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MISE A JOUR DE LA BIBLIOGRAPHIE SUR LE DELIRIUM
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Le 24 décembre 2007
(2007). "Delirium in the orthopaedic patient." Orthopaedic Nursing 26(6): 364-5.
(2007). "How to try this: detecting delirium." American Journal of Nursing 107(12): 60.
Adamis, D., A. Treloar, et al. (2007). "Associations of delirium with in-hospital and in 6months mortality in elderly medical inpatients." Age & Ageing 36(6): 644-9.
BACKGROUND: Studies on the association between mortality and delirium in
older hospital inpatients have produced conflicting results. This insconsistency
might be explained by case-mix differences in terms of clinical or underlying
patho-physiological processes. For example, both albumin and C-reactive protein
(CRP) have been reported as predictors of in-hospital mortality and interleukin-6
of longer-term mortality. METHODS: We used data from a longitudinal study of
delirium to investigate the delirium-mortality relationship. A cohort of 164
patients, 70+ years were assessed within 3 days of acute hospital admission and
hence twice weekly until hospital discharge, for the presence and severity of
delirium and a range of clinical and laboratory measures, including initial albumin
(n = 149), CRP (n = 76) and cytokine (n = 60) levels. In-hospital and 6-months
mortality were determined from clinical records and telephone contact.
RESULTS: During hospitalisation 14 (8.5%) patients died, 6 with delirium:
mortality was not associated with delirium. At 6 months, 119 of 150 (77.3%)
discharged patients were still alive, 21 (14.0%) dead, and 13 (8.7%)
uncontactable. In bivariate analysis, 6-months mortality was associated with
older age (P = 0.013), lower albumin (P = 0.001), higher CRP (P = 0.014) and
higher interleukin-6 levels (P = 0.007), but not with presence or severity of inhospital delirium. After controlling for other variables significant predictors (P <
0.05) for six-month mortality were initial MMSE, albumin, interferon-lambda and
interleukin-6. CONCLUSIONS: The lack of demonstrable association between
delirium and mortality may reflect inadequate statistical power in this study due to
low numbers. These findings, however, highlight specific patho-physiological
factors which may be important in the prognosis after delirium.
Adamis, D., A. Treloar, et al. (2007). "APOE and cytokines as biological markers for
recovery of prevalent delirium in elderly medical inpatients." International Journal of
Geriatric Psychiatry 22(7): 688-94.
BACKGROUND: Delirium frequently occurs in the context of infection and other
inflammatory conditions associated with elevated levels of cytokines. Cytokines
used therapeutically can induce symptoms of delirium as an adverse effect. We
hypothesized that a causal relationship might exist between delirium and
cytokine production during illness. Further, we speculated that the APOE
genotype of patients might influence their rate of recovery from delirium given
that APOE is associated with amyloid deposition, increased susceptibility to
exogenous neurotoxins, and can affect the immune response. METHODS: A
cohort of 164 acutely ill patients, 70 years or older, admitted to an elderly medical
unit were studied within 3 days of hospital admission and re-assessed twice
weekly until their discharge, to identify and follow the clinical course of delirium.
The APOE genotype and the level of circulating cytokines were determined for
116 and 60 patients respectively. RESULTS: Prevalent delirium was significantly
(p < 0.05) associated with a previous history of dementia, age, illness severity,
disability and low levels of circulating IGF-I. Recovery was significantly
associated (p < 0.05) with lack of APOE 4 allele and higher initial IFN-gamma. A
model incorporating gender, APOE epsilon 4 status and IGF-I levels predicted
recovery or not from delirium in 76.5% of cases, with a sensitivity 0.77 and
specificity 0.75. CONCLUSIONS: A relationship between delirium with APOE
genotype, IFN-gamma, and IGF-I, but not with IL-6, IL-1, TNF-alpha, and LIF was
found. A predictive model of recovery was derived from gender, APOE status,
and IGF-I levels. This model needs replication with further studies.
Al-Ghamdi, S. M. (2002). "Reversible Encephalopathy and Delirium in Patients with
Chronic Renal Failure who had Received Ciprofloxacin." Nasrat Amrad Wa Ziraat
Alkulat 13(2): 163-70.
We describe four patients with chronic renal failure (CRF) who developed
significant neurotoxicity after receiving short-term ciprofloxacin. Three of them
had developed encephalopathy with myoclonic jerks and one patient had
delirium. All patients had advanced chronic renal failure (mean estimated
creatinine clearance 16 +/- 6 ml/minute), although they were not yet on renal
replacement therapy. The mean received dose of ciprofloxacin was 2150 +/1300 mg and symptoms started to appear after the first 24 hours of drug intake.
Investigations ruled out other possible causes of these neurological
presentations, and withdrawal of ciprofloxacin was followed by complete
resolution, after a mean of 8.5 +/- 4 days. Advanced renal failure in all patients
and underlying neurologic diseases in two patients may have predisposed them
to the neurotoxicity. The report of these cases should help to draw the attention
of clinicians to the potential occurrence of these adverse effects in patients with
CRF.
Aouad, M. T., V. G. Yazbeck-Karam, et al. (2007). "A single dose of propofol at the end
of surgery for the prevention of emergence agitation in children undergoing strabismus
surgery during sevoflurane anesthesia." Anesthesiology 107(5): 733-8.
BACKGROUND: Emergence agitation in children after sevoflurane is common.
Different drugs have been used to decrease its occurrence with variable efficacy.
The authors compared the incidence and severity of emergence agitation in
children who received a single dose of propofol at the end of strabismus surgery
versus children who received saline. METHODS: In this prospective,
randomized, double-blind study, the authors enrolled 80 healthy children aged 26 yr. The children were randomly allocated to the propofol group (n = 41), which
received 1 mg/kg propofol at the end of surgery, or to the saline group (n = 39),
which received saline. RESULTS: The mean scores on the Pediatric Anesthesia
Emergence Delirium scale were significantly lower in the propofol group
compared with the saline group (8.6 +/- 3.9 vs. 11.5 +/- 4.5; P = 0.004). Also, the
incidence of agitation was significantly lower in the propofol group compared with
the saline group (19.5% vs. 47.2%; P = 0.01). A threshold score greater than 10
on the Pediatric Anesthesia Emergence Delirium scale was the best discriminator
between presence and absence of emergence agitation. Times to removal of the
laryngeal mask airway (10.6 +/- 1.5 vs. 9.4 +/- 1.9 min; P = 0.004) and
emergence times (23.4 +/- 5.7 vs. 19.7 +/- 5 min; P = 0.004) were significantly
longer in the propofol group. However, discharge times were similar between the
two groups (propofol: 34.1 +/- 8.4 min; saline: 34.9 +/- 8.6 min). More parents in
the propofol group were satisfied. CONCLUSIONS: In children undergoing
strabismus surgery, 1 mg/kg propofol at the end of surgery after discontinuation
of sevoflurane decreases the incidence of agitation and improves parents'
satisfaction without delaying discharge from the postanesthesia care unit.
Arora, V. M., M. Johnson, et al. (2007). "Using assessing care of vulnerable elders
quality indicators to measure quality of hospital care for vulnerable elders." Journal of
the American Geriatrics Society 55(11): 1705-1711.
OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders
using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality
indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic
medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the
University of Chicago general medicine inpatient service who were defined as
vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool
based on age, self-reported health, and functional status. MEASUREMENTS:
Inpatient interview and chart review using ACOVE-based process-of-care
measures referring to 16 QIs in general hospital care and geriatric-prevalent
conditions (e. g., pressure ulcers, dementia, and delirium); adherence rates
calculated for type of care process ( screening, diagnosis, and treatment) and
type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older
patients participated. Of these, 349 (58%) were deemed vulnerable based on
VES-13 score. Three hundred twenty-eight (94%) charts were available for
review. QIs for general medical care were met at a significantly higher rate than
for pressure ulcer care (81.5%, 95% confidence interval (CI) 579.3 -83.7% vs
75.8%, 95% CI=70.5-81.1%, P= .04) and for delirium and dementia care (81.5%,
95% CI = 79.3-83.7 vs 31.4% 95% CI = 27.5-35.2%, P <. 01). According to
standard nursing assessment forms, nurses were responsible for high rates of
adherence to certain screening indicators (pain, nutrition, functional status,
pressure ulcer risk; P <. 001 when compared with physicians), although in
patients with functional limitations, nurse admission assessments of functional
limitations often did not agree with reports of limitations by patients on admission.
CONCLUSION: Adherence to geriatric-specific QIs is lower than adherence to
general hospital care QIs. Hospital care QIs that focus on screening may
overestimate performance by detecting standard nursing or protocol-driven care.
[References: 21]
Arora, V. M., M. Johnson, et al. (2007). "Using assessing care of vulnerable elders
quality indicators to measure quality of hospital care for vulnerable elders." Journal of
the American Geriatrics Society 55(11): 1705-11.
OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders
using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality
indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic
medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the
University of Chicago general medicine inpatient service who were defined as
vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool
based on age, self-reported health, and functional status. MEASUREMENTS:
Inpatient interview and chart review using ACOVE-based process-of-care
measures referring to 16 QIs in general hospital care and geriatric-prevalent
conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates
calculated for type of care process (screening, diagnosis, and treatment) and
type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older
patients participated. Of these, 349 (58%) were deemed vulnerable based on
VES-13 score. Three hundred twenty-eight (94%) charts were available for
review. QIs for general medical care were met at a significantly higher rate than
for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3-83.7% vs
75.8%, 95% CI=70.5-81.1%, P=.04) and for delirium and dementia care (81.5%,
95% CI=79.3-83.7 vs 31.4% 95% CI=27.5-35.2%, P<.01). According to standard
nursing assessment forms, nurses were responsible for high rates of adherence
to certain screening indicators (pain, nutrition, functional status, pressure ulcer
risk; P<.001 when compared with physicians), although in patients with functional
limitations, nurse admission assessments of functional limitations often did not
agree with reports of limitations by patients on admission. CONCLUSION:
Adherence to geriatric-specific QIs is lower than adherence to general hospital
care QIs. Hospital care QIs that focus on screening may overestimate
performance by detecting standard nursing or protocol-driven care.
Arsura, E. L. and J. Nfonoyim (2007). "Less confusion and greater clarity regarding
delirium." Critical Care Medicine 35(11): 2645-6.
Battaglia, J., D. G. Robinson, et al. (2007). "The treatment of acute agitation in
schizophrenia." Cns Spectrums 12(8 Suppl 11): 1-13.
Acute agitation is a nonspecific term applied to an array of syndromes and
behaviors. It is frequently defined as an increase in psychomotor activity,
aggression, disinhibition/impulsivity, and irritable or labile mood. Etiologies of
acute agitation include medical disorders, delirium, substance intoxication or
withdrawal, psychiatric disorders, and medication side effects. Treatment of
acute agitation requires both environmental and pharmacologic intervention.
Patients should be calmed with sedating agents early in the course of treatment,
allowing for diagnostic tests to take place. Failure to correctly diagnose causes of
agitation may lead to delayed treatment for serious conditions, and can even
exacerbate agitation.The most common cause of agitation in patients with
schizophrenia is psychotic relapse due to medication nonadherence.
Pharmacologic treatment options for these patients include lorazepam and
antipsychotic agents. Lorazepam causes nonspecific sedation and treats some
substance withdrawal, but has little effect on psychosis. First-generation
antipsychotics treat psychosis and, at high enough doses, cause sedation, but
may induce extrapyramidal side effects (EPS). Some second-generation
antipsychotics have been approved for the treatment of agitation in
schizophrenia. These agents treat psychosis with a favorable EPS profile, but are
comparatively expensive and cause risks such as hypotension. However,
avoiding EPS may reduce patients' resistance to antipsychotic treatment. In this
expert roundtable supplement, Joseph Battaglia, MD, provides an overview of
the definition of acute agitation. Next, Delbert G. Robinson, MD, outlines
evaluation methods for actue agitation. Finally, Leslie Citrome, MD, MPH,
reviews interventions for acute and ongoing management of agitation.
Bellelli, G., G. B. Frisoni, et al. (2007). "Delirium superimposed on dementia predicts 12month survival in elderly patients discharged from a postacute rehabilitation facility."
Journals of Gerontology Series A-Biological Sciences & Medical Sciences 62(11): 13069.
BACKGROUND: Delirium superimposed on dementia (DSD) is highly prevalent
and associated with high mortality among hospitalized elderly patients, yet little is
known about the effect of DSD on midterm mortality. The purpose of this study
was to assess 12-month survival in patients with DSD and matched groups with
dementia alone, delirium alone, or neither delirium nor dementia. METHODS:
Among 1278 consecutively admitted elderly participants (aged >/=65 years) to
our Rehabilitation Unit between January 2002 and May 2005, four matched
samples of 47 participants each (DSD, dementia alone, delirium alone, or neither
delirium nor dementia) were selected. Matching was based on age, gender, and
reason for admission. Postdischarge 12-month survival was assessed in the four
groups with Kaplan-Meyer analysis and compared with Cox proportional hazard
regression models adjusted for confounders. RESULTS: Survival was
significantly lower for DSD patients than for the other three groups. After
adjustment for comorbidity and Barthel Index score before admission, patients
with DSD had significantly higher mortality (hazard ratio, 2.3; 95% confidence
interval, 1.1-5.5; p =.04) than did patients with neither delirium nor dementia.
CONCLUSIONS: Demented patients who experienced delirium during
hospitalization had a more than twofold increased risk of mortality in the 12
months following discharge than did patients with dementia alone, with delirium
alone, or with neither dementia nor delirium.
Bellelli, G., S. Speciale, et al. "Delirium subtypes and 1-year mortality among elderly
patients discharged from a post-acute rehabilitation facility." Journal.
Bellelli, G., S. Speciale, et al. (2007). "Delirium subtypes and 1-year mortality among
elderly patients discharged from a post-acute rehabilitation facility.[comment]." Journals
of Gerontology Series A-Biological Sciences & Medical Sciences 62(10): 1182-3.
Bhat, R. and K. Rockwood (2007). "Delirium as a disorder of consciousness." Journal of
Neurology, Neurosurgery & Psychiatry 78(11): 1167-70.
Britton, A. and R. Russell (2007). "WITHDRAWN: Multidisciplinary team interventions
for delirium in patients with chronic cognitive impairment.[update of Cochrane Database
Syst Rev. 2004;(2):CD000395; PMID: 15106152]." Cochrane Database of Systematic
Reviews(3): CD000395.
BACKGROUND: Delirium is common in hospitalized elderly people. Delirium
may affect 60% of frail elderly people in hospital. Among the cognitively impaired,
45% have been found to develop delirium and these patients have longer lengths
of hospital stay and a higher rate of complications which, with other factors,
increase costs of care. The management of delirium has commonly been
multifaceted, the primary emphasis has to be on the diagnosis and therapy of
precipitating factors, but as these may not be immediately resolved, symptomatic
and supportive care are also of major importance. OBJECTIVES: The objective
of this review is to assess the available evidence for the effectiveness, if any, of
multidisciplinary team interventions in the coordinated care of elderly patients
with delirium superimposed on an underlying chronic cognitive impairment in
comparison with usual care. SEARCH STRATEGY: The trials were identified
from a last updated search of the Specialized Register of the Cochrane Dementia
and Cognitive Improvement Group on 3 July 2003 using the terms delirium and
confus* . The Register is regularly updated and contains records of all major
health care databases and many ongoing trial databases. SELECTION
CRITERIA: Selection for possible inclusion in this review was made on the basis
of the research methodology - controlled trials whose participants are reported as
having chronic cognitive impairment, and who then developed incident delirium
and were randomly assigned to either coordinated multidisciplinary care or usual
care. DATA COLLECTION AND ANALYSIS: Nine controlled trials were identified
for possible inclusion in the review, only one of which met the inclusion criteria.
At present the data from that study cannot be analysed. We have requested
additional data from the authors and are awaiting their reply. MAIN RESULTS:
No studies focused on patients with prior cognitive impairment, so management
of delirium in this group could not be assessed. There is very little information on
the management of delirium in the literature despite an increasing body of
information about the incidence, risks and prognosis of the disorder in the elderly
population. AUTHORS' CONCLUSIONS: The management of delirium needs to
be studied in a more clearly defined way before evidence-based guidelines can
be developed.Insufficient data are available for the development of evidencebased guidelines on diagnosis or management. There is scope for research in all
areas - from basic pathophysiology and epidemiology to prevention and
management.Though much recent research has focused on the problem of
delirium, the evidence is still difficult to utilize in management programmes.
Research needs to be undertaken targeting specific groups known to be at high
risk of developing delirium, for example the cognitively impaired and the frail
elderly. As has been highlighted by Inouye 1999, delirium has very important
economic and health policy implications and is a clinical problem that can affect
all aspects of care of an ill older person.Delirium, though a frequent problem in
hospitalized elderly patients, is still managed empirically and there is no evidence
in the literature to support change to current practice at this time. [References:
29]
Brown, S., M. Fitzgerald, et al. (2007). "Delirium dichotomy: a review of recent
literature." Contemporary Nurse 26(2): 238-47.
Delirium remains a commonly occurring problem for older people and staff in
acute care settings. The aim of this review of current literature is to find
contemporary evidence on which to base practice modalities. Although the
literature provides an exposition of the concerns with which practitioners are
currently faced and highlights the consistent themes identified, there is little
research evidence regarding the effectiveness of treatment protocols for the
management of older people with delirium in acute care setting.
Buffum, M. D., E. Hutt, et al. (2007). "Cognitive impairment and pain management:
review of issues and challenges." Journal of Rehabilitation Research & Development
44(2): 315-30.
The assessment and treatment of pain in persons with cognitive impairments
pose unique challenges. Disorders affecting cognition include
neurodegenerative, vascular, toxic, anoxic, and infectious processes. Persons
with memory, language, and speech deficits and consciousness alterations are
often unable to communicate clearly about their pain and discomfort. Past
research has documented that persons with cognitive impairments, particularly
dementia, are less likely to ask for and receive analgesics. This article provides
an overview of the assessment, treatment, and management of pain in adults
with cognitive impairments. We review types of cognitive impairment; recent work
specific to best practices for pain management in patients with dementia,
including assessment-tool development and pharmacological treatment;
challenges in patients with delirium and in medical intensive care and palliative
care settings; and directions for future research.
Buss, M. K., L. C. Vanderwerker, et al. (2007). "Associations between caregiverperceived delirium in patients with cancer and generalized anxiety in their caregivers."
Journal of Palliative Medicine 10(5): 1083-92.
BACKGROUND: Delirium, a common complication of advanced cancer, may put
caregivers at risk for poor mental health outcomes. We looked for a relationship
between caregiver-perceived delirium in a patient with advanced cancer and
rates of caregiver psychiatric disorders. METHODS: Using cross-sectional data
from 200 caregivers of patients with cancer with a life expectancy of less than 6
months, we determined the frequency of caregiver-perceived delirium, which was
defined as caregivers who reported witnessing the patient "confused, delirious"
on the Stressful Caregiving Response to Experiences of Dying (SCARED)
weekly or more often. We tested for associations between caregiver-reported
delirium and presence of caregiver mental disorders, using the Structured
Clinical Interview for the DSM-IV to diagnose mental disorders and caregiver
burden, as measured by the caregiver burden scale (CBS). RESULTS: Of the
200 caregivers who completed the SCARED, 38 (19.0%) reported seeing the
patient "confused, delirious" at least once per week in the month prior to study
enrollment and 7 (3.5%) met criteria for generalized anxiety (GA). Caregivers of
patients with caregiver-perceived delirium were 12 times more likely to have GA
(odds ratio [OR] 12.12; p < 0.01). The relationship between caregiver-perceived
delirium and caregiver GA persisted after adjusting for caregiver burden and
exposure to other stressful patient experiences (OR = 9.99; p = 0.04).
CONCLUSIONS: This is the first report of an association between caregiverperceived delirium and a caregiver mental health outcome. Further studies, using
improved measures of delirium, are needed.
Cameron, O. G. (2007). "Delirium, depression, and other psychosocial and
neurobehavioral issues in cardiovascular disease." Critical Care Clinics 23(4): 881-900.
Understanding relevant psychosocial (neural, behavioral, psychiatric) issues is
essential to optimal care of individuals who have cardiovascular disorders.
Delirium, a condition of diffuse cerebral dysfunction caused by underlying
systemic or central nervous system pathology, and often requiring measures of
acute neurobehavioral management with nonpharmacological and
pharmacological means, in addition to treatment of the underlying medical
disorder, often occurs in association with severe cardiovascular disease.
Depression is a psychiatric disorder known to be associated with cardiovascular
disease. Substantial improvement in understanding the nature of this association
has occurred in the past 10 to 20 years, including very preliminary data
suggesting that pharmacological treatment with selective serotonin reuptake
inhibitor (SSRI) antidepressants might improve postmyocardial infarction cardiac
prognosis. Numerous other factors-anxiety, stress, social support, anger, and
other personality factors-also are implicated in the relationship of psychosocial
issues to cardiovascular disease.
Cengiz, S. L. and A. Baysefer (2007). "A unique case of delirium resulting from electrical
accident-induced spinal trauma." Primary Care Companion to the Journal of Clinical
Psychiatry 9(4): 319.
Chiang, S., K. A. Gerten, et al. (2007). "Optimizing outcomes of surgery in advanced
age - Perioperative factors to consider." Clinical Obstetrics & Gynecology 50(3): 813825.
The gynecologic surgeon should be knowledgeable about the normal physiologic
changes associated with aging and skilled at assessing baseline medical
comorbidities, neuropsychiatric, nutritional, social, and functional status as
increasing numbers of older women seek and undergo surgical interventions to
improve their quality of life. A multidisciplinary approach to the perioperative care
of the older woman, aiming for prevention and early intervention, can help
minimize both typical surgical complications and "geriatric" complications.
[References: 25]
Cigolle, C. T., K. M. Langa, et al. (2007). "Geriatric conditions and disability: the Health
and Retirement Study." Annals of Internal Medicine 147(3): 156-64.
BACKGROUND: Geriatric conditions, such as incontinence and falling, are not
part of the traditional disease model of medicine and may be overlooked in the
care of older adults. The prevalence of geriatric conditions and their effect on
health and disability in older adults has not been investigated in population-based
samples. OBJECTIVE: To investigate the prevalence of geriatric conditions and
their association with dependency in activities of daily living by using nationally
representative data. DESIGN: Cross-sectional analysis. SETTING: Health and
Retirement Study survey administered in 2000. PARTICIPANTS: Adults age 65
years or older (n = 11 093, representing 34.5 million older Americans) living in
the community and in nursing homes. MEASUREMENTS: Geriatric conditions
(cognitive impairment, falls, incontinence, low body mass index, dizziness, vision
impairment, hearing impairment) and dependency in activities of daily living
(bathing, dressing, eating, transferring, toileting). RESULTS: Of adults age 65
years or older, 49.9% had 1 or more geriatric conditions. Some conditions were
as prevalent as common chronic diseases, such as heart disease and diabetes.
The association between geriatric conditions and dependency in activities of daily
living was strong and significant, even after adjustment for demographic
characteristics and chronic diseases (adjusted risk ratio, 2.1 [95% CI, 1.9 to 2.4]
for 1 geriatric condition, 3.6 [CI, 3.1 to 4.1] for 2 conditions, and 6.6 [CI, 5.6 to
7.6] for > or =3 conditions). LIMITATIONS: The study was cross-sectional and
based on self-reported data. Because measures were limited by the survey
questions, important conditions, such as delirium and frailty, were not assessed.
Survival biases may influence the estimates. CONCLUSIONS: Geriatric
conditions are similar in prevalence to chronic diseases in older adults and in
some cases are as strongly associated with disability. The findings suggest that
geriatric conditions, although not a target of current models of health care, are
important to the health and function of older adults and should be addressed in
their care.
Cremer, O. L. and C. J. Kalkman (2007). "Cerebral pathophysiology and clinical
neurology of hyperthermia in humans." Progress in Brain Research 162: 153-69.
Deliberate hyperthermia has been used clinically as experimental therapy for
neoplastic and infectious diseases. Several case fatalities have occurred with this
form of treatment, but most were attributable to systemic complications rather
than central nervous system toxicity. Nonetheless, demyelating peripheral
neuropathy and neurological symptoms of nausea, delirium, apathy, stupor, and
coma have been reported. Temperatures exceeding 40 degrees C cause
transient vasoparalysis in humans, resulting in cerebral metabolic uncoupling and
loss of pressure-flow autoregulation. These findings may be related to the
development of brain edema, intracerebral hemorrhage, and intracranial
hypertension observed after prolonged therapeutic hyperthermia. Furthermore,
deliberate hyperthermia critically worsens the extent of histopathological damage
in animal models of traumatic, ischemic, and hypoxic brain injury. However, it is
unknown whether these findings translate to episodes of spontaneous fever in
neurologically injured patients. In a clinical setting fever is a strong prognostic
marker of a patient's primary degree of neuronal damage, and a causal relation
with long-term functional neurological outcome has not been established for most
types of brain injury. Furthermore, in the neurosurgical intensive-care unit fever is
extremely common whereas antipyretic therapy is only poorly effective. Therefore
maintaining strict normothermia may be an impossible goal in many patients.
Although there are several physiological arguments for avoiding exogenous
hyperthermia in neurologically injured patients, there is no evidence that
aggressive attempts at controlling spontaneous fever can improve clinical
outcome.
Devlin, J. W., J. J. Fong, et al. (2007). "Use of a validated delirium assessment tool
improves the ability of physicians to identify delirium in medical intensive care unit
patients." Critical Care Medicine 35(12): 2721-4; quiz 2725.
OBJECTIVE: Although medical intensive care unit nurses at our institution
routinely use the Intensive Care Delirium Screening Checklist (ICDSC) to identify
delirium, physicians rely on traditional diagnostic methods. We sought to
measure the effect of physicians' use of the ICDSC on their ability to detect
delirium. DESIGN: Before-after study. SETTING: Medical intensive care unit of
an academic medical center. PATIENTS AND PARTICIPANTS: A total of 25
physicians with >or=1 month of clinical experience in the medical intensive care
unit conducted 300 delirium assessments in 100 medical intensive care unit
patients. MEASUREMENTS AND MAIN RESULTS: Physicians sequentially
evaluated two patients for delirium using whatever diagnostic method preferred.
Following standardized education regarding ICDSC use, each physician
evaluated two different patients for delirium using the ICDSC. Each physician
assessment was preceded by consecutive, but independent, evaluations for
delirium by the patient's nurse and then a validated judge using the ICDSC.
Before (PRE) physician ICDSC use, the validated judge identified delirium in five
patients; the physicians and nurses identified delirium in zero and four of these
patients, respectively. The physicians incorrectly identified delirium in four
additional patients. After (POST) physician ICDSC use, the validated judge
identified delirium in 11 patients; the physicians and nurses identified delirium in
eight and ten of these patients, respectively. The physicians incorrectly identified
delirium in one patient. After physician ICDSC use, agreement improved between
both the physicians and validated judge (PRE kappa = -0.14 [95% confidence
interval {CI} = -0.27 to -0.02] to POST kappa = 0.67 [95% CI = 0.38 to 0.96]) and
physicians and nurses (PRE kappa = -0.15 [95% CI = -0.29 to -0.02] to POST
kappa = 0.58 [95% CI = 0.25 to 0.91]). Nurses vs. validated judge agreement
was strong in both periods (PRE kappa = 0.65 [95% CI = 0.29 to 1.00] and POST
kappa = 0.92 [95% CI = 0.76 to 1.00]). CONCLUSIONS: Use of the ICDSC,
along with education supporting its use, improves the ability of physicians to
detect delirium in the medical intensive care unit.
Ebell, M. H. "Predicting delirium in hospitalized older patients." Journal.
Ebell, M. H. (2007). "Predicting delirium in hospitalized older patients." American Family
Physician 76(10): 1527-9.
Edlund, A., M. Lundstr..m, et al. (2007). "Symptom profile of delirium in older people
with and without dementia." Journal of Geriatric Psychiatry & Neurology 20(3): 166-71.
Clinical profiles of delirium in 717 older people with and without dementia age 75
years and older in 4 different types of care were studied. Delirium and dementia
were diagnosed according to DSM-IV criteria. Delirious demented participants (n
= 135) had more often had previous delirium episodes and were more often
being treated with analgesics compared to delirious participants without dementia
(n = 180). The clinical profile of delirium in the participants with dementia was
more frequently characterized by aggressivity, latency in reaction to verbal
stimuli, restlessness and agitation, delusions, anxiousness, hallucinations, and a
poorer orientation and recognition. Delirium among demented participants more
often had a fluctuating course during the day and was more common in the
evening and at night. In conclusion, clinical profiles of delirium in participants with
and without dementia are different, which might indicate a different etiology or
pathophysiology, or both, and a need for different treatment strategies.
Fadul, N., G. Kaur, et al. (2007). "Evaluation of the memorial delirium assessment scale
(MDAS) for the screening of delirium by means of simulated cases by palliative care
health professionals." Supportive Care in Cancer 15(11): 1271-6.
BACKGROUND: Delirium is among the most common neuropsychiatric
complications of advanced cancer. The Memorial Delirium Assessment Scale
(MDAS) is a widely used and validated screening tool for delirium in cancer
patients. OBJECTIVE: The purpose of this study was to assess the use of the
MDAS by different palliative care health professionals after receiving formal
training and a guiding manual for administration and scoring. MATERIALS AND
METHODS: Thirty-one palliative care health professionals received a training
session on the MDAS, including description of the tool, validation, and scoring.
Participants also received copies of a proposed standardized manual for
completion of the MDAS. Two of the investigators presented three simulated
cases to the participants, who independently completed a scoring sheet for each
case. The data were then analyzed according to the cases and the profession of
the operators. RESULTS: Thirty-one scoring sheets were analyzed (11
physicians, 12 nurses, and 8 others). A correct diagnosis was achieved by 30
(96.8%) of the 31 participants in case 1 (nondelirious, true score = 5, median = 5,
range = 2-15), 28 of 31 (90.3%) in case 2 (severe mixed delirium, true score =
20, median = 18, range = 10-26), and 31 of 31 in case 3 (mild hypoactive
delirium, true score = 14, median = 19, range = 13-25). Overall percentage of
error was 31% for items 2, 3, and 4 (cognitive) and 45% for all other items
(observational) (p < 0.001). The percentage of error did not differ between
physicians and nurses and other palliative care professionals (p > 0.99).
CONCLUSIONS: Our preliminary results suggest that adequate training and a
guiding manual can enhance the application of MDAS by palliative care health
professionals in the teaching settings. Clinical studies to assess the utility of the
MDAS as a screening tool are justified to further confirm these findings.
Fick, D., A. Kolanowski, et al. (2007). "High prevalence of central nervous system
medications in community-dwelling older adults with dementia over a three-year period."
Aging & Mental Health 11(5): 588-95.
Few recent studies have investigated the prevalence and outcomes for central
nervous system (CNS)-active medication use in older persons with dementia
(PWD) who live in the community. Thus, the purpose of this study was to
describe the health outcomes and patterns of use of CNS-active drugs in PWD
living in the community. Using a retrospective study design from a southeastern
managed care organization (MCO), claims data were collected for three years on
all identified cases with dementia and included age, gender, medical diagnoses
for each claim (International Classification of Disease [ICD-9 code]) and
prescription drugs (National Drug Code [NDC]). Individuals (N = 960) were
selected who were continuously enrolled and had prescription drug coverage.
Over 79% of PWD in this sample were on a CNS-active medication during the
three-year period and 35% were on a benzodiazepine. The highest number of
drug-related problems (DRPs) within 45 days after receiving a CNS drug
prescription were for syncope, fatigue, altered level of consciousness, delirium,
constipation, falls and fractures. This study illustrates the need to further examine
inappropriate CNS-active medication use in PWD and to test non-pharmacologic
therapies for the clinical problems that initiate their use in PWD.
Flaherty, J. H., J. Rudolph, et al. (2007). "Delirium is a serious and under-recognized
problem: why assessment of mental status should be the sixth vital sign." Journal of the
American Medical Directors Association 8(5): 273-5.
Fletcher, K., P. Hawkes, et al. (2007). "Using nurse practitioners to implement best
practice care for the elderly during hospitalization: the NICHE journey at the University
of Virginia Medical Center." Critical Care Nursing Clinics of North America 19(3): 32137.
The Nurses Improving Care to Health System (NICHE) program has provided a
valuable framework for developing initiatives that address the needs of the
elderly. Three NICHE models have been implemented within the University of
Virginia Health System since 1992. These include the Geriatric Resource Nurse
model, the Acute Care of the Elderly model, and, most recently, the Geriatric
Consultation Service model. Nurse practitioners (NPs) with geriatric expertise
have provided the leadership in implementing these initiatives to achieve the goal
of improving geriatric care delivery within the health system. Each NP functions
in a broad role that is tailored to meet the needs of the patients and staff and
includes the role components of clinician, educator, team leader, and care
coordinator. Sustainability and growth of NICHE is contingent upon
demonstrating favorable outcomes that can be directly attributed to NICHE.
Forbes, R. A., H. Kalra, et al. (2007). "Deliberate self-poisoning with tiagabine: an
unusual toxidrome." Emergency Medicine Australasia 19(6): 556-8.
Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial
gamma-aminobutyric acid uptake, resulting in increased gamma-aminobutyric
acid-mediated inhibition in the brain. Few reports in the literature describe the
clinical course of severe tiagabine intoxication. A 44-year-old woman presented
after deliberate self-poisoning with 100 tiagabine 15 mg tablets (1,500 mg; 25
mg/kg). Serum tiagabine level was 4,600 microg/L (1,725 mmol/L) at
presentation, 20 times levels associated with therapeutic dosing. Intoxication was
manifested by profuse vomiting, coma, myoclonus, generalized rigidity,
bradycardia, hypertension, hypersalivation and generalized piloerection within 2
h of ingestion. The patient was intubated and management was supportive.
Coma lasted until 10 h post-ingestion, but recovery was complicated by severe
agitated delirium lasting 12 h. The patient recovered fully within 26 h of ingestion.
Tiagabine deliberate self-poisoning was associated with the rapid onset of coma
and an unusual toxidrome. Recovery, although complicated by agitated delirium,
was complete within 26 h.
Furlaneto, M. E. and L. z. E. n. Garcez-Leme (2007). "Impact of delirium on mortality
and cognitive and functional performance among elderly people with femoral fractures."
Clinics (Sao Paulo, Brazil) 62(5): 545-52.
OBJECTIVE: To evaluate the evolution of cognitive and functional performance
and mortality among elderly patients who were delirious during hospitalization
due to femoral fracture. STUDY TYPE: Prospective cohort. LOCATION:
Orthopedics and Traumatology Institute of HC-FMUSP; geriatric orthopedic ward.
PATIENTS: 103 patients, aged 60 years or over, who were hospitalized in the
geriatric orthopedics ward with femoral fracture in 2001-2002. Thirty of them
(29.1%) presented with delirium during their hospital stay and were compared
with another 73 (70.9%) who did not present with delirium. There were six
deaths, and 97 patients were discharged from the hospital. We obtained
information on 85 of these patients four years after discharge; 42 patients were
still alive and 43 had died at the time of the evaluation. METHODS: Data on vital
status was obtained for 85 patients. For the 42 survivors, we acquired
information on their basic activities of daily living (ADL), instrumental activities of
daily living (IADL), and cognitive performance (BDRS) by means of telephone
interview with the same caregivers who had provided information at the time of
the hospitalization. We compared this data with that obtained during their
hospitalizations four years prior. For the 43 patients who died, we obtained
information regarding their deaths and used this data in the analysis of mortality.
RESULTS: No relationships were observed between delirium and mortality,
delirium and cognitive loss, or delirium and functional loss, after four years from
discharge of elderly patients with hip fractures. An initial cognitive deficit was a
predictor for mortality (RR = 2.54; p = 0.016), functional loss (OR = 1.80; p =
0.027) and cognitive loss (OR = 1.53; p = 0.024). Cognitive loss was also related
to age. CONCLUSIONS: Delirium had no impact on mortality or functional or
cognitive losses in long term evolution (2 years) among elderly patients with
femoral fractures. An initial cognitive impairment may identify patients at risk of
mortality, functional and cognitive losses over the long term evolution.
Ganai, S., K. F. Lee, et al. "Adverse outcomes of geriatric patients undergoing
abdominal surgery who are at high risk for delirium." Journal.
Hypothesis: Among geriatric patients undergoing abdominal surgery who are at
high risk for in-hospital delirium, clinical factors associated with delirium correlate
with adverse outcomes. Design: Retrospective case series study. Setting:
University-affiliated referral hospital. Patients: Among 228 consecutive patients
70 years or older who underwent major abdominal surgery from September 1,
2002, through December 31, 2003, 89 patients with risk factors for delirium were
included in the study. Main Outcome Measures: Preoperative, intraoperative, and
postoperative clinical factors known to affect the incidence of in-hospital delirium
were tested for correlation with adverse outcomes. Incidence of delirium,
mortality, and prolonged length of stay (LOS) of 14 days or longer were
evaluated as adverse outcomes. Results: Postoperative delirium occurred in
60%, death in 20%, and prolonged LOS in 32% of patients. Multivariate analysis
identified independent predictors of adverse outcomes. Poor preoperative
functional and nutritional status correlated with postoperative delirium and
mortality. Inadequate postoperative glycemic control also correlated with
mortality. Complications in 2 or more organ systems and postoperative
hypoalbuminemia (albumin level <3.0 mg/dL[<.003 g/dL; to convert to grams per
liter, multiply by 10]) correlated with prolonged LOS. Suboptimal care was
identified in the following clinical areas: use of precipitative medications,
prolonged bedrest, uncontrolled pain, hypoxia, and glycemic control.
Conclusions: In a subset of geriatric patients undergoing abdominal surgery who
are at high risk for inhospital delirium, adverse outcomes correlated only with key
clinical variables, such as hyperglycemia and poor nutritional and functional
states. A high incidence of suboptimal care was observed in several clinical
areas, suggesting opportunities for intervention. copyright2007 American Medical
Association. All rights reserved.
Ganai, S., K. F. Lee, et al. (2007). "Adverse outcomes of geriatric patients undergoing
abdominal surgery who are at high risk for delirium." Archives of Surgery 142(11): 10728.
HYPOTHESIS: Among geriatric patients undergoing abdominal surgery who are
at high risk for in-hospital delirium, clinical factors associated with delirium
correlate with adverse outcomes. DESIGN: Retrospective case series study.
SETTING: University-affiliated referral hospital. PATIENTS: Among 228
consecutive patients 70 years or older who underwent major abdominal surgery
from September 1, 2002, through December 31, 2003, 89 patients with risk
factors for delirium were included in the study. MAIN OUTCOME MEASURES:
Preoperative, intraoperative, and postoperative clinical factors known to affect
the incidence of in-hospital delirium were tested for correlation with adverse
outcomes. Incidence of delirium, mortality, and prolonged length of stay (LOS) of
14 days or longer were evaluated as adverse outcomes. RESULTS:
Postoperative delirium occurred in 60%, death in 20%, and prolonged LOS in
32% of patients. Multivariate analysis identified independent predictors of
adverse outcomes. Poor preoperative functional and nutritional status correlated
with postoperative delirium and mortality. Inadequate postoperative glycemic
control also correlated with mortality. Complications in 2 or more organ systems
and postoperative hypoalbuminemia (albumin level <3.0 mg/dL[<.003 g/dL; to
convert to grams per liter, multiply by 10]) correlated with prolonged LOS.
Suboptimal care was identified in the following clinical areas: use of precipitative
medications, prolonged bedrest, uncontrolled pain, hypoxia, and glycemic
control. CONCLUSIONS: In a subset of geriatric patients undergoing abdominal
surgery who are at high risk for in-hospital delirium, adverse outcomes correlated
only with key clinical variables, such as hyperglycemia and poor nutritional and
functional states. A high incidence of suboptimal care was observed in several
clinical areas, suggesting opportunities for intervention.
Gentric, A., P. Le Deun, et al. (2007). "[Prevention of delirium in an acute geriatric care
unit]." Revue de Medecine Interne 28(9): 589-93.
PURPOSE: Delirium is the most common complication of hospitalization in frail
elderly. The prognosis is poor with increased mortality and morbidity. Confusion
results from one or several precipitating factors in patients at risk. In a
randomized study, a preventive multicomponent intervention reduced the
incidence of delirium by 40%. The aim of our study was to evaluate the efficacy
of such a preventive strategy, in the setting of an acute geriatric care unit.
METHODS: The study was conducted in a French 26-bed geriatric acute care
ward. The primary outcome was the comparison of the incidence of delirium
among patients aged 75 years and older, before and after the implementation of
a preventive strategy. The overall adherence of the ward staff to the prevention
procedures was also determined. RESULTS: Before intervention, 367 patients
were admitted (mean age: 80.6 years). The incidence of delirium was of 8.99%.
In the subgroup of 123 demented patients, the incidence of delirium was of
15.4%. After intervention, 372 patients were admitted (mean age 84.9). The
incidence of delirium was of 2.4% (relative risk reduction of 73%, P=0.001). In the
subgroup of 133 demented patients, the incidence of delirium was 5.3% (relative
risk reduction of 66%, P=0.01). The ward staff applied the prevention procedures
in 96% of the 10 230 patients-day during the study period. CONCLUSION: This
study shows that it is possible to apply the results of clinical research in clinical
practice to prevent delirium in frail elderly hospitalized in an acute geriatric care
unit. Such an easy preventive strategy could be applied in medical units
admitting old patients at risk, in the context of a quality procedure.
Girard, T. D., A. K. Shintani, et al. (2007). "Comment on "Incidence, risk factors and
consequences of ICU delirium" by Ouimet et al." Intensive Care Medicine 33(8): 147980; author reply 1481-2.
Gordon, G. (2007). "JPM patient information. Delirium." Journal of Palliative Medicine
10(5): 1216-7.
Gosney, M. (2007). "Contribution of the geriatrician to the management of cancer in
older patients." European Journal of Cancer 43(15): 2153-2160.
With an increasingly aged population, many patients will present with cancer in
their 80s and 90s. Although some may be very fit, frail individuals will require the
input of geriatricians to aid in the assessment of co-existing morbidity, in an
attempt to assess those most likely to benefit from active treatment of their
cancer, and those in whom the 'giants of geriatric medicine' require special
consideration before undergoing definitive cancer therapy. The role of the
geriatrician in assessment and management of such patients, together with
communication and end of life care, may be more important in ensuring a good
quality of life, than the cancer therapy itself. Whilst numbers of geriatricians will
not be adequate to care for all elderly patients with cancer, a variety of
assessment scales will help target financial and manpower resources to those
most at risk. (C) 2007 Elsevier Ltd. All rights reserved. [References: 64]
Gunther, M. L., J. C. Jackson, et al. (2007). "The cognitive consequences of critical
illness: practical recommendations for screening and assessment." Critical Care Clinics
23(3): 491-506.
Critically ill patients are at risk for several secondary complications, including
delirium and long-term cognitive impairment. The exact mechanisms of delirium
and ICU-related cognitive decline are not fully understood; however, the authors
review several recent investigations that have proposed plausible explanations.
This article also includes several practical guidelines for the identification and
management of delirium to aid in the development and implementation of clinical
procedures that will lower the risk for ICU delirium and cognitive decline.
Gunther, M. L., J. C. Jackson, et al. (2007). "Loss of IQ in the ICU brain injury without
the insult." Medical Hypotheses 69(6): 1179-82.
Critically ill patients are at high risk of developing serious neurological
dysfunctions including delirium and long-term neurocognitive impairment. Here a
novel mechanism is proposed for this highly deleterious condition. A growing
body of evidence has shown that critical illness and its treatment can lead to de
novo cerebral atrophy including white and grey matter abnormalities, delirium,
and neurocognitive decline. In healthy individuals, normal and consistent
connectivity between the posterior parietal cortex (PPC), medial temporal lobe
(MTL) and prefrontal cortex (PFC) maintains consciousness and normal cognitive
functioning. The circuit is innervated, activated and maintained by the ascending
reticular activating system (ARAS) arising from the brainstem. As elderly
individuals begin to show signs of grey matter atrophy in the PPC, MTL and PFC,
functional connectivity between these regions remains intact; however, the
strength of the connections is no longer robust as it once was in the healthy
CNS. This circuit continues to be activated and maintained via the ARAS.
Individuals treated in the ICU are subject to a number of medical and
pharmacological challenges which may disrupt normal CNS connectivity. Serious
illnesses such as sepsis, acute respiratory distress syndrome (ARDS), and acute
lung injury (ALI), as well as sedative and analgesic medications commonly
prescribed in the ICU have the potential to disrupt the functional link in the circuit
described above. Minor fluctuations in the ARAS (i.e. hyper or hypo activation)
may be sufficient in elderly individuals to cause a disruption which surpasses the
critical threshold of functional connectivity necessary to maintain normal (i.e. nondelirious) consciousness. In combination with exposure to other ICU related
threats to neurocognitive function, prolonged decoupling of this circuit may lead
to deleterious neurodegenerative consequences such as excitotoxicity. Over time
this has the potential to result in apoptosis and long-term cognitive impairment.
Delirium appears to be a good candidate for the causal mechanism of ICU
related cognitive decline and may be a critical point of intervention.
Harari, D., F. C. Martin, et al. (2007). "The older persons' assessment and liaison team
'OPAL': evaluation of comprehensive geriatric assessment in acute medical inpatients."
Age & Ageing 36(6): 670-5.
BACKGROUND: Reducing hospital length of stay (LOS) in older acute medical
inpatients is a key productivity measure. Evidence-based predictors of greater
LOS may be targeted through Comprehensive Geriatric Assessment (CGA).
OBJECTIVE: Evaluate a novel service model for CGA screening of older acute
medical inpatients linked to geriatric intervention. SETTING: Urban teaching
hospital. SUBJECTS: Acute medical inpatients aged 70+ years.
INTERVENTION: Multidisciplinary CGA screening of all acute medical
admissions aged 70+ years leading to (a) rapid transfer to geriatric wards or (b)
case-management on general medical wards by Older Persons Assessment and
Liaison team (OPAL). METHODS: Prospective pre-post comparison with
statistical adjustment for baseline factors, and use of national benchmarking LOS
data. Pre-OPAL (n = 46) and post-OPAL (n = 49) cohorts were similarly identified
as high-risk by the CGA screening tool, but only post-OPAL patients received the
intervention. RESULTS: Pre-OPAL, 0% fallers versus 92% post-OPAL were
specifically assessed and/or referred to a falls service post-discharge.
Management of delirium, chronic pain, constipation, and urinary incontinence
similarly improved. Over twice as many patients were transferred to geriatric
wards, with mean days from admission to transfer falling from 10 to 3. Mean LOS
fell by 4 days post-OPAL. Only the OPAL intervention was associated with LOS
(P = 0.023) in multiple linear regression including case-mix variables (e.g. age,
function, 'geriatric giants'). Benchmarking data showed the LOS reduction to be
greater than comparable hospitals. CONCLUSION: CGA screening of acute
medical inpatients leading to early geriatric intervention (ward-based case
management, appropriate transfer to geriatric wards), improved clinical
effectiveness and general hospital performance.
Harston, S. (2007). "[Pitfalls in the diagnosis of epilepsy in the elderly.]." Psychologie et
Neuropsychiatrie du Vieillissement 5 Suppl 1: 10-8.
The current increase of life expectancy amplifies the visibility of the higher
prevalence of epilepsy during the course of aging, first described in the 1970's.
The epileptic symptoms do not fundamentally differ after the age of 75 from those
met in younger adults, but the increase in the frequency, on one hand, of other
neurological conditions (especially dementias and their psycho-behavioral
complications, and strokes) and, on the other hand, of non-specific geriatric
syndromes such as delirium, can result in diagnostic mistakes detrimental for
appropriate geriatric care. We report the case of a seventy-eight year old female
patient who initially presented as a probable dementia with Lewy bodies, then
featured a status epilepticus mainly revealed by a delirium first related to an
iatrogenic event, followed by partial recovery, then presented a reversible nonsituationnal status epilepticus, and was finally proven to have a CreutzfeldtJakob's disease. If dementia is nowadays considered as one of the major
elements to be taken into account in the organization of neurological and geriatric
care, a pluridisciplinary approach should, in the same way, better define the
place of diagnosis and care of epilepsy in older patients.
Heckman, G. A., C. J. Patterson, et al. (2007). "Heart failure and cognitive impairment:
challenges and opportunities." Clinical Interventions In Aging 2(2): 209-18.
As populations age, heart failure (HF) is becoming increasingly common, and in
addition to a high burden of morbidity and mortality, HF has an enormous
financial impact. Though disproportionately affected by HF, the elderly are less
likely to receive recommended therapies, in part because clinical trials of HF
therapy have ignored outcomes of importance to this population, including
impaired cognitive function (ICF). HF is associated with ICF, manifested primarily
as delirium in hospitalized patients, or as mild cognitive impairment or dementia
in otherwise stable outpatients. This association is likely the result of shared risk
factors, as well as perfusion and rheological abnormalities that occur in patients
with HF. Evidence suggests that these abnormalities may be partially reversible
with standard HF therapy. The clinical consequences of ICF in HF patients are
significant. Clinicians should consider becoming familiar with screening
instruments for ICF, including delirium and dementia, in order to identify patients
at risk of nonadherence to HF therapy and related adverse consequences.
Preliminary evidence suggests that optimal HF therapy in elderly patients may
preserve or even improve cognitive function, though the impact on related
outcomes remains to be determined.
Heidrich, D. E. (2007). "Delirium: an under-recognized problem." Clinical Journal of
Oncology Nursing 11(6): 805-7.
Case Study: Ms. G, a 78-year-old woman with a history of heart failure and a left
ventricular ejection fraction of 45%, had an exploratory laparotomy with colon
resection and colostomy two days ago for an obstructive stage IIIB
adenocarcinoma of the colon. She is a patient on a general surgical unit. Upon
assessment at 7 am, Ms. G was easily aroused and oriented. She has a patientcontrolled analgesia (PCA) pump for postoperative pain control with 1 mg of
morphine available every 30 minutes; she used a total of 4 mg of morphine via IV
since midnight. Ms. G requires belladonna and opium suppositories about every
eight hours to treat bladder spasms associated with her urinary catheter.
Heymann, A., M. Sander, et al. "Hyperactive delirium and blood glucose control in
critically ill patients." Journal.
Delirium is a common complication of critically ill patients and is often associated
with metabolic disorders. One of the most frequent metabolic disorders in
intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective
study of 196 adult ICU patients was to determine if there is an association
between hyperactive delirium and blood glucose levels in ICU patients.
Hyperactive delirium was diagnosed using the delirium detection score. Blood
glucose levels were monitored by blood gas analysis every 4 h. Hyperactive
delirium was detected in 55 (28%) patients. Delirious patients showed
significantly higher blood glucose levels than non-delirious patients Higher overall
complication rates, length of ventilation, ICU stay and mortality rates were seen
in the delirium group. In a multivariate analysis, glucose level, alcohol abuse,
APACHE II score, complication by hospital-acquired pneumonia and a diagnosis
of polytrauma on-admission all significantly influenced the appearance of
delirium.
Heymann, A., M. Sander, et al. (2007). "Hyperactive delirium and blood glucose control
in critically ill patients." Journal of International Medical Research 35(5): 666-77.
Delirium is a common complication of critically ill patients and is often associated
with metabolic disorders. One of the most frequent metabolic disorders in
intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective
study of 196 adult ICU patients was to determine if there is an association
between hyperactive delirium and blood glucose levels in ICU patients.
Hyperactive delirium was diagnosed using the delirium detection score. Blood
glucose levels were monitored by blood gas analysis every 4 h. Hyperactive
delirium was detected in 55 (28%) patients. Delirious patients showed
significantly higher blood glucose levels than non-delirious patients Higher overall
complication rates, length of ventilation, ICU stay and mortality rates were seen
in the delirium group. In a multivariate analysis, glucose level, alcohol abuse,
APACHE II score, complication by hospital-acquired pneumonia and a diagnosis
of polytrauma on-admission all significantly influenced the appearance of
delirium.
Homsi, J. and D. Luong (2007). "Symptoms and survival in patients with advanced
disease." Journal of Palliative Medicine 10(4): 904-9.
Predicting survival in patients with advanced disease is challenging for health
care providers. Accurate survival estimation using symptom assessment may
assist physicians and patients in determining treatment options. This report
analyzes prospective studies in adult patients with a median/mean survival of 6
months or less and identifies symptoms that are associated with decreased
survival. To be included in this analysis, a study needed to have at least one
symptom associated with decreased survival in a univariate or multivariate
analysis. Twenty-two studies were identified and 15 symptoms were associated
with decreased survival. Anorexia, delirium, and dyspnea were associated with
decreased survival in most studies. Delirium and anorexia (but not dyspnea)
were associated with decreased survival in most studies that included patients
with a median survival of 30 days or less. More research is needed to investigate
any associations between symptom characteristics and survival in patients with
advanced disease. Short assessment tools using symptoms identified in this
report, with a focus on symptoms that were found in multiple studies, need to be
developed to better predict survival and guide patient treatment. [References: 35]
Hwang, U. and S. Morrison (2007). "The geriatric emergency department." Journal of
the American Geriatrics Society 55(11): 1873-1876.
With the aging of the population and the demographic shift of older adults in the
healthcare system, the emergency department (ED) will be increasingly
challenged with complexities of providing care to geriatric patients. The special
care needs of older adults unfortunately may not be aligned with the priorities for
how ED physical design and care is rendered. Rapid triage and diagnosis may
be impossible in the older patient with multiple comorbidities, polypharmacy, and
functional and cognitive impairments who often presents with subtle clinical signs
and symptoms of acute illness. The use of Geriatric Emergency Department
Interventions, structural and process of care modifications addressing the special
care needs of older patients, may help to address these challenges. [References:
30]
Inott, T. (2007). "Is it delirium, dementia, or depression? How can I differentiate between
delirium, dementia, and depression in the older adults I care for in the medical/surgical
unit?" Nursing 37(11): 65.
Iseli, R. K., C. Brand, et al. "Delirium in elderly general medical inpatients: A prospective
study." Journal.
Background: More than 49% of all US hospital days are spent caring for patients
with delirium. There are few Australian data on this important condition. The aim
of the study was to determine the prevalence and incidence of delirium in older
medical inpatients in a metropolitan teaching hospital, the incidence of known
risk factors and current practice in identifying and managing patients at risk of
this condition. Methods: Patients aged 65 years or more, and admitted to a
general medical unit, were eligible for study inclusion. Participants were screened
with an Abbreviated Mental Test Score (AMTS) and chart review. Confusion
Assessment Method was used to diagnose delirium if confusion was documented
or AMTS <8. Barthel Index (BI), demographics, delirium risk factors and
management were recorded. Results: Prevalent delirium was diagnosed in 19 of
104 (18%) and incident delirium in 2 of 85 (2%) participants. Pre-existing
cognitive impairment and admission AMTS <8 were strongly associated with
prevalent delirium (P-values <0.01). Age >80 years, Barthel Index [less-than or
equal to]50, use of high-risk medications and electrolyte disturbance were also
associated with prevalent delirium. Prevalent delirium was not recognized by the
treating unit in 4 of 19 cases (21%). Five of 104 (4.8%) of participants had a
formal cognitive assessment on admission. One of 19 patients (5.3%) with
prevalent delirium had an orientation device in their room. Conclusion: Pre-
existing cognitive impairment and admission AMTS are strong predictors of
delirium. Despite this, formal cognitive assessment is not routinely carried out in
elderly medical patients. Recognition of delirium may be improved by routine
cognitive assessment in elderly medical patients. copyright 2007 Royal
Australasian College of Physicians.
Iseli, R. K., C. Brand, et al. (2007). "Delirium in elderly general medical inpatients: a
prospective study." Internal Medicine Journal 37(12): 806-11.
BACKGROUND: More than 49% of all US hospital days are spent caring for
patients with delirium. There are few Australian data on this important condition.
The aim of the study was to determine the prevalence and incidence of delirium
in older medical inpatients in a metropolitan teaching hospital, the incidence of
known risk factors and current practice in identifying and managing patients at
risk of this condition. METHODS: Patients aged 65 years or more, and admitted
to a general medical unit, were eligible for study inclusion. Participants were
screened with an Abbreviated Mental Test Score (AMTS) and chart review.
Confusion Assessment Method was used to diagnose delirium if confusion was
documented or AMTS < 8. Barthel Index (BI), demographics, delirium risk factors
and management were recorded. RESULTS: Prevalent delirium was diagnosed
in 19 of 104 (18%) and incident delirium in 2 of 85 (2%) participants. Pre-existing
cognitive impairment and admission AMTS < 8 were strongly associated with
prevalent delirium (P-values < 0.01). Age > 80 years, Barthel Index < or = 50,
use of high-risk medications and electrolyte disturbance were also associated
with prevalent delirium. Prevalent delirium was not recognized by the treating unit
in 4 of 19 cases (21%). Five of 104 (4.8%) of participants had a formal cognitive
assessment on admission. One of 19 patients (5.3%) with prevalent delirium had
an orientation device in their room. CONCLUSION: Pre-existing cognitive
impairment and admission AMTS are strong predictors of delirium. Despite this,
formal cognitive assessment is not routinely carried out in elderly medical
patients. Recognition of delirium may be improved by routine cognitive
assessment in elderly medical patients.
Katsumata, Y., M. Harigai, et al. (2007). "Diagnostic reliability of cerebral spinal fluid
tests for acute confusional state (delirium) in patients with systemic lupus
erythematosus: interleukin 6 (IL-6), IL-8, interferon-alpha, IgG index, and Q-albumin."
Journal of Rheumatology 34(10): 2010-7.
OBJECTIVE: Acute confusional state (ACS) is an uncommon but severe central
nervous system (CNS) syndrome in systemic lupus erythematosus (SLE) defined
by clinical manifestations. To develop useful and reliable diagnostic tools for
ACS, we evaluated the association of cerebral spinal fluid (CSF) tests with ACS
and their predictive values for the diagnosis of ACS in SLE. METHODS: We
performed a prospective study using a cohort of 59 patients with SLE and
compared those with and without ACS. Associations between ACS and each
CSF test [interleukin 6 (IL-6), IL-8, interferon-alpha, IgG index, and Q-albumin]
were statistically evaluated. Each patient underwent all CSF evaluations.
RESULTS: ACS was diagnosed in 10 patients (ACS group), SLE-related CNS
syndromes except ACS in 13, and no CNS syndromes in 36 (non-CNS group).
CSF IL-6 levels in the ACS group were significantly higher than those in the nonCNS group (p < 0.05). A positive IgG index (p = 0.028) was significantly
associated with ACS. No other test showed a significant association with ACS.
The positive and negative predictive values for the diagnosis of ACS in SLE were
80% and 85% for elevated CSF IL-6 levels (> or = 31.8 pg/ml), and 75% and
83% for the IgG index, respectively. CONCLUSION: No single CSF test had
sufficient predictive value to diagnose ACS in SLE, although CSF IL-6 levels and
the IgG index showed statistical associations with ACS. Use of CSF tests
combined with careful history and clinical examinations is recommended for
proper diagnosis of ACS in SLE.
Kawanishi, C., H. Onishi, et al. (2007). "Unexpectedly high prevalence of akathisia in
cancer patients." Palliative & Supportive Care 5(4): 351-4.
OBJECTIVES: Complications of neuropsychiatric disorders are often detected in
cancer patients. Adjustment disorders, depression, or delirium are common
psychiatric disorders in these patients, and drug-induced neuropsychiatric
problems are sometimes referred for psychiatric consultation. Prochlorperazine
and other antiemetic drugs that are phenothiazine derivates are also reported to
cause akathisia due to the blockade of the dopamine receptor in the central
nervous system, but the, prevalence of akathisia in patients undergoing cancer
treatment has not been reported. This study seeks to explore the prevalence of
such drug-induced syndromes (e.g., akathisia) in this population. METHODS:
This present study was a prospective study. The subjects of this study were 483
consecutive patients with cancer who had been referred to the Department of
Psychiatry in Kanagawa Prefecture Cancer Center from February 1, 2004, to
November 30, 2005. Trained psychiatrists conducted a nonstructured psychiatric
interview and neurologic examination to establish psychiatric diagnoses
according to DSM-IV and the presence or absence of drug-induced extra
pyramidal symptoms. The past and current medications used in their cancer
treatment were also examined in detail for an accurate evaluation. Results: A
psychiatric diagnosis was made in 420 (87.0%) of the 483 cancer patients
examined, and akathisia, a drug-induced movement disorder, was unexpectedly
prevalent among the patients; 20 of 420 (4.8%) patients had developed akathisia
from an antiemetic drug, prochlorperazine. SIGNIFICANCE OF RESULTS:
Diagnosing such adverse drug reactions may be difficult due to complicating
factors in cancer treatment, and the inner restlessness observed in akathisia is
likely to be regarded as a symptom of a primary psychiatric disorder. The authors
suggest that oncologists should optimize the use of antiemetic drugs and be
aware of akathisia as a possible complication of cancer treatment.
Kirshner, H. S. (2007). "Delirium: a focused review." Current Neurology & Neuroscience
Reports 7(6): 479-82.
Delirium is a common condition, especially in hospitalized patients. It is also
associated with increased morbidity and mortality. Several studies have
investigated risk factors for the development of delirium during hospitalization.
This article reviews the clinical features, etiology, clinical evaluation, and
treatment of this syndrome.
Kishi, Y., M. Kato, et al. "Delirium: patient characteristics that predict a missed diagnosis
at psychiatric consultation." Journal.
Objective: This study evaluates patient characteristics that might predict a
missed diagnosis of delirium prior to being seen by a psychiatric consultant.
Method: Study participants were assessed using quantitative standardized scales
of cognitive function, delirium and physical impairment. Results: Referring service
personnel missed the diagnosis of delirium in 46% of psychiatric consultations.
Two factors were associated with their failure to identify delirium accurately: use
of a past psychiatric diagnosis to explain delirium symptoms and the presence of
pain. Symptoms of delirium and quantitative scale scores did not distinguish
between patients with whom diagnosis had been missed and those with accurate
diagnoses. Conclusion: The consulting physicians of patients with delirium often
incorrectly turn to past psychiatric diagnoses and/or are distracted by the
presence of pain and, thus, fail to accurately diagnose delirium. copyright 2007
Elsevier Inc. All rights reserved.
Kishi, Y., M. Kato, et al. (2007). "Delirium: patient characteristics that predict a missed
diagnosis at psychiatric consultation." General Hospital Psychiatry 29(5): 442-5.
OBJECTIVE: This study evaluates patient characteristics that might predict a
missed diagnosis of delirium prior to being seen by a psychiatric consultant.
METHOD: Study participants were assessed using quantitative standardized
scales of cognitive function, delirium and physical impairment. RESULTS:
Referring service personnel missed the diagnosis of delirium in 46% of
psychiatric consultations. Two factors were associated with their failure to identify
delirium accurately: use of a past psychiatric diagnosis to explain delirium
symptoms and the presence of pain. Symptoms of delirium and quantitative scale
scores did not distinguish between patients with whom diagnosis had been
missed and those with accurate diagnoses. CONCLUSION: The consulting
physicians of patients with delirium often incorrectly turn to past psychiatric
diagnoses and/or are distracted by the presence of pain and, thus, fail to
accurately diagnose delirium.
Kohen, I. "Oseltamivir-induced delirium in a geriatric patient [5]." Journal.
Kohen, I. (2007). "Oseltamivir-induced delirium in a geriatric patient." International
Journal of Geriatric Psychiatry 22(9): 935-6.
Kong, V. K. F. and M. G. Irwin (2007). "Gabapentin: a multimodal perioperative drug?"
British Journal of Anaesthesia 99(6): 775-86.
Gabapentin is a second generation anticonvulsant that is effective in the
treatment of chronic neuropathic pain. It was not, until recently, thought to be
useful in acute perioperative conditions. However, a growing body of evidence
suggests that perioperative administration is efficacious for postoperative
analgesia, preoperative anxiolysis, attenuation of the haemodynamic response to
laryngoscopy and intubation, and preventing chronic post-surgical pain,
postoperative nausea and vomiting, and delirium. This article reviews the clinical
trial data describing the efficacy and safety of gabapentin in the setting of
perioperative anaesthetic management. [References: 131]
Landers, J. and A. Bonner (2007). "Evaluating and managing delirium, dementia, and
depression in older adults hospitalized with otorhinolaryngic conditions." ORL - Head &
Neck Nursing 25(3): 14-25.
Nurses caring for patients who have otorhinolaryngic conditions undergoing
medical and surgical treatments find that their patient populations are becoming
older and sicker. These patients are more likely to develop delirium, often
superimposed on depression or dementia. Sorting out the medical, surgical, and
psychosocial changes in geriatric patients presents unique challenges to
otorhinolaryngology (ORL) nurses. This paper reviews the evaluation and
management of delirium, dementia, and depression in hospitalized elders,
focusing on a new resource, the evidence-based Mental Health Toolkit,
developed by the National Conference of Gerontological Nurse Practitioners
(NCGNP). The paper further provides material for a structured journal club
activity, including a common ORL clinical scenario and learning objectives, as
well as discussion questions and answers. [References: 45]
Lescot, T., A. R. Pereira, et al. (2007). "Effect of loxapine on electrical brain activity,
intracranial pressure, and middle cerebral artery flow velocity in traumatic brain-injured
patients." Neurocritical Care 7(2): 124-7.
INTRODUCTION: Delirium is a frequent complication of traumatic brain injury,
especially during the weaning period. Antipsychotic drugs are often used in this
case. Loxapine is a tricyclic antipsychotic drug with sedating properties. The
effects of intravenous loxapine on EEG as well as on systemic and cerebral
hemodynamics after traumatic brain injury are unknown. METHODS: Seven
sedated and mechanically ventilated traumatic brain injured patients were
studied 11 +/- 5 days after trauma. They were on continuous perfusion of
sufentanil and midazolam. Left and right spectral edge frequency (SEFl, SEFr) of
continuous EEG recording, intracranial pressure (ICP), mean flow velocity of the
middle cerebral artery (MFV(MCA)) and mean arterial pressure (MAP) were
simultaneously recorded and digitalized before and after loxapine infusion (10 mg
in 10 min of continuous infusion). RESULTS: Loxapine induced no significant
change on MAP, MFV. On the contrary, it decreased ICP and both SEFl, SEFr.
ETCO(2 )and the dose of vasopressors were not altered during the study period.
CONCLUSION: 10 mg of loxapine administered intravenously over 10 min
decreased brain electrical activity. There is a concomitant reduction in ICP
without any significant change in cerebral blood flow velocity. The use of
intravenous loxapine to control agitation is not accompanied by deleterious
hemodynamic or systemic effects in ICU's traumatic brain injured patients.
Lester, P. and T. Varghese "Delirium in a nursing home resident." Journal.
Leung, J. M., L. P. Sands, et al. (2007). "Apolipoprotein E e4 allele increases the risk of
early postoperative delirium in older patients undergoing noncardiac surgery."
Anesthesiology 107(3): 406-11.
BACKGROUND: Whether patients who subsequently develop early
postoperative delirium have a genetic predisposition that renders them at risk for
postoperative delirium has not been determined. METHODS: The authors
conducted a nested cohort study to include patients aged > or = 65 yr who were
scheduled to undergo major noncardiac surgery requiring anesthesia. A
structured interview was conducted preoperatively and for the first 2 days
postoperatively to determine the presence of delirium, defined using the
Confusion Assessment Method. Blood was drawn for measurement of the
apolipoprotein genotypes. Bivariate tests of association were conducted between
delirium and apolipoprotein genotypes and other potentially important risk
factors. Variables that had significant bivariate association with postoperative
delirium were entered in a forward multivariable logistic regression model.
RESULTS: Of the 190 patients studied, 15.3% developed delirium on both days
1 and 2 after surgery. Forty-six patients (24.2%) had at least one copy of the
apolipoprotein e4 allele. The presence of one copy of the e4 allele was
associated with an increased risk of early postoperative delirium (28.3% vs.
11.1%; P = 0.005). Even after adjusting for covariates, patients with one copy of
the e4 allele were still more likely to have an increased risk of early postoperative
delirium (odds ratio, 3.64; 95% confidence interval, 1.51-8.77) compared with
those without the e4 allele. CONCLUSIONS: Apolipoprotein e4 carrier status was
associated with an increased risk for early postoperative delirium after controlling
for known demographic and clinical risk factors. These results suggest that
genetic predisposition plays a role and may interact with anesthetic/surgical
factors contributing to the development of early postoperative delirium.
Levy, M. (2007). "Delirium likely caused by interaction between phenytoin and
temozolomide." Psychosomatics 48(4): 359-60.
Lleshi, V., P. Budry, et al. (2007). "[Acute confusional episode--delirium in elderly
patients. Definition, etiology and treatment]." Revue Medicale Suisse 3(131): 2491-4.
Delirium, (acute confusional episode in European nomenclature) frequently
occurs to elderly patients. This confusional condition is characterized by a
sudden beginning and fluctuating clinical manifestations. It can bring out or
showup a large number of illnesses. Generally transient and reversible,
confusional state remains a medical emergency, motivating numerous consilium
and psychiatric admissions. On the base of a case report, we aim to recall the
high frequency of this affection in a somatic context and the importance of early
diagnosis and treatment.
Locca, J. F., S. Zumbach, et al. "[Management of elderly patients with delirium or
dementia in Swiss nursing homes]." Revue Medicale Suisse 3(132): 2519-20.
Management of elderly patients with delirium or dementia in Swiss nursing
homes Dementia and delirium are among the most frequent medical conditions in
older nursing home residents. Their management require a coordinated
interdisciplinary approach, including for drug prescription. Using a systematic
literature review of published meta-analyses and guidelines, prescription
algorithms were developed adressing the pharmacological management of
cognitive symptoms of dementia and delirium in older nursing home residents in
the canton of Fribourg.
Maneeton, B., N. Maneeton, et al. (2007). "An open-label study of quetiapine for
delirium." Journal of the Medical Association of Thailand 90(10): 2158-63.
OBJECTIVE: To evaluate the effects of quetiapine treatment in patients with
delirium. MATERIAL AND METHOD: All patients with delirium were assessed.
The diagnosis of delirium was confirmed by using the Confusion Assessment
Method (CAM). Quetiapine at the dose between 25 and 100 mg/day was given
for 7 days. The efficacy of quetiapine on delirium was evaluated by using the
Delirium Rating Scale (DRS) and the Clinical Global Impression-Severity scale
(CGI-S). The extrapyramidal side effects were assessed by using the Modified
(9-item) Simpson-Angus Scale (MSAS). RESULTS: Twenty-two patients had
delirium. Seventeen (10 males and 7 females) subjects with a mean age (SD) of
55.6 (18.6) years were included in the present study. Means (SDs) dose and
duration (SD) of quetiapine treatment were 45.7 (28.7) mg/day and 6.5 (2.0)
days, respectively. The DRS and CGI-S scores of days 2-7 were significantly
lower than those of day 0 (p < 0. 001) for all comparisons). Only two subjects
were shown to have mild tremor. CONCLUSION: Quetiapine within the range of
25-100 mg/day improves delirious condition within 24 hours of treatment. It is
well-tolerated and has a very low propensity to induce extrapyramidal side
effects. Further randomized, placebo-controlled trials are warranted.
Marc, B., A. Martis, et al. (2007). "[Acute Datura stramonium poisoning in an emergency
department]." Presse Medicale 36(10 Pt 1): 1399-403.
BACKGROUND: The toxic effects of Datura stramonium most often include
visual and auditory hallucinations, confusion and agitation. Severe and even fatal
complications (coma, respiratory distress or death in more than 5% of cases) are
not rare since the lethal concentration of the drug's toxic substances (i.e.,
atropine and scopolamine) is close to the level at which delirium occurs. CASES:
A 17-year-old man was admitted to our emergency department with agitation,
delirium with persecutory ideation and frightening hallucinations of being
assaulted by animals. Blood samples taken 12 hours after Datura stramonium
ingestion and analyzed with liquid chromatography and mass spectrometry (LCMS/MS) found 1.7 ng/mL of atropine, close to the lethal level. After restraint and
treatment with the antipsychotic drug cyamemazine, the young man returned to
normal 36 hours after drug ingestion. A 17-year-old woman was admitted to our
emergency department after losing consciousness on a public thoroughfare. At
the emergency department, 2 hours after she had ingested Datura stramonium,
she was agitated, with delirium, anxiety, and frightening visual and tactile
hallucination of green turtles walking on her as well as auditory hallucinations.
Blood samples at D0, D1 and D2 after Datura stramonium ingestion, analyzed
with LC-MS/MS, found: 1.4, 1.0, and 0.2 ng/mL of scopolamine, respectively.
Atropine was massively eliminated in urine on D1 (114 ng/mL). After restraint and
cyamemazine treatment, the young woman returned to normal 40 hours after she
had first ingested this hallucinogen. DISCUSSION: These cases of intoxication
with Datura stramonium are, to our knowledge, the first clinical reports correlated
with toxicologic analysis by the reference method (LC-MS/MS) in an emergency
setting. Since neither the drug-users nor those accompanying them usually
volunteer information about drug use, it is important to consider this specific risk
in cases of agitation and confusion in adolescents or young adults.
Marquis, F. o., S. b. Ouimet, et al. (2007). "Individual delirium symptoms: do they
matter?" Critical Care Medicine 35(11): 2533-7.
OBJECTIVES: To evaluate the impact of individual manifestations of delirium on
outcome, describe them in critically ill adults, and validate nurses' bedside item
assessments from the Intensive Care Delirium Screening Checklist (ICDSC).
DESIGN: Prospective study. SETTING: Single 16-bed medical/surgical university
hospital intensive care unit. PATIENTS: Six hundred consecutive patients
admitted to the intensive care unit for >24 hrs. INTERVENTIONS: All patients
were evaluated with the eight-item ICDSC throughout their intensive care unit
stay. In all patients scoring positive on any ICDSC item, individual checklist items
were tallied throughout the intensive care unit stay and assessed for impact on
mortality. In addition, when the ICDSC score indicated delirium (> or = 4 of 8),
the subsequent overall frequency of each item was also independently
documented to describe delirious patient symptoms. ICDSC items were tested
for discrimination between delirious and nondelirious patients. Throughout the
study, the validity of bedside delirium assessments was assessed in 30 nurses.
MEASUREMENTS AND MAIN RESULTS: We were able to assess 537 patients.
In nondelirious patients, psychomotor agitation by ICDSC assessment was
associated with a higher risk of mortality after adjustment for Acute Physiology
and Chronic Health Evaluation, age, and the presence of coma. One hundred
eight-nine patients (35.1%) developed delirium (i.e., ICDSC score > or = 4). On
presentation (and throughout the intensive care unit stay), the most frequent
features of delirium were inattention, disorientation, and psychomotor agitation.
Each ICDSC item was highly discriminating between delirious vs. nondelirious
patients. Correlation between gold standard adjudicators and nurses for the
overall bedside evaluations of delirium were excellent (Pearson's correlation R =
0.924, p < .0005). Individual symptom evaluation by nurses varied: Alteration in
level of consciousness was poorest (R = 0.681, p < .0005), and both
disorientation and hallucinations evaluated best (R = 1.000). CONCLUSIONS: In
nondelirious patients, agitation was associated with a higher risk of mortality.
Each of the eight ICDSC items is highly discriminating for the diagnosis of
delirium, suggesting that any screening or diagnostic scales should incorporate
them. Quality assurance and educational efforts should, therefore, emphasize
independent assessment of the individual features of delirium.
Masica, A. L., T. D. Girard, et al. (2007). "Clinical sedation scores as indicators of
sedative and analgesic drug exposure in intensive care unit patients." American Journal
Geriatric Pharmacotherapy 5(3): 218-31.
BACKGROUND: It is unclear how best to measure sedative/analgesic drug
exposure in the clinical care of critically ill patients. Large doses and prolonged
use of sedatives and analgesics in the intensive care unit (ICU) may lead to
oversedation and adverse effects, including delirium and long-term cognitive
impairment. These issues are of particular concern in elderly patients (aged > or
=65 years), who account for at least half of all ICU admissions and nearly two
thirds of ICU days. OBJECTIVE: This pilot study explored the relationships
between clinical sedation scores, sedative/analgesic drug doses, and plasma
drug concentrations in critically ill patients, the majority of whom were elderly.
METHODS: This was a prospective, observational study conducted in a 500-bed,
tertiary care community hospital. Study patients included a cohort of
mechanically ventilated, medical ICU patients who were admitted to the hospital
between April and June 2004 who required use of fentanyl, lorazepam, or
propofol. Sedative/analgesic medications were administered according to clinical
guidelines. Patients' sedation levels were measured twice daily using the
Richmond Agitation-Sedation Scale (RASS). Dosing of fentanyl, lorazepam, and
propofol was recorded. Blood was sampled twice daily for up to 5 days to
analyze plasma drug concentrations. To specifically evaluate the effects of acute,
extended (rather than chronic) sedative and analgesic exposure, the study
focused on an ICU population receiving these agents for at least 48 hours but <2
weeks. RESULTS: Eighteen medical ICU patients (11 females, 7 males; mean
[SD] age, 66.1 [18.1] years) on mechanical ventilation comprised the study
cohort. Fifteen patients were aged >62 years, and 11 of those were aged > or
=71 years. Plasma drug concentrations (median and interquartile range) were as
follows: fentanyl--2.1 ng/mL, 0.9-3.4 ng/mL; lorazepam--266 ng/mL, 112-412
ng/mL; and propofol--845 ng/mL, 334-1342 ng/mL. Maximum concentrations
were 3- to 12-fold higher than medians (fentanyl, 7.3 ng/mL; lorazepam, 3108
ng/mL; propofol, 10,000 ng/mL). Medication doses were only moderately
correlated with RASS scores (Spearman rho): fentanyl--rho = -0.39, P = 0.002;
lorazepam--rho = -0.28, P = 0.001; and propofol--rho = -0.46, P < 0.001. Plasma
drug concentrations of fentanyl and lorazepam demonstrated moderate
correlations with sedation scores (fentanyl--rho = -0.46, P = 0.002; lorazepam:
rho = -0.49, P < 0.001), while propofol concentrations correlated poorly with
sedation scores (rho = -0.18, P = 0.07). Associations between interval drug
doses and plasma concentrations were as follows: fentanyl, rho = 0.84;
lorazepam, rho = 0.76; and propofol, rho = 0.61 (all, P < 0.001). Instructive
examples of discrepant dose versus plasma concentration profiles and drug
interactions are provided, including 3 cases with patients aged > or =64 years.
CONCLUSIONS: Elderly patients are commonly encountered in the ICU setting.
Only moderate correlations existed between clinical sedation levels and dose or
plasma concentration of sedative/analgesic medications in this study population.
Further work is needed to understand appropriate and feasible measures of
exposure to sedatives/analgesics relating to clinical outcomes.
Matsuo, N. and T. Morita (2007). "Efficacy, safety, and cost effectiveness of intravenous
midazolam and flunitrazepam for primary insomnia in terminally ill patients with cancer:
a retrospective multicenter audit study." Journal of Palliative Medicine 10(5): 1054-62.
BACKGROUND: Although intravenous midazolam and flunitrazepam are
frequently administered for primary insomnia in Japan, there is no empirical study
on their efficacy and safety. DESIGN AND SUBJECTS: To compare the efficacy,
safety, and cost-effectiveness of midazolam and flunitrazepam, a multicenter
retrospective audit study was performed on 104 and 59 patients receiving
midazolam and flunitrazepam, respectively, from 18 certified palliative care units.
RESULTS: Median administration periods were 6 days and 9 days for midazolam
and flunitrazepam, respectively. The median initial and maximum doses were 10
mg per night and 18 mg per night for midazolam, and 2 mg per night and 2 mg
per night for flunitrazepam, respectively. There were no significant differences in
the efficacy (91% in the midazolam group versus 81% in the flunitrazepam group,
p = 0.084), hangover effect (34% versus 19%, p = 0.094), delirium at night (12%
versus 10%, p = 1.0) and delirium next morning (11% versus 15%, p = 0.33),
treatment withdrawal (4.8% versus 1.7%, p = 0.41), and treatment-related death
(0% versus 0%, p = 1.0). Flunitrazepam caused respiratory depression defined
as physician or nurses records such as apnea, respiratory arrest, decreased
respiratory rate, and respiratory depression significantly more frequently than
midazolam (17% versus 3.8%, p = 0.0073). The maximum dose was more highly
correlated with the administration period in the midazolam group than in the
flunitrazepam group (rho = 0.52, versus rho = 0.39), and, for patients treated for
14 days or longer, the daily escalation dose ratio required for maintaining
adequate sleep was significantly higher in the midazolam group than in the
flunitrazepam group (11% versus 2.6%, p = 0.015). The costs of the initial and
maximum administration were significantly higher in the midazolam group than in
the flunitrazepam group (p < 0.001). CONCLUSION: Intravenous midazolam and
flunitrazepam appeared to be almost equal about efficacy and safety for primary
insomnia, but flunitrazepam is less expensive and shows lower risk of tolerance
development. A future prospective comparison study is necessary.
McManus, J., R. Pathansali, et al. (2007). "Delirium post-stroke." Age & Ageing 36(6):
613-8.
Delirium is not only one of the most common complications that older patients
develop after admission to hospital but it is also one of the most serious.
Although stroke is a known predisposing factor for delirium, few studies have
investigated this association and results from existing studies give conflicting
results with prevalence estimates ranging from 13 to 48%. The aetiology of
delirium post-stroke is poorly understood. There is no consensus on the best
screening tool to use to detect delirium in the post-stroke setting. Specific stroke
types may be more likely to precipitate delirium than others, for example, delirium
is more frequent after intracerebral haemorrhage and total anterior circulation
infarction (TACI). In addition, case reports have suggested that delirium may be
associated with specific lesions, for example, in the thalamus and caudate
nucleus. There is a lack of intervention data in both the prevention and treatment
of delirium post-stroke. However, it is known that the development of delirium
post-stroke has grave prognostic implications. It is associated with longer stay in
hospital, increased mortality and increased risk of institutionalisation post
discharge. In this article, we review the literature to date on delirium in the acute
stroke setting.
Meagher, D. and P. T. Trzepacz (2007). "Phenomenological distinctions needed in
DSM-V: delirium, subsyndromal delirium, and dementias." Journal of Neuropsychiatry &
Clinical Neurosciences 19(4): 468-70.
Milavec, A. (2007). "The last kiss." Journal of Pain & Palliative Care Pharmacotherapy
21(3): 43-4.
This short story depicts the final musings and fits of delirium of an old man dying
of kidney failure. The sexual rapture of male cicadas outside his window gives
rise to his own final rapture following his unexpected reception of his last kiss.
Morandi, A., I. Sleiman, et al. (2007). "C-reactive protein and delirium in acute ill elderly
patients.[comment]." Age & Ageing 36(4): 473.
Morita, T., T. Akechi, et al. "Terminal Delirium: Recommendations from Bereaved
Families' Experiences." Journal.
Although delirium is a common complication in terminally ill cancer patients and
can cause considerable distress for family members, little is known about
effective care strategies for terminal delirium. The primary aims of this study were
1) to clarify the distress levels of bereaved families and their perceived necessity
of care; and 2) to explore the association between these levels and familyreported professional care practice, family-reported patient behavior, and their
interpretation of the causes of delirium. A multicenter questionnaire survey was
conducted on 560 bereaved family members of cancer patients who developed
delirium during their final two weeks in eight certified palliative care units across
Japan. We obtained 402 effective responses (response rate, 72%) and, as 160
families denied delirium episodes, 242 responses were analyzed. The bereaved
family members reported that they were very distressed (32%) and distressed
(22%) about the experience of terminal delirium. On the other hand, 5.8%
reported that considerable or much improvement was necessary, and 31%
reported some improvement was necessary in the professional care they had
received. More than half of the respondents had ambivalent wishes, guilt and
self-blame, and worries about staying with the patient. One-fourth to one-third
reported that they felt a burden concerning proxy judgments, burden to others,
acceptance, and helplessness. High-level emotional distress and familyperceived necessity of improvement were associated with a younger family age;
male gender; their experience of agitation and incoherent speech; their
interpretation of the causes of delirium as pain/physical discomfort, medication
effects, or mental weakness/death anxiety; and their perception that medical staff
were not present with the family, not respecting the patient's subjective world, not
explaining the expected course with daily changes, and not relieving family care
burden. In terminal delirium, a considerable number of families experienced high
levels of emotional distress and felt some need for improvement of the
specialized palliative care service. Control of agitation symptoms with careful
consideration of ambivalent family wishes, providing information about the
pathology of delirium, being present with the family, respecting the patient's
subjective world, explaining the expected course with daily changes, and
relieving family care burden can be useful care strategies. copyright 2007 U.S.
Cancer Pain Relief Committee.
Morita, T., T. Akechi, et al. (2007). "Terminal delirium: recommendations from bereaved
families' experiences." Journal of Pain & Symptom Management 34(6): 579-89.
Although delirium is a common complication in terminally ill cancer patients and
can cause considerable distress for family members, little is known about
effective care strategies for terminal delirium. The primary aims of this study were
1) to clarify the distress levels of bereaved families and their perceived necessity
of care; and 2) to explore the association between these levels and familyreported professional care practice, family-reported patient behavior, and their
interpretation of the causes of delirium. A multicenter questionnaire survey was
conducted on 560 bereaved family members of cancer patients who developed
delirium during their final two weeks in eight certified palliative care units across
Japan. We obtained 402 effective responses (response rate, 72%) and, as 160
families denied delirium episodes, 242 responses were analyzed. The bereaved
family members reported that they were very distressed (32%) and distressed
(22%) about the experience of terminal delirium. On the other hand, 5.8%
reported that considerable or much improvement was necessary, and 31%
reported some improvement was necessary in the professional care they had
received. More than half of the respondents had ambivalent wishes, guilt and
self-blame, and worries about staying with the patient. One-fourth to one-third
reported that they felt a burden concerning proxy judgments, burden to others,
acceptance, and helplessness. High-level emotional distress and familyperceived necessity of improvement were associated with a younger family age;
male gender; their experience of agitation and incoherent speech; their
interpretation of the causes of delirium as pain/physical discomfort, medication
effects, or mental weakness/death anxiety; and their perception that medical staff
were not present with the family, not respecting the patient's subjective world, not
explaining the expected course with daily changes, and not relieving family care
burden. In terminal delirium, a considerable number of families experienced high
levels of emotional distress and felt some need for improvement of the
specialized palliative care service. Control of agitation symptoms with careful
consideration of ambivalent family wishes, providing information about the
pathology of delirium, being present with the family, respecting the patient's
subjective world, explaining the expected course with daily changes, and
relieving family care burden can be useful care strategies.
Namba, M., T. Morita, et al. "Terminal delirium: Families' experience." Journal.
Background: Although delirium is a common complication in terminally ill cancer
patients and can cause considerable distress to family members, little is known
about the actual experience of family members. The primary aims of this study
were thus to explore: (1) what the family members of terminally ill cancer patients
with delirium actually experienced, (2) how they felt, (3) how they perceived
delirium and (4) what support they desired from medical staff. Methods: A singlecenter in-depth qualitative study on 20 bereaved family members of cancer
patents who developed delirium during the last two weeks before death. Content
analysis of transcribed text was performed. Results: Families experienced
various events including other than psychiatric symptoms, such as 'patients
talked about events that actually occurred in the past', 'patients were distressed
as they noticed that they were talking strangely,' 'patients talked about
uncompleted life tasks', and 'patients expressed physiologic desires such as
excretion and thirst'. Family emotions were positive, neutral, or negative (eg,
distress, guilt, anxiety and worry, difficulty coping with delirium, helplessness,
exhaustion and feeling a burden on others). Families perceived the delirium to
have different meanings, including positive meanings (eg, relief from real
suffering), a part of the dying process, and misunderstanding of the causes of
delirium (effects of drugs, mental weakness and pain). Families recommended
several support measures specifically for delirium, in addition to information and
general support: 'respect the patients' subjective world', 'treating patients as the
same person as before', 'facilitating preparations for the patients' death', and
'relieving family's physical and psychological burden'. Conclusions: From the
results of this study, we generated a potentially useful care strategy for terminal
delirium: respect the patients' subjective world, treat patients as the same
persons as before, explore unmet physiological needs behind delirium
symptoms, consider ambivalent emotions when using psychotropics, coordinate
care to achieve meaningful communication according to changes in
consciousness levels during the day, facilitate preparations for the patients'
death, alleviate the feelings of being a burden on others, relieve. family's physical
and psychological burden and information support. copyright 2007 Sage
Publications, Los Angeles, London, New Delhi and Singapore.
Namba, M., T. Morita, et al. (2007). "Terminal delirium: families' experience." Palliative
Medicine 21(7): 587-94.
BACKGROUND: Although delirium is a common complication in terminally ill
cancer patients and can cause considerable distress to family members, little is
known about the actual experience of family members. The primary aims of this
study were thus to explore: (1) what the family members of terminally ill cancer
patients with delirium actually experienced, (2) how they felt, (3) how they
perceived delirium and (4) what support they desired from medical staff.
METHODS: A single-center in-depth qualitative study on 20 bereaved family
members of cancer patents who developed delirium during the last two weeks
before death. Content analysis of transcribed text was performed. RESULTS:
Families experienced various events including other than psychiatric symptoms,
such as ;patients talked about events that actually occurred in the past', ;patients
were distressed as they noticed that they were talking strangely,' ;patients talked
about uncompleted life tasks', and ;patients expressed physiologic desires such
as excretion and thirst'. Family emotions were positive, neutral, or negative (eg,
distress, guilt, anxiety and worry, difficulty coping with delirium, helplessness,
exhaustion and feeling a burden on others). Families perceived the delirium to
have different meanings, including positive meanings (eg, relief from real
suffering), a part of the dying process, and misunderstanding of the causes of
delirium (effects of drugs, mental weakness and pain). Families recommended
several support measures specifically for delirium, in addition to information and
general support: ;respect the patients' subjective world', ;treating patients as the
same person as before', ;facilitating preparations for the patients' death', and
;relieving family's physical and psychological burden'. CONCLUSIONS: From the
results of this study, we generated a potentially useful care strategy for terminal
delirium: respect the patients' subjective world, treat patients as the same
persons as before, explore unmet physiological needs behind delirium
symptoms, consider ambivalent emotions when using psychotropics, coordinate
care to achieve meaningful communication according to changes in
consciousness levels during the day, facilitate preparations for the patients'
death, alleviate the feelings of being a burden on others, relieve family's physical
and psychological burden and information support.
Naylor, M. D., K. B. Hirschman, et al. (2007). "Care coordination for cognitively impaired
older adults and their caregivers." Home Health Care Services Quarterly 26(4): 57-78.
Dementia and delirium, the most common causes of cognitive impairment (CI)
among hospitalized older adults, are associated with higher mortality rates,
increased morbidity and higher health care costs. A growing body of science
suggests that these older adults and their caregivers are particularly vulnerable
to systems of care that either do not recognize or meet their needs. The
consequences can be devastating for these older adults and add to the burden of
hospital staff and caregivers, especially during the transition from hospital to
home. Unfortunately, little evidence exists to guide optimal care of this patient
group. Available research findings suggest that hospitalized cognitively impaired
elders may benefit from interventions aimed at improving care management of
both CI and co-morbid conditions but the exact nature and intensity of
interventions needed are not known. This article will explore the need for
improved transitional care for this vulnerable population and their caregivers.
Nemoto, K., Y. Kawanishi, et al. "Isolated adrenocorticotropic hormone deficiency
presenting with delirium [9]." Journal.
Nemoto, K., Y. Kawanishi, et al. (2007). "Isolated adrenocorticotropic hormone
deficiency presenting with delirium." American Journal of Psychiatry 164(9): 1440.
Neville, S. and J. Gilmour (2007). "Differentiating between delirium and dementia."
Nursing New Zealand (Wellington) 13(9): 22-4.
Olofsson, B., M. Stenvall, et al. (2007). "Malnutrition in hip fracture patients: an
intervention study." Journal of Clinical Nursing 16(11): 2027-2038.
Aim. To investigate whether a nutritional intervention in older women and men
with femoral neck fracture had an effect on postoperative complications during
hospitalization and on nutritional status at a four-month follow-up. Methods. The
design was a randomized controlled trial. The present study sample consisted of
157 patients aged 70 years and above with femoral neck fracture. The nutritional
intervention included, among other things, a nutritional journal to detect nutrition
deficiencies and protein-enriched meals for at least four days postoperatively.
Further, at least two nutritional and protein drinks were served each day during
the whole hospitalization and other factors that would influence the patient's
nutrition were also considered and dealt with. Postoperative complications were
registered and patients were assessed using the Mini Nutritional Assessment
(MNA) scale, including body mass index (BMI), on admission and at a four-month
follow-up. Results. Malnutrition was common and low MNA scores were
associated with postoperative complications such as delirium and decubitus
ulcers. There were significantly fewer days of delirium in the intervention group,
seven patients in the intervention group developed decubitus ulcers vs. 14
patients in the control group and the total length of hospitalization was shorter.
There were no detectable significant improvements regarding nutritional
parameters between the intervention and the control group at the four-month
follow-up but men improved their mean BMI, body weight and MNA scores in
both the intervention and the control groups while women deteriorated in both
groups. Conclusions. Malnutrition was common among older people with hip
fractures admitted to hospital. The nutritional intervention might have contributed
to the patients suffering fewer days with delirium, fewer decubitus ulcers and
shorter hospitalization but did not improve the long-term nutritional status, at
least not in women. Relevance to clinical practice. This nutritional intervention,
which was included in a multifactorial multidisciplinary intervention, is
inexpensive and relatively easy to implement. It has significant effects on
complications but no long-term effect on nutritional parameters, at least not in
women. [References: 41]
Ouimet, S., R. Riker, et al. (2007). "Subsyndromal delirium in the ICU: evidence for a
disease spectrum." Intensive Care Medicine 33(6): 1007-13.
OBJECTIVE: ICU delirium is common and adverse. The Intensive Care Delirium
Screening Checklist (ICDSC) score ranges from 0 to 8, with a score of 4 or
higher indicating clinical delirium. We investigated whether lower (subsyndromal)
values affect outcome. PATIENTS: 600 patients were evaluated with the ICDSC
every 8[Symbol: see text]h. MEASUREMENTS AND RESULTS: Of 558
assessed patients 537 noncomatose patients were divided into three groups: no
delirium (score = 0; n = 169, 31.5%), subsyndromal delirium (score = 1-3; n =
179, 33.3%), and clinical delirium (score >or=4; n = 189, 35.2%). ICU mortality
rates were 2.4%, 10.6%, and 15.9% in these three groups, respectively. PostICU mortality was significantly greater in the clinical delirium vs. no delirium
groups (hazard ratio = 1.67) after adjusting for age, APACHE II score, and
medication-induced coma. Relative ICU length of stay was: no delirium <
subsyndromal delirium < clinical delirium and hospital LOS: no delirium <
subsyndromal delirium approximately clinical delirium. Patients with no delirium
were more likely to be discharged home and less likely to need convalescence or
long-term care than those with subsyndromal delirium or clinical delirium. ICDSC
score increments higher than 4/8 were not associated with a change in mortality
or LOS. CONCLUSIONS: Clinical delirium is common, important and adverse in
the critically ill. A graded diagnostic scale permits detection of a category of
subsyndromal delirium which occurs in many ICU patients, and which is
associated with adverse outcome.
Palfai, T. P. (2007). "Watching a video of themselves experiencing delirium tremens
reduces relapse rates for up to three months in people with severe alcohol
dependence.[comment]." Evidence-Based Mental Health 10(4): 120.
Pandharipande, P., B. A. Cotton, et al. (2007). "Motoric subtypes of delirium in
mechanically ventilated surgical and trauma intensive care unit patients." Intensive Care
Medicine 33(10): 1726-1731.
Objective: Acute brain dysfunction or delirium occurs in the majority of
mechanically ventilated (MV) medical intensive care unit (ICU) patients and is
associated with increased mortality. Unfortunately delirium often goes
undiagnosed as health care providers fail to recognize in particular the
hypoactive form that is characterized by depressed consciousness without the
positive symptoms such as agitation. Recently, clinical tools have been
developed that help to diagnose delirium and determine the subtypes. Their use,
however, has not been reported in surgical and trauma patients. The objective of
this study was to identify the prevalence of the motoric subtypes of delirium in
surgical and trauma ICU patients. Methods: Adult surgical and trauma ICU
patients requiring MV longer than 24 h were prospectively evaluated for arousal
and delirium using well validated instruments. Sedation and delirium were
assessed using the Richmond Agitation Sedation Scale (RASS) and the
Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients
were monitored for delirium for a maximum of 10 days or until ICU discharge.
Patients: A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in
this study. Three patients were excluded from the final analysis because they
stayed persistently comatose prior to their death. Measurements and results:
Prevalence of delirium was 70% for the entire study population with 73% surgical
and 67% trauma ICU patients having delirium. Evaluation of the subtypes of
delirium revealed that in surgical and trauma patients, hypoactive delirium (64%
and 60%, respectively) was significantly more prevalent than the mixed (9% and
6%) and the pure hyperactive delirium (0% and 1%). Conclusions: The
prevalence of the hypoactive or " quiet" subtype of delirium in surgical and
trauma ICU patients appears similar to that of previously published data in
medical ICU patients. In the absence of active monitoring with a validated clinical
instrument (CAM- ICU), however, this subtype of delirium goes undiagnosed and
the prevalence of delirium in surgical and trauma ICU patients remains greatly
underestimated. [References: 39]
Pandharipande, P., B. A. Cotton, et al. (2007). "Motoric subtypes of delirium in
mechanically ventilated surgical and trauma intensive care unit patients." Intensive Care
Medicine 33(10): 1726-31.
OBJECTIVE: Acute brain dysfunction or delirium occurs in the majority of
mechanically ventilated (MV) medical intensive care unit (ICU) patients and is
associated with increased mortality. Unfortunately delirium often goes
undiagnosed as health care providers fail to recognize in particular the
hypoactive form that is characterized by depressed consciousness without the
positive symptoms such as agitation. Recently, clinical tools have been
developed that help to diagnose delirium and determine the subtypes. Their use,
however, has not been reported in surgical and trauma patients. The objective of
this study was to identify the prevalence of the motoric subtypes of delirium in
surgical and trauma ICU patients. METHODS: Adult surgical and trauma ICU
patients requiring MV longer than 24 h were prospectively evaluated for arousal
and delirium using well validated instruments. Sedation and delirium were
assessed using the Richmond Agitation Sedation Scale (RASS) and the
Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients
were monitored for delirium for a maximum of 10[Symbol: see text]days or until
ICU discharge. PATIENTS: A total of 100 ICU patients (46 surgical and 54
trauma) were enrolled in this study. Three patients were excluded from the final
analysis because they stayed persistently comatose prior to their death.
MEASUREMENTS AND RESULTS: Prevalence of delirium was 70% for the
entire study population with 73% surgical and 67% trauma ICU patients having
delirium. Evaluation of the subtypes of delirium revealed that in surgical and
trauma patients, hypoactive delirium (64% and 60%, respectively) was
significantly more prevalent than the mixed (9% and 6%) and the pure
hyperactive delirium (0% and 1%). CONCLUSIONS: The prevalence of the
hypoactive or "quiet" subtype of delirium in surgical and trauma ICU patients
appears similar to that of previously published data in medical ICU patients. In
the absence of active monitoring with a validated clinical instrument (CAM-ICU),
however, this subtype of delirium goes undiagnosed and the prevalence of
delirium in surgical and trauma ICU patients remains greatly underestimated.
Pandharipande, P. P., B. T. Pun, et al. (2007). "Effect of sedation with dexmedetomidine
vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the
MENDS randomized controlled trial." JAMA 298(22): 2644-53.
CONTEXT: Lorazepam is currently recommended for sustained sedation of
mechanically ventilated intensive care unit (ICU) patients, but this and other
benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and
coma, associated with prolonged hospital stays, costs, and increased mortality.
Dexmedetomidine induces sedation via different central nervous system
receptors than the benzodiazepine drugs and may lower the risk of acute brain
dysfunction. OBJECTIVE: To determine whether dexmedetomidine reduces the
duration of delirium and coma in mechanically ventilated ICU patients while
providing adequate sedation as compared with lorazepam. DESIGN, SETTING,
PATIENTS, AND INTERVENTION: Double-blind, randomized controlled trial of
106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary
care centers between August 2004 and April 2006. Patients were sedated with
dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were
titrated to achieve the desired level of sedation, measured using the Richmond
Agitation-Sedation Scale (RASS). Patients were monitored twice daily for
delirium using the Confusion Assessment Method for the ICU (CAM-ICU). MAIN
OUTCOME MEASURES: Days alive without delirium or coma and percentage of
days spent within 1 RASS point of the sedation goal. RESULTS: Sedation with
dexmedetomidine resulted in more days alive without delirium or coma (median
days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P <
.001) than sedation with lorazepam. Patients sedated with dexmedetomidine
spent more time within 1 RASS point of their sedation goal compared with
patients sedated with lorazepam (median percentage of days, 80% vs 67%; P =
.04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the
lorazepam group (P = .18) and cost of care was similar between groups. More
patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to
complete post-ICU neuropsychological testing, with similar scores in the tests
evaluating global cognitive, motor speed, and attention functions. The 12-month
time to death was 363 days in the dexmedetomidine group vs 188 days in the
lorazepam group (P = .48). CONCLUSION: In mechanically ventilated ICU
patients managed with individualized targeted sedation, use of a
dexmedetomidine infusion resulted in more days alive without delirium or coma
and more time at the targeted level of sedation than with a lorazepam infusion.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00095251.
Pisani, M. A., T. E. Murphy, et al. (2007). "Characteristics associated with delirium in
older patients in a medical intensive care unit." Archives of Internal Medicine 167(15):
1629-34.
BACKGROUND: Delirium is a highly prevalent disorder among older patients in
the intensive care unit. METHODS: We performed a prospective cohort study of
304 patients 60 years or older admitted from September 5, 2002, through
September 30, 2004, to a 14-bed ICU in an urban university teaching hospital.
The main outcome measure was ICU delirium that developed within 48 hours of
ICU admission. Patients were assessed for delirium with the Confusion
Assessment Method for the ICU and medical record review. Risk factors for
delirium were assessed on ICU admission by interview with proxies and medical
record review. A model was developed using multivariate logistic regression and
internally validated with bootstrapping methods. RESULTS: Delirium occurred in
214 study participants (70.4%) within the first 48 hours of ICU admission. In a
multivariate regression model, 4 admission risk factors for delirium were
identified. These risk factors included dementia (odds ratio [OR], 6.3; 95%
confidence interval [CI], 2.9-13.8), receipt of benzodiazepines before ICU
admission (OR, 3.4; 95% CI, 1.6-7.0), elevated creatinine level (OR, 2.1; 95% CI,
1.1-4.0), and low arterial pH (OR, 2.1; 95% CI, 1.1-3.9). The C statistic was 0.78.
CONCLUSIONS: Delirium is frequent among older ICU patients. Admission
characteristics can be important markers for delirium in these patients.
Knowledge of these admission risk factors can prompt early correction of
metabolic abnormalities and may subsequently reduce delirium duration.
Prakanrattana, U. and S. Prapaitrakool (2007). "Efficacy of risperidone for prevention of
postoperative delirium in cardiac surgery." Anaesthesia & Intensive Care 35(5): 714-9.
This randomised, double-blinded, placebo-controlled study was primarily aimed
to evaluate the potential of risperidone to prevent postoperative delirium following
cardiac surgery with cardiopulmonary bypass and the secondary objective was to
explore clinical factors associated with postoperative delirium. One-hundred-andtwenty-six adult patients undergoing elective cardiac surgery with
cardiopulmonary bypass were randomly assigned to receive either 1 mg of
risperidone or placebo sublingually when they regained consciousness. Delirium
and other outcomes were assessed. The confusion assessment method for
intensive care unit was used to assess postoperative delirium. The incidence of
postoperative delirium in the risperidone group was lower than the placebo group
(11.1% vs. 31.7% respectively, P=0.009, relative risk = 0.35, 95% confidence
interval [CI] = 0.16-0.77). Other postoperative outcomes were not statistically
different between the groups. In exploring the factors associated with delirium,
univariate analysis showed many factors were associated with postoperative
delirium. However multiple logistic regression analysis showed a lapse of 70
minutes from the time of opening eyes to following commands and postoperative
respiratory failure were independent risk factors (P=0.003, odds ratio [OR] =
4.57, 95% CI = 1.66-12.59 and P=0.038, OR = 13.78, 95% CI = 1.15-165.18
respectively). A single dose of risperidone administered soon after cardiac
surgery with cardiopulmonary bypass reduces the incidence of postoperative
delirium. Multiple factors tended to be associated with postoperative delirium, but
only the time from opening eyes to following commands and postoperative
respiratory failure were independent risk factors in this study.
Pun, B. T. and E. W. Ely (2007). "The importance of diagnosing and managing ICU
delirium." Chest 132(2): 624-36.
ICU delirium represents a form of brain dysfunction that in many cohorts has
been diagnosed in 60 to 85% of patients receiving mechanical ventilation. This
organ dysfunction is grossly underrecognized because a majority of patients
have hypoactive or "quiet" delirium characterized by "negative" symptoms (eg,
inattention and a flat affect) not alarming the treating team. Hyperactive delirium,
formerly called ICU psychosis, stands out because of symptoms such as
agitation that may cause harm to self or staff, but is actually rare relative to
hypoactive delirium and associated with a better prognosis. Delirium is often
incorrectly thought to be transient and of little consequence. After adjusting for
numerous covariates, delirium is a strong, independent predictor of prolonged
length of stay, reintubation, higher mortality, and cost of care. Expanded work on
patient safety and recommendations by professional societies have established
the importance of delirium monitoring and recommended it as standard practice
in ICUs all over the world. This evidence-based review for physicians, nurses,
respiratory therapists, and pharmacists will outline why it is imperative that
patients be routinely monitored for delirium. This review will discuss modifiable
risk factors for delirium, such as metabolic disturbances or potent sedative and
analgesic medications. Attention to mitigating risk factors, along with
recommended pharmacologic approaches such as antipsychotic medications,
may provide resolution of delirium in some patients, while others will persist with
refractory brain dysfunction and long-term cognitive impairment following critical
illness. [References: 90]
Ritvo, J. I. and C. Park (2007). "The psychiatric management of patients with alcohol
dependence." Current Treatment Options in Neurology 9(5): 381-92.
Alcohol dependence is a chronic, relapsing biobehavioral disease mediated by
various parts of the brain, including reward systems, memory circuits, and the
prefrontal cortex. It is characterized by loss of the ability to drink alcohol in
moderation and continued drinking despite negative consequences. The alcohol
withdrawal syndrome is a common but not universal diagnostic feature of alcohol
dependence. Benzodiazepine detoxification of the alcohol withdrawal syndrome
prevents the development of withdrawal seizures and delirium tremens, and
makes patients more comfortable, which promotes engagement in treatment.
Symptom-triggered dosing, based on a withdrawal rating scale such as the
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, is optimal for
minimizing the total benzodiazepine dosage. Use of a long-acting
benzodiazepine (eg, chlordiazepoxide) is preferred in uncomplicated patients.
Thiamine should be administered routinely before the administration of
intravenous fluids to prevent the development of Wernicke's encephalopathy and
Wernicke-Korsakoff syndrome. In combination with psychosocial treatment,
disulfiram, naltrexone, and acamprosate can reduce the frequency of relapse.
Naltrexone may be more effective for reduction of loss of control with the first
drink and cue-related craving, and acamprosate may be more effective for
stabilizing the physiology of post-acute withdrawal. Disulfiram, an aversive
deterrent, can be useful if administration can be monitored and tied to meaningful
contingencies or when used prophylactically for situations anticipated to carry
high risk of relapse. Psychiatric comorbidity, especially depression, is common
and is best addressed concurrently, although definitive diagnosis may have to
await a period of prolonged sobriety. Prescription of addictive substances,
including benzodiazepines beyond the period of acute detoxification, should be
avoided, and if necessary should be closely monitored (eg, by frequent visits with
small prescriptions, clinic-administered disulfiram, and/or urine or breath alcohol
screenings). Abstinence from alcohol is recommended for persons with alcohol
dependence. Psychosocial treatment and participation in Alcoholics Anonymous
can help patients achieve and maintain abstinence.
Roberts, B. L., C. M. Rickard, et al. (2007). "Factual memories of ICU: recall at two
years post-discharge and comparison with delirium status during ICU admission--a
multicentre cohort study." Journal of Clinical Nursing 16(9): 1669-77.
AIMS AND OBJECTIVE: To examine the relationship between observed delirium
in ICU and patients' recall of factual events up to two years after discharge.
BACKGROUND: People, the environment, and procedures are frequently cited
memories of actual events encountered in ICU. These are often perceived as
stressors to the patients and the presence of several such stressors has been
associated with the development of reduced health-related quality of life or posttraumatic stress syndrome. DESIGN: Prospective cohort study using interview
technique. METHOD: The cohort was assembled from 152 patients who
participated in a previously conducted multi-centre study of delirium incidence in
Australian ICUs. The interviews involved a mixture of closed- and open-ended
questions. Qualitative responses regarding factual memories were analysed
using thematic analysis. A five-point Likert scale with answers from 'always' to
'never' was used to ask about current experiences of dream, anxiety, sleep
problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with
a mid-point value of 18 indicating a threshold value for the diagnosis of posttraumatic stress syndrome. A P-value of <0.05 was considered significant for all
analyses. RESULTS: Forty-one (40%) out of 103 potential participants consented
to take part in the follow-up interview; 18 patients (44%) had been delirious and
23 patients (56%) non-delirious during the ICU admission. The non-participants
(n = 62) formed a control group to ensure a representative sample; 83% (n = 34)
reported factual memories either with or without recall of dreaming. Factual
memories were significantly less common (66% cf. 96%) in delirious patients (OR
0.09, 95%CI 0.01-0.85, p = 0.035). Five topics emerged from the thematic
analysis: 'procedures', 'staff', 'comfort', 'visitors', and 'events'. Based on the
current experiences, five patients (12%, four non-delirious and one delirious)
scored > or =18 indicative of symptoms of post-traumatic stress syndrome; this
did not reach statistical significance. Memory of transfer out of ICU was less
frequent among the delirious patients (56%, n = 10) than among the non-delirious
patients (87%, n = 20) (p = 0.036). CONCLUSION: Most patients have factual
memories of their ICU stay. However, delirious patients had significantly less
factual recall than non-delirious patients. Adverse psychological sequelae
expressed as post-traumatic stress syndrome was uncommon in our study.
Every attempt must be made to ensure that the ICU environment is as hospitable
as possible to decrease the stress of critical illness. Post-ICU follow-up should
include filling in the 'missing gaps', particularly for delirious patients. Ongoing
explanations and a caring environment may assist the patient in making a
complete recovery both physically and mentally. RELEVANCE TO CLINICAL
PRACTICE: This study highlights the need for continued patient information, reassurance and optimized comfort. While health care professionals cannot
remove the stressors of the ICU treatments, we must minimize the impact of the
stay. It must be remembered that most patients are aware of their surroundings
while they are in the ICU and it should, therefore, be part of ICU education to
include issues regarding all aspects of patient care in this particularly vulnerable
subset of patients to optimize their feelings of security, comfort and self-respect.
Rudolph, J. L., R. N. Jones, et al. (2007). "Independent vascular and cognitive risk
factors for postoperative delirium." American Journal of Medicine 120(9): 807-13.
BACKGROUND: Delirium is a common, morbid, and costly syndrome that occurs
frequently after surgery for atherosclerosis. We hypothesized that vascular risk
factors and mildly impaired cognitive performance would independently
predispose nondemented patients to develop delirium after noncardiac surgery.
METHODS: The International Study of Postoperative Cognitive Dysfunction
recruited patients undergoing noncardiac surgery from 8 countries. Subjects
provided detailed medical history and underwent preoperative testing of multiple
cognitive domains with a neuropsychologic battery. Postoperatively, subjects
(n=1161) were assessed daily for delirium. RESULTS: Ninety-nine subjects (8%)
developed delirium. In bivariable analysis, several vascular risk factors were
significantly associated with the likelihood of delirium, including male sex,
exposure to tobacco, previous myocardial infarction, and vascular surgery. After
adjustment for age, tobacco exposure and vascular surgery were independent
vascular risk factors for delirium (adjusted relative risk [RR] 3.2, 95% confidence
interval [CI], 2.1-4.9). In addition, mildly impaired cognitive performance, defined
as performance 1.5 standard deviation below the mean on either of 2
neuropsychologic tests, was independently associated with delirium (adjusted
RR 2.2, 95% CI, 1.4-3.6). Subjects with both vascular risk factors and mildly
impaired cognitive performance were at double the risk of delirium (RR 2.2, 95%
CI, 1.2-4.2) compared with those with either of these risk factors alone.
CONCLUSIONS: Vascular risk and mildly impaired cognitive performance
independently predispose patients to delirium after noncardiac surgery. These
factors will help to identify high-risk patients for delirium and to design and target
future intervention strategies.
Seem..ller, F., E. Volkmer, et al. (2007). "Quetiapine as treatment for delirium during
weaning from ventilation: a case report." Journal of Clinical Psychopharmacology 27(5):
526-8.
Sharan, P., R. Bharadwaj, et al. (2007). "Dependence syndrome and intoxication
delirium associated with zolpidem." National Medical Journal of India 20(4): 180-1.
The use of zolpidem by general practitioners and specialists alike has increased.
Earlier, it was considered safe by physicians, i.e. devoid of dependence potential
and the risk of serious adverse events. We report 5 patients seen over a 36month period at the Post Graduate Institute of Medical Education and Research,
which highlight the need for caution in the use of this drug.
Shih, H.-T., W.-S. Huang, et al. (2007). "Confusion or delirium in patients with posterior
cerebral arterial infarction.[see comment]." Acta Neurologica Taiwanica 16(3): 136-42.
OBJECTIVE: To identify the possible anatomic sites and risk factors for the
development of confusion or delirium in patients with posterior cerebral arterial
(PCA) infarction. MATERIALS AND METHODS: Twenty-nine patients aged 3486 years with PCA infarction were divided into two groups: one with and the other
without perturbed mentation. The clinical and laboratory data, including
neuroimages, were retrospectively reviewed. Student-t, chi-square and Fisher's
exact tests were performed for data analysis. RESULTS: Confusion or delirium
tended to develop in the left (10/13) or bilateral (5/5) PCA infarction as compared
to the right PCA infarction (3/15) (P< 0.05) and medial occipital-temporal gyri
involvement was crucial for its development (P< 0.05). The results were also
noted in the patients with first-ever stroke. Diabetes mellitus was the sole
biochemical factor to be associated with confusion or delirium (P< 0.01).
CONCLUSIONS: The involvement of the medial occipito-temporal gyri, especially
on the left side was the pivotal factor for the development of confusion or delirium
in patients with PCA infarction. Higher prevalence of diabetes mellitus was also
observed in the group with mental perturbation.
Stan, H., C. Popa, et al. "Combined endoscopically guided third ventriculostomy with
prepontine cistern placement of the ventricular catheter in a ventriculo-peritoneal shunt:
Technical note." Journal.
The authors present the management of non-obstructive hydrocephalus using
two surgical procedures, both at the same time: first, we perform an endoscopic
third ventriculostomy and second, we place the ventricular catheter of the
ventriculo-peritoneal shunt in the prepontine cistern under endoscopic guidance.
The main rationale is the fact that the ventricular catheter passes through
multiple fixed cerebrospinal fluid circulation points in order to allow the free
circulation of the cerebrospinal liquid. The authors present here details of the
technique and short-term results. copyright Georg Thieme Verlag KG Stuttgart.
Tagarakis, G. I., F. Tsolaki-Tagaraki, et al. (2007). "The role of SOAT-1 polymorphisms
in cognitive decline and delirium after bypass heart surgery." Clinical Research in
Cardiology 96(9): 600-3.
BACKGROUND : Cognitive decline (CD) and delirium (PD) are commonly
observed complications after bypass heart surgery. In this study we aimed to
investigate whether certain genetic factors (alleles of the SOAT-1 gene) play a
role in their appearance. PATIENTS AND METHODS : We examined 137
patients receiving coronary bypass surgery with a neuropsychiatric test battery
consisting of the Mini Mental State Examination (MMSE), the Brief Psychiatric
Rating Scale (BPRS), the Wechsler's Memory Scale-Revised (WMS-R) on
admission and one month after surgery, and the Delirium Rating Scale
postoperatively, when indicated, and genotyped them in relation to the SOAT-1
genotypes (AA positive group with augmented protection of the nerve cells
against stress and the AA negative group - AC and CC subgroups - with
diminished protection against stress). RESULTS : We noted a significant decline
in test results postoperatively and a high frequency of delirium (29.92% of the
patients). None of these complications could be associated to the SOAT-1
genotypes. CONCLUSIONS : Our study confirmed the expected cognitive
decline and highly frequent delirium after bypass heart surgery and excluded the
possible role of SOAT-1 genotype polymorphisms in their genesis.
Tagarakis, G. I., F. Tsolaki-Tagaraki, et al. (2007). "The role of apolipoprotein E in
cognitive decline and delirium after bypass heart operations." American Journal of
Alzheimer's Disease & Other Dementias 22(3): 223-8.
Cognitive decline and delirium are common complications after heart bypass
surgery. Based on the reported role of the APOE-epsilon 4 allele in
neurodegenerative diseases, we studied its association with these complications.
A neuropsychological test battery consisting of the Mini Mental State
Examination, the Wechsler's Memory Scale Revised, the Brief Psychiatric Rating
Scale, and the Delirium Rating Scale was applied to 137 APOE-genotyped
patients on admission and 1 month after bypass surgery. We correlated the
APOE (apolipoprotein E) polymorphism with the postoperative test outcome by
taking into account all factors known to influence cognitive capacity after heart
surgery. There was a significant decline in all test results 1 month after surgery
and a high frequency of postoperative delirium. Neither this decline nor the
frequency of delirium was associated with the APOE-epsilon 4 allele. This study
confirms the high incidence of cognitive decline and delirium after coronary
surgery, but it does not support the role of the APOE-epsilon 4 allele in the
occurrence of these complications.
Tumial..n, L. M., M. Gupta, et al. "A 55-year-old man with liver failure, delirium and
seizures." Brain Pathology 17(4): 472-3.
van Munster, B. C., J. C. Korevaar, et al. (2007). "The association between delirium and
the apolipoprotein E epsilon4 allele in the elderly." Psychiatric Genetics 17(5): 261-6.
OBJECTIVE: As not all patients with similar risk factors and eliciting conditions
develop delirium; it may be hypothesized that genetic variation may play a role in
the risk of delirium. On the basis of the relationship between dementia,
respectively reduced cholinergic activity, and the APOE epsilon4-allele, and the
similarities between dementia and delirium in reduced cholinergic activity, the
APOE epsilon4-allele is a rational candidate-gene for delirium. This study
examined the association between APOE epsilon4-allele and delirium in elderly
patients. METHODS: Acutely admitted patients to the Department of Medicine of
65 years and over were included during a 27-month time period. Delirium was
scored by the confusion assessment method. Cognitive impairment was
diagnosed by Mini Mental State Examination and informant questionnaire on
cognitive decline. Genotyping was done with matrix-assisted laserdesorption/ionization time-of flight mass spectrometry. RESULTS: Of 415
included patients, a random sample of 264 patients was genotyped for APOE.
The patients who met the criteria for delirium (35%) were significantly older and
more frequently had preexisting functional and cognitive impairment. APOE
genotype was borderline significantly associated with cognitive impairment in
patients below 75 years (P=0.057). The odds ratio for carriers of an APOE
epsilon4-allele compared with patients without an APOE epsilon4-allele for
developing delirium was 1.17 (95% confidence interval (CI): 0.49-2.78) in the
cognitively intact patients and 0.42 (95% CI: 0.14-1.30) in the cognitively
impaired patients. No relation existed between the total number of APOE
epsilon4-alleles and the different delirium subtypes (P=0.12). CONCLUSIONS:
We found no convincing evidence that carriers of the APOE epsilon4-allele have
a higher risk of delirium.
Vollmer, C., C. Rich, et al. (2007). "How to prevent delirium: a practical protocol."
Nursing 37(8): 26-8.
Volpe-Gillot, L. (2007). "[Cognitive disorders, dementia and epilepsy in the elderly.]."
Psychologie et Neuropsychiatrie du Vieillissement 5 Suppl 1: 31-40.
Cognitive and behavioral disorders can occur in epileptic subjects and can even
simulate dementia in elderly patients. These cognitive disorders are often
multifactorial, in relationship with: 1) the causal disease (type and course of brain
lesions), 2) the clinical manifestations of epileptic seizure or post-crisis fit,
function of localisation and lateralization of the lesions (psychological symptoms
during or after seizures can lead to misdiagnosis. Delirium and/or cognitive
disorders are attributed to dementia or confusion), 3) antiepileptic drugs, and 4)
the psychosocial impact of the disease. At the opposite, epilepsy represents an
unrecognized and underated complication of dementia, and specially of
Alzheimer's disease. If partial seizures are predominant in old non demented
subjects, generalized seizures (tonicoclonic, myoclonic...) are not rare in
demented patients. The diagnosis of epilepsy and seizure typology are therefore
often difficult in this population, and impose, in every case, an etiological
analysis, to look after an associated pathology and to establish a therapeutic and
psychosocial care, so great are the medico-social consequences of the epilepsy
in these subjects.
Wakeno, M., G. Okugawa, et al. "Delirium associated with paroxetine in an elderly
depressive patient: A case report [1]." Journal.
Wakeno, M., G. Okugawa, et al. (2007). "Delirium associated with paroxetine in an
elderly depressive patient: a case report." Pharmacopsychiatry 40(5): 199-200.
Waszynski, C. M. (2007). "How to try this: detecting delirium." American Journal of
Nursing 107(12): 50-9.
For patients and their loved ones, delirium can be a frightening experience. A
fluctuating mental status is important to identify because it often signals a need
for additional treatment. The Confusion Assessment Method (CAM) diagnostic
algorithm enables nurses to assess for delirium by identifying the four features of
the disorder that distinguish it from other forms of cognitive impairment. It can be
completed in five minutes and is easily incorporated into ongoing assessments of
hospitalized patients. (This screening tool is included in the series Try This: Best
Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric
Nursing at New York University's College of Nursing.) For a free online video
demonstrating the use of this tool, go to http://links.lww.com/A209.
White, C., M. A. McCann, et al. (2007). "First do no harm... Terminal restlessness or
drug-induced delirium." Journal of Palliative Medicine 10(2): 345-51.
Terminal restlessness is a term frequently used to refer to a clinical spectrum of
unsettled behaviors in the last few days of life. Because there are many
similarities between the clinical pictures observed in terminal restlessness and
delirium, we postulate that at times what is referred to as terminal restlessness
may actually be an acute delirium sometimes caused by medication used for
symptom control. It is important therefore to consider the causes for this
distressing clinical entity, treat it appropriately, and ensure the treatment provided
does not increase its severity. This brief review aims to consider the medications
that are commonly used toward the end of life that may result in a picture of
delirium (or terminal restlessness). These include opioids, antisecretory agents,
anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and
nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise
awareness regarding the recognition and diagnosis of delirium and to highlight
the fact that delirium may be reversible in up to half of all cases. Good
management of delirium has the potential to significantly improve patient care at
the end of life. [References: 31]
Yang, H.-H., Y.-P. Hsiao, et al. (2007). "Acyclovir-induced neuropsychosis successfully
recovered after immediate hemodialysis in an end-stage renal disease patient."
International Journal of Dermatology 46(8): 883-4.
A 70-year-old man developed herpes zoster over the right L5-S2 region for 3
days and was admitted for acyclovir therapy. He had a medical history of rectal
cancer status post-colostomy and end-stage renal disease undergoing thrice
weekly hemodialysis. Without a prior loading dose, acyclovir 500 mg (7.7 mg/kg)
daily was given intravenously in two divided doses. On the third dosage, the
patient became confused and agitated and developed insomnia. Within the
following 24 h, delirium, visual and auditory hallucinations, disorientation to place
and time, as well as impaired recent memory occurred. At the same time, a
transient low grade fever (38 degrees C) was noted but resolved spontaneously
after ice pillow (Fig. 1). The etiology was vigorously explored. He had no history
of any neurological or psychiatric disorders. Drug history was reviewed, but no
other medications besides acyclovir were currently being used. Physical
examination revealed neither meningeal signs nor focal neurological deficits.
Serum blood urea nitrogen, glucose, and electrolytes were within normal limits
except for an elevated creatinine level at 6.2 and 5.7 mg/dl (before and after
neuropsychotic symptoms, respectively). Complete blood count with
differentiation was also unremarkable. Cerebrospinal fluid examination was not
possible as the patient's family refused the lumbar puncture. Moreover, an
electroencephalograph study and head computed tomography scan disclosed no
abnormalities. Acyclovir-induced neurotoxicity was suspected. Therefore,
acyclovir was discontinued. Subsequently, serum acyclovir and CMMG were
checked by enzyme-linked immunosorbent assay. Serum acyclovir level was 1.6
mg/l (normal therapeutic level, 0.12-10.8 mg/l) and CMMG level was 5 mg/l.
Emergent hemodialysis (4-h/session) was given; the neuropsychotic symptoms,
including agitation, delirium, and visual and auditory hallucinations, greatly
abated after the second session. The patient fully recovered after three
consecutive days of hemodialysis; the serum was rechecked and revealed that
the acyclovir level was below 0.5 mg/l and the CMMG level was undetectable. At
the same time, his herpetic skin lesions resolved well.