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DELIRIUM – Diagnostic différentiel. Par ordre d’auteur. 2000-2005
Arnold, E. (2004). "Sorting out the 3 D's: delirium, dementia, and depression." Nursing
34(6): 36-42; quiz 43.
Bostwick, J. M. and K. L. Philbrick (2002). "The use of electroencephalography in
psychiatry of the medically ill." Psychiatric Clinics of North America 25(1): 17-25.
The psychiatrist considering recommending an EEG should look for acute
changes in the history or examination suggestive of an organic cause. If he or
she judges that the EEG will help to clarify or confirm the diagnostic impression
already formulated, it is worth considering whether adding provocative
maneuvers could increase the yield. The authors cannot overemphasize the
importance of using the EEG in correlation to further inform old-fashioned clinical
detective work already in process, particularly when the EEG could rule out a
potential organic contributor to a psychiatric phenotype. For routine screening
without an elevated index of suspicion or for thoughtless "fishing expeditions,"
EEG results will surely disappoint.
Camus, V., R. Gonthier, et al. (2000). "Etiologic and outcome profiles in hypoactive and
hyperactive subtypes of delirium." Journal of Geriatric Psychiatry & Neurology 13(1): 3842.
The existence of hyperactive, hypoactive, or mixed clinical subtypes of delirium is
widely accepted. But relationships between these motor profiles and etiology or
outcome remain unclear. The aim of this study was to compare etiologic and
outcome profiles in a case series of 183 elderly patients (mean age = 84.1 years,
SD = 5.9) consecutively admitted into the geriatric wards of two French university
hospitals or referred to a geriatric psychiatry consultation-liaison unit within a
Swiss university hospital. All patients met DSM-III-R criteria for delirium and were
classified into clinical subtypes according to the results of a previous factor
analysis of scores on a 19-item checklist rating a wide range of delirium
symptoms. The hyperactive subtype was more frequent (n = 85, 46.5%) than the
unspecified (n = 50, 27.3%) and hypoactive subtypes (n = 48, 26.2%). There was
no significant difference in terms of etiologic or outcome profile between clinical
subtype groups. The presence of acute metabolic disorders, cardiovascular
disease, and hyperthermia as etiologic factors was significantly associated with
full recovery of the episode at 3 weeks follow-up, whereas probable preexisting
dementia was significantly associated with partial recovery or failure to recover.
Chan, D. and N. J. Brennan "Delirium: making the diagnosis, improving the prognosis."
Geriatrics 54(3): 28-30.
Delirium is a common development in at-risk older patients hospitalized for acute
illness or postoperative care. Although delirium's risk factors are well
documented, less is known about its pathophysiology and long-term prognosis or
about the relationship between delirium, dementia, and depression. Evaluation
and management of delirium is a medical emergency. Diagnostic tools include
the Confusion Assessment Method rating scale, patient history from capable
informants, and physical/mental examinations. Management consists of
prevention, treatment of underlying causes or associated factors, supportive
care, and pharmacologic intervention (as indicated). Studies that have looked at
the reversibility of delirium suggest that patients often are slow to recover their
previous level of function. [References: 21]
Cole, M. G., N. Dendukuri, et al. (2003). "An empirical study of different diagnostic
criteria for delirium among elderly medical inpatients." Journal of Neuropsychiatry &
Clinical Neurosciences 15(2): 200-7.
This study compared the sensitivity and specificity of DSM-IV criteria for delirium
with the sensitivity and specificity of DSM-III and ICD-10 criteria among elderly
medical inpatients with or without dementia. Secondary objectives were to
examine the effect of changing the definition of criterion A on sensitivity and
specificity and to compare the sensitivity and specificity of different numbers of
symptoms of delirium. A total of 322 elderly patients who had been admitted from
the emergency department to the medical services were classified into one of
four groups using DSM-III-R criteria: delirium and dementia (n = 128), delirium
only (n = 40), dementia only (n = 94), and neither (n = 60). The sensitivity and
specificity of DSM-IV, DSM-III, and ICD-10 criteria were determined against
DSM-III-R criteria using three definitions of criterion A (clouding of consciousness
only, clouding of consciousness and inattention, clouding of consciousness or
inattention). When criterion A was defined as clouding of consciousness or
inattention, the sensitivity and specificity of DSM-IV, DSM-III, and ICD-10 criteria
were 100% and 71%, 96% and 91%, and 61% and 91%, respectively. The
results were similar among patients with or without dementia. The lower
specificity of DSM-IV was accounted for by its inclusion of patients who did not
show disorganized thinking. DSM-IV criteria for delirium are the most inclusive
criteria to date for elderly medical patients with or without dementia.
Conn, D. K. and S. Lieff (2001). "Diagnosing and managing delirium in the elderly."
Canadian Family Physician 47: 101-8.
OBJECTIVE: To outline current approaches to diagnosing and managing
delirium in the elderly. QUALITY OF EVIDENCE: A literature review was based
on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used
as the basis for discussion of diagnosis and etiology. We planned to include all
published randomized controlled trials regarding management but found only
two. Consequently, we also used review articles and recent practice guidelines
for delirium published by the American Psychiatric Association. MAIN FINDINGS:
Clinical diagnosis of delirium can be aided by using DSM-IV criteria, the Delirium
Symptom Interview, or the confusion assessment method. Management must
include investigation and treatment of underlying causes and general supportive
measures. Providing optimal levels of stimulation, reorienting patients, education,
and supporting families are important. Pharmacologic management of delirium
should be considered only for specific symptoms or behaviours, e.g., aggression,
severe agitation, or psychosis. Only one randomized controlled trial of
tranquilizer use for delirium in medically ill people has been published. Findings
support the current belief that neuroleptics are superior to benzodiazepines in
most cases of delirium. Most authorities still consider haloperidol the neuroleptic
of choice. Controlled trials of the new atypical neuroleptics for treating delirium
are not yet available. Benzodiazepines with relatively short half-lives, such as
lorazepam, are the drugs of choice for withdrawal symptoms. CONCLUSION:
Delirium is frequently underdiagnosed in clinical practice. It should be suspected
with acute changes in behaviour. Careful investigation of the underlying cause
permits appropriate management. [References: 44]
Curtin, A. J. (2004). "Changes in mental status." Journal of the American Podiatric
Medical Association 94(2): 118-25.
