptoms by nurses.
Delirium is a transient organic mental syndrome characterized by disturbances in
consciousness, thinking and memory. The incidence in older hospitalized
patients is about 25%. The causes of delirium are multi-factorial; risk factors
include high age, cognitive impairment and severity of illness. The consequences
of delirium include high morbidity and mortality, lengthened hospital stay and
nursing home placement. Delirium develops in a short period and symptoms
fluctuate, therefore nurses are in a key position to recognize symptoms. Delirium
is often overlooked or misdiagnosed due to lack of knowledge and awareness in
nurses and doctors. To improve early recognition of delirium, emphasis should
be given to terminology, vision and knowledge regarding health in ageing and
delirium as a potential medical emergency, and to instruments for systematic
screening of symptoms. [References: 105]
Schuurmans, M. J., S. A. Duursma, et al. (2003). "Elderly patients with a hip fracture:
the risk for delirium." Applied Nursing Research 16(2): 75-84.
This prospective study investigated risk factors for delirium in elderly hip fracture
patients that could be recognized by nurses. Data were collected on predisposing
and precipitating factors for delirium from 92 elderly patients with a hip fracture.
Predisposing factors included age, gender, sensory impairments, functional
impairment before the hip fracture, residency before admission, pre-existing
cognitive impairment, comorbidities, and medication use. Precipitating factors
included factors related to surgery and to the postoperative period. Factors
related to surgery included time between admission and surgery, type of surgery,
type of anesthesia, duration of surgery and anesthesia, and complications during
surgery. Factors studied in the postoperative period were slow recovery,
malnutrition, dehydration, addition of three or more medications, introduction of
bladder catheter, infections, complications and falls, and use of morphine.
Eighteen patients developed delirium, as diagnosed by a geriatrician by using the
Diagnostic Statistical Manual-IV criteria. Data on delirious patients were
compared with the data on non-delirious patients. The findings confirm that
elderly hip fracture patients with premorbid ADL dependency, psychiatric
comorbidities (including dementia), and a high number of other comorbid
problems are at risk for the development of delirium. Based on these findings, it
is recommended that nurses should assess patients' pre-fracture functional and
cognitive capacities in an early stage of the hospital stay. Nurses should also be
alert to postoperative delirium in "healthy elderly" patients. Monitoring of
symptoms postoperatively in all elderly patients is advised. Copyright 2003
Elsevier Inc. All rights reserved.
Schuurmans, M. J., L. M. Shortridge-Baggett, et al. (2003). "The Delirium Observation
Screening Scale: a screening instrument for delirium." Research & Theory for Nursing
Practice 17(1): 31-50.
The Delirium Observation Screening (DOS) scale, a 25-item scale, was
developed to facilitate early recognition of delirium, according to the Diagnostic
and Statistical Manual-IV criteria, based on nurses' observations during regular
care. The scale was tested for content validity by a group of seven experts in the
field of delirium. Internal consistency, predictive validity, and concurrent and
construct validity were tested in two prospective studies with high risk groups of
patients: geriatric medicine patients and elderly hip fracture patients. Among the
patients admitted to a geriatric department (N = 82), 4 became delirious; among
the elderly hip fracture patients (N = 92), 18 became delirious. The DOS scale
was determined to be content valid and showed high internal consistency, alpha
= 0.93 and alpha = 0.96. Predictive validity against the Diagnostic and Statistical
Manual-IV diagnosis of delirium made by a geriatrician was good in both studies.
Correlations of the DOS scale with the Mini Mental State Examination (MMSE)
were Rs -0.79 (p < or = 0.001) in the hip fracture patients and Rs -0.66 (p < or =
0.001) in the geriatric medicine patients. Concurrent validity, as tested by
comparison of the research nurse's ratings of the DOS scale and the Confusion
Assessment Method (CAM), for the group of hip fracture patients was 0.63 (p <
or = 0.001). Construct validity of the DOS was tested against the Informant
Questionnaire of Cognitive Decline in Elderly (IQCODE), a preexisting psychiatric
diagnosis and the Barthel Index. Correlation with the IQCODE was 0.74 (p < or =
0.001) in the study with the hip fracture patients and 0.33 (p < or = 0.05) in the
study with the geriatric medicine patients. Correlation with the Barthel Index was
-0.26 (p < or = 0.05) in the geriatric medicine patients and -0.55 (p < or = 0.001)
in the hip fracture patients. The overall conclusion of these studies is that the
DOS scale shows satisfactory validity and reliability, to guide early recognition of
delirium by nurses' observation.
Schwartz, C. E. (1999). "Delirium in hospitalized older patients.[comment]." New
England Journal of Medicine 341(5): 369-70; author reply 370.
Sharma, P. T., F. E. Sieber, et al. "Recovery room delirium predicts postoperative
delirium after hip-fracture repair." Anesthesia & Analgesia 101(4): 1215-20.
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.
IMPLICATIONS: In patients undergoing hip-fracture repair, recovery room
delirium is a strong predictor of postoperative delirium when using a standardized
protocol for general anesthesia and postoperative pain management.
Shigeta, H., A. Yasui, et al. (2001). "Postoperative delirium and melatonin levels in
elderly patients." American Journal of Surgery 182(5): 449-54.
BACKGROUND: Melatonin, a hormone produced in the pineal gland, is involved
in circadian rhythms and the sleep-wake cycle. Postoperative delirium is
encountered frequently in elderly patients after major surgery; whether changes
in the pattern of melatonin secretion are associated is unclear. METHODS:
Plasma samples were obtained every 2 hours from 19 patients without delirium
and 10 with delirium after major abdominal surgery. Postoperative delirium was
determined using the Confusion Assessment Method in the Practice Guideline of
the American Psychiatric Association. RESULTS: All patients without delirium
showed nearly identical preoperative and postoperative melatonin secretion for
24 hours, although peak values were significantly lower in patients more than 80
years old (7.2 +/- 2.3 pg/mL) than in patients younger than 80 years (24.4 +/- 4.1
pg/mL, P = 0.022). Patients with delirium showed two different abnormal
postoperative patterns: in 5 patients without complications, melatonin levels were
lower than preoperative values (11.0 +/- 5.8 versus 6.5 +/- 4.2 pg/mL, P = 0.079);
and in 5 patients with complications, melatonin levels were markedly increased
(21.1 +/- 4.5 versus 58.8 +/- 12.4 pg/mL, P = 0.043). CONCLUSIONS: Abnormal
melatonin secretion may be involved in postoperative sleep disturbances, which
triggered delirium in elderly patients.
Somprakit, P., J. Lertakyamanee, et al. (2002). "Mental state change after general and
regional anesthesia in adults and elderly patients, a randomized clinical trial." Journal of
the Medical Association of Thailand 85 Suppl 3: S875-83.
BACKGROUND: Mental state changes after anesthesia seemed to be more
frequent in older patients, but the results were still unclear. OBJECTIVE: To
compare the mental scores between adults and elderly patients after general and
regional anesthesia. METHODS: This was a stratified randomized trial with
factorial design. Sixty patients > or = 60 years old and sixty patients < 60 years
old were randomly assigned to receive general or regional anesthesia. Their
mental states were assessed blind by investigators, using the Thai Mental State
Examination score. RESULTS: The two anesthetic groups showed no difference
in the mental scores, but the two age groups showed significantly different
scores. The components of mental states that were significantly different were
orientation and recall. There were no significant differences in registration,
attention, calculation and language. The model for predicting the score included
age, education level and narcotics given within six hours before assessment.
Sex, weight, intraoperative hypotension, blood loss and duration of anesthesia
could not explain the change in the scores. CONCLUSION: Age, but not
anesthetic technique, affected the mental scores after anesthesia.
Taggart, D. P. and S. Westaby (2001). "Neurological and cognitive disorders after
coronary artery bypass grafting." Current Opinion in Cardiology 16(5): 271-6.
Cerebral injury is a major cause of mortality and morbidity of coronary artery
bypass grafting. Stroke occurs in 3% of patients and is largely caused by
embolization of atheromatous debris during manipulation of the diseased aorta.
Cognitive impairment, which is predominantly caused by microembolization of
gaseous and particulate matter, mainly generated by cardiotomy suction, is more
common. Demonstration of similar cognitive impairment in patients operated on
without cardiopulmonary bypass indicates that other pathophysiological
mechanisms, such as anaesthesia and hypoperfusion, are also involved.
Advances in medical, anesthetic, and surgical management have resulted in a
reduction in the incidence of neurological injury in CABG patients over the past
decade. On the other hand, an increasingly elderly population with more severe
comorbidity, who are more prone to cerebral injury, are increasingly being
referred for CABG. Possible mechanisms to reduce overt and subtle cerebral
injury are discussed. The use of composite arterial grafts performed on the
beating heart may be the most effective way of minimizing the risk of cerebral
injury associated with CABG. [References: 58]
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.
Timmermans, M. and J. Carr (2004). "Neurosyphilis in the modern era." Journal of
Neurology, Neurosurgery & Psychiatry 75(12): 1727-30.
OBJECTIVE: To review the nature of the presentation of neurosyphilis, the value
of diagnostic tests, and the classification of the disease. METHODS: A
retrospective review was carried out of the records of patients who had been
identified as possible cases of neurosyphilis by a positive FTA-abs test in the
CSF. The review extended over 10 years at a single hospital which served a
population of mixed ancestry in a defined catchment area in the Western Cape
province of South Africa. Patients were placed in predefined diagnostic
categories, and clinical, radiological, and laboratory features were assessed.
RESULTS: 161 patients met diagnostic criteria for neurosyphilis: 82 presented
with combinations of delirium and dementia and other neuropsychiatric
conditions, and the remainder had typical presentations such as stroke (24),
spinal cord disease (15), and seizures (14). The average age of presentation
ranged from 35.9 to 42.6 years in the different categories of neurosyphilis. Of
those followed up, 77% had residual deficits from their initial illness.
Cerebrospinal fluid (CSF) VDRL was positive in 73% of cases. CONCLUSIONS:
The diagnosis of neurosyphilis can be made with reasonable certainty if there is
an appropriate neuropsychiatric syndrome associated with a positive CSF VDRL.
If the VDRL is negative, a positive FTA-abs in an appropriate clinical setting,
associated with raised CSF cell count, protein, or IgG index, is a useful method
of identifying neurosyphilis. Tabes dorsalis has become uncommon, but this is
likely to be the only manifestation of neurosyphilis that has been altered during
the antibiotic era.
Torres, R., D. Mittal, et al. (2001). "Use of quetiapine in delirium: case reports."
Psychosomatics 42(4): 347-9.
Tremont-Lukats, I. W., G. Bobustuc, et al. (2003). "Brain metastasis from prostate
carcinoma: The M. D. Anderson Cancer Center experience." Cancer 98(2): 363-8.
BACKGROUND: The objective of this study was to estimate the incidence and
describe distribution, clinical presentation, and prognosis of brain metastases in
patients with prostate carcinoma who were seen at The University of Texas M. D.
Anderson Cancer Center (MDACC). METHODS: The authors reviewed the
charts of 16,280 patients with prostate carcinoma in the MDACC patient data
base. Of 131 patients with craniospinal metastases confirmed by neuroimaging
(n=53 patients) or autopsy (n=78 patients), 103 of 16,280 patients (0.63%) had
parenchymal metastases. RESULTS: The median patient age at diagnosis was
64 years (range, 16-85 years). The median interval from the diagnosis of prostate
carcinoma to the detection of brain metastasis was 35 months for patients with
adenocarcinoma and 48 months for patients with small cell carcinoma (SCC).
Confusion, headache, and memory deficits were the most frequent initial
symptoms. Eighty-six percent of patients had single lesions, and 14% of patients
had > or = 2 lesions. Metastases were supratentorial in 81 of 103 patients (76%),
infratentorial in 22 of 103 patients (21%), and both supratentorial and
infratentorial in 3 of 103 patients (3%). SCC and cribriform subtypes were more
likely than adenocarcinoma to metastasize to the brain (relative risk, 20.36; 95%
confidence interval, 9.91-41.84). Regardless of histology, the median survival in
untreated patients was 1 month compared with 3.5 months in patients who were
treated with radiotherapy. Patients who underwent stereotactic radiosurgery (n=5
patients) had a longer median survival (9 months). Survival was not affected by
supratentorial or infratentorial location of metastases. CONCLUSIONS: Brain
metastasis from prostate carcinoma is a rare, terminal event with death in <1
year frequently due to advanced, systemic disease. The majority of metastases
were single and supratentorial. The most common clinical presentation was
nonfocal neurologic symptoms related to intracranial hypertension. A better
understanding of the biology of prostate carcinoma will help clarify the basis for
its metastasis to the brain. Copyright 2003 American Cancer Society.
Tullmann, D. F. and K. Dracup (2000). "Creating a healing environment for elders."
AACN Clinical Issues 11(1): 34-50; quiz 153-4.
The number of elderly, both in society at large and in the critical care population,
is increasing at an unprecedented rate. Critical care nurses must address how
best to provide care to these elders. The authors focus on physiologic, cognitive,
and psychosocial characteristics of the elderly that place them at risk for
complications during their stay in critical care. The critical care environment also
contributes to complications such as sleep deprivation, sensory deprivation or
overload, painful procedures, and decreased social support. The critical care
environment may also be a factor in facilitating delirium, common in critically ill
elders. Critical care nurses can proactively help to create a healing environment
for these elders by facilitating sleep, implementing strategies to reduce delirium,
preventing or minimizing painful experiences, and liberalizing family visitations.
[References: 128]
van der Mast, R. C. (1999). "Postoperative delirium." Dementia & Geriatric Cognitive
Disorders 10(5): 401-5.
This article reviews the incidence, pathophysiological hypotheses, and etiology of
postoperative delirium, especially in the elderly. Preoperative, intraoperative, and
postoperative risk factors for delirium following surgery are discussed. Results of
various studies on postoperative delirium appear hardly comparable due to
methodological and population differences. Therefore, it is difficult to draw any
conclusions on postoperative delirium in general. Special attention is paid to
delirium after cardiac surgery since this syndrome has been studied most.
[References: 28]
van der Mast, R. C. and D. Fekkes (2000). "Serotonin and amino acids: partners in
delirium pathophysiology?" Seminars in Clinical Neuropsychiatry 5(2): 125-31.
Delirium may be the result of dysfunction of multiple interacting neurotransmitter
systems. Changes in the levels of various amino acids being precursors of
cerebral neurotransmitters may affect their function and, thus, contribute to the
development of delirium. Serotonin is one of the neurotransmitters that may play
an important role in medical and surgical delirium. Normal serotonin synthesis
and release in the human brain is, among others, dependent on the availability of
its precursor tryptophan (Trp) from blood. The essential amino acid Trp competes
with the other large neutral amino acids (LNAA) tyrosine, phenylalanine, valine,
leucine, and isoleucine for transport across the blood-brain barrier. This
competition determines its uptake into the brain, represented by the ratio of the
plasma level of Trp to the sum of the other LNAA. The plasma ratio of Trp/LNAA,
plasma level of Trp, and serotonin in plasma and platelets have been used as
indirect peripheral measures for central serotonergic functioning. Both increased
and decreased serotonergic activity have been associated with delirium.
Serotonin agonists can induce psychosis, both elevated Trp availability and
increased cerebral serotonin have been associated with hepatic encephalopathy,
and excess serotonergic brain activity has been related to the development of the
serotonin syndrome of which delirium is a main symptom. On the other hand,
alcohol withdrawal delirium, delirium in levodopa-treated Parkinson patients, and
postoperative delirium have been related to reduce cerebral Trp availability from
plasma suggesting diminished serotonergic function. Rick factors for delirium
such as severe illness, surgery, and trauma can induce immune activation and a
physical stress response comprising increased activity of the limbichypothalamic-pituitary-adrenocortical axis, the occurrence of a low T3 syndrome,
and, possibly, changes in the permeability of the blood-brain barrier. There are
indications that these changes have their effect on plasma amino acid
concentrations, e.g., Trp, and multiple cerebral neurotransmitters, including
serotonin. This stress response may be different depending on the stage of
illness being acute or chronic. It will require further study to determine the
complex influence of the stress response and immune activation on plasma
amino acids, neurotransmitter function and the development of delirium,
especially in the more vulnerable older patients. [References: 52]
Vatsavayi, V., S. Malhotra, et al. (2003). "Agitated delirium with posterior cerebral artery
infarction." Journal of Emergency Medicine 24(3): 263-6.
Infarction of the posterior cerebral artery may present only with signs of agitated
delirium and an acute confusional state. In the absence of other prominent
neurological deficits, this can be easily mistaken for toxic-metabolic
encephalopathy, head trauma, post-ictal confusion, or a psychiatric disorder.
Appropriate head imaging studies are important to detect an illness that might
otherwise be missed and left untreated.
Villalpando-Berumen, J. M., A. M. Pineda-Colorado, et al. (2003). "Incidence of delirium,
risk factors, and long-term survival of elderly patients hospitalized in a medical specialty
teaching hospital in Mexico City." International Psychogeriatrics 15(4): 325-36.
BACKGROUND: We determined the incidence, probable risk factors, causes,
and long-term survival of delirium in patients hospitalized in a medical specialty
teaching hospital in Mexico City. METHOD: From June to December 1995, 667
elderly patients 60 years and older were hospitalized and assessed within 48
hours, excluding those with delirium at admission, those sedated, on respiratory
support, or unable to speak. RESULTS: Twelve percent of the population
developed delirium, identified by means of the daily application of the Confusion
Assessment Method; its appearance was attributed in 50% to two or more
causes, in 10% to an insufficient control of pain, in 7.5% to a preceding surgical
event, and in the rest to other causes. Each case was compared randomly with
three nonpaired control patients of the same cohort who did not develop delirium.
There was a significant increase in the number of cases of delirium in patients
older than 75 years (p <.001), those with low schooling (p =.04), those with
greater comorbidity (p <.001), those with a hematocrit lower than 30% (relative
risk [RR] 2.1, confidence interval [CI] 1.2-4.1), and those with a glucose level
greater than 140 mg/dl (RR 2.1, CI 1.2-3.6). Patients with delirium remained
hospitalized longer than controls (p =.02). There was no significant difference in
the intrahospital mortality of both groups, although during 5 years' follow-up,
survivors demonstrated a significant increase in mortality (p =.03) in the group of
individuals with delirium during the hospital stay when compared to controls.
CONCLUSION: In this geriatric population of Mexican patients, delirium
incidence was similar to that previously reported in the worldwide literature. Its
incidence is associated with longer hospital stay and greater mortality. Age, low
level of schooling, greater comorbidity, high glucose levels, poor pain control,
and hematocrit lower than 30% were independently associated with a greater
incidence of delirium.
Wang, S. G., U. J. Lee, et al. (2004). "Factors associated with postoperative delirium
after major head and neck surgery." Annals of Otology, Rhinology & Laryngology
113(1): 48-51.
Postoperative delirium (POD) is an acute change in cognitive status
characterized by fluctuating consciousness and is associated with high
incidences of morbidity, high complication rates, and long hospitalizations. This
study was performed to determine the incidence of POD and the perioperative
risk factors in order to predict which patients have an increased risk and thus to
prevent POD after major head and neck surgery. The authors retrospectively
evaluated 341 patients who underwent laryngectomy or the Commando
(combined operation of mouth, mandible, and neck dissection) procedure at
Pusan National University Hospital from January 1986 through July 2001.
Postoperative delirium developed in 13.8% of the patients who underwent
laryngectomy (42 of 304) and 13.5% of the patients who underwent the
Commando procedure (5 of 37). A multivariate analysis showed that older age,
hypertension, low postoperative O2 saturation, and decreased postoperative
hemoglobin levels were risk factors for POD (p <.05). Postoperative delirium is
preventable, and its incidence can be decreased by predicting these risk factors
during the preoperative and postoperative periods.
Wendel, I. (2002). "A case study of postoperative delirium." AORN Journal 75(3): 595600.
Winawer, N. (2001). "Postoperative delirium." Medical Clinics of North America 85(5):
1229-39.
Delirium is a common postoperative complication that is associated with
substantial patient morbidity and mortality. Because of the variability in its
presentation, delirium has the potential to be overlooked or misdiagnosed. There
are few well-designed prospective studies looking at the incidence of delirium;
however, retrospective data reveal it to be highly variable. The cause is
multifactorial, with the largest predisposing factors being patient age, cerebral
disease, and poor preoperative medical status. Common precipitants of delirium
postoperatively include infection, hypoxia, myocardial ischemia, metabolic
derangements, and anticholinergic drugs. The pathogenesis of delirium is
incompletely understood; cholinergic pathways appear to play a crucial role.
Physicians evaluating postoperative patients for mental status changes need to
identify delirium accurately (the diagnostic criteria for which are clearly set out in
the DSM-IV). Further investigations center on searching for organic precipitants,
which can be treated effectively. The diagnostic workup is not algorithmic and
must be tailored to the specifics of each individual case. If there is no readily
identifiable cause, treatment should focus on the disorder itself. Supportive care
should consist of a multidisciplinary approach aimed at preventing functional
decline. Pharmacologic therapy, usually with haloperidol, may be indicated if
patients remain agitated. Investigations have supported the premise that delirium
is a potentially preventable condition. This prevention can be accomplished by
maximizing the patient's medical status and conscientiously avoiding the
conditions that are known to precipitate delirium. [References: 19]
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.
Yennurajalingam, S., F. Braiteh, et al. "Pain and terminal delirium research in the
elderly." Clinics in Geriatric Medicine 21(1): 93-119.
This article highlights new developments in assessment and management of pain
and delirium. [References: 95]