Change in mental status is a common symptom in the older, hospitalized patient.
Often referred to as delirium, it may be the first indication of a serious medical
condition. If delirium is not identified and treated promptly, it may lead to severe
complications. The podiatric physician can prevent many cases of delirium by
maintaining a high level of suspicion, performing a thorough clinical assessment,
and identifying older patients at risk in the hospital setting. [References: 11]
Edwards, N. (2003). "Differentiating the three D's: delirium, dementia, and depression."
MEDSURG Nursing 12(6): 347-57; quiz 358.
Confusion often presents a challenge to nurses caring for older adults. Three
common states that result in confusion are delirium, dementia, and depression.
The three conditions are compared and contrasted in this article. [References:
29]
Fayers, P. M., M. J. Hjermstad, et al. (2005). "Which mini-mental state exam items can
be used to screen for delirium and cognitive impairment?" Journal of Pain & Symptom
Management 30(1): 41-50.
Cognitive impairment is common in palliative care patients, but it is frequently
undetected. The clinical consequence is that psychiatric states such as delirium,
which often present with cognitive impairment, are inadequately treated. A short
and simple questionnaire for screening of cognitive impairment is required for
these patients, in order to proceed with more advanced testing if necessary. In
this study, we explored the results from two samples of patients (n=290 and
n=217) who had completed the Mini-Mental State Examination (MMSE). Cases
of cognitive impairment are considered indicated by an MMSE score of less than
24 of the total 30. We found that caseness could be fairly accurately screened by
using four of the original 20 MMSE items, and that a six-item questionnaire
further greatly improved the discrimination.
Fink, M. (1999). "Delirious mania." Bipolar Disorders 1(1): 54-60.
OBJECTIVES: To define the characteristics of delirious mania. METHODS: A list
of patients exhibiting both delirium and mania admitted to an academic
psychiatric treatment unit of a tertiary care medical center was maintained for 6
years. A literature review for the terms 'delirium' and 'bipolar disorder' was
undertaken. RESULTS: Few articles identify the syndrome. Most cite Bell (On a
form of disease resembling some advanced stages of mania and fever. Am J
Insanity 1849; 6: 97-127) as the first observer and Bond (Recognition of acute
delirious mania. Arch Gen Psychiatry 1980; 37: 553 554) as the most recent.
Fourteen instances were identified in the case list. Delirious mania is a syndrome
of the acute onset of the excitement, grandiosity, emotional lability, delusions,
and insomnia characteristic of mania, and the disorientation and altered
consciousness characteristic of delirium. Almost all patients exhibited signs of
catatonia. Bond (1980) recommends lithium and a neuroleptic combination as the
treatment. In the present series, electroconvulsive therapy was found to be safe
and rapidly effective, with all cases responding within three treatments and
requiring less than six treatments in the course. The rapidity of response is the
same as that of patients with catatonia. CONCLUSION: Delirious mania warrants
specific identification in the diagnostic nomenclature. The distinction between
delirious mania and the excited or malignant forms of catatonia requires study.
Gerrah, R., Y. Abramovitch, et al. (2001). "Traumatic memory: a cause for postoperative
delirium--a diagnostic dilemma." Israel Medical Association Journal: Imaj 3(11): 858-9.
Grassi, L., B. Biancosino, et al. (2001). "Depression or hypoactive delirium? A report of
ciprofloxacin-induced mental disorder in a patient with chronic obstructive pulmonary
disease." Psychotherapy & Psychosomatics 70(1): 58-9.
Hanley, C. (2004). "Delirium in the acute care setting." MEDSURG Nursing 13(4): 21725.
Older adults are at particular risk for developing delirium, which is often not
recognized by health care providers in the acute care setting. Early recog nition
with a standardized assessment process provides early treatment. Multifactorial
approaches that can be utilized when treating the patient with delirium are
described. [References: 39]
Henry, M. (2002). "Descending into delirium.[see comment]." American Journal of
Nursing 102(3): 49-56; quiz 57.
Holschneider, D. P. and A. F. Leuchter (1999). "Clinical neurophysiology using
electroencephalography in geriatric psychiatry: neurobiologic implications and clinical
utility." Journal of Geriatric Psychiatry & Neurology 12(3): 150-64.
Electroencephalography (EEG) offers a unique contribution to the
armamentarium of imaging technologies used in the evaluation of brain function.
The primary clinical application of EEG is in the diagnosis of delirium, dementia,
and epilepsy, which are frequently encountered in the practice of geropsychiatry.
This review summarizes the principles behind generation of the EEG signal, its
strengths and limitations as a technology, clinical indications for performing an
EEG, the principles underlying quantitative EEG (QEEG), and how QEEG is
allowing us to probe brain function and connectivity in new ways. [References:
160]
Huffman, J. C. and G. L. Fricchione (2005). "Hypercalcemic delirium associated with
hyperparathyroidism and a vitamin D analog." Gen Hosp Psychiatry 27(5): 374-6.
Hughes, A. (2001). "Recognising the causes of delirium in older people." Nursing Times
97(33): 32-3.
Ignatavicius, D. (1999). "Resolving the delirium dilemma." Nursing 29(10): 41-6; quiz
N289.
Inouye, S. K., M. J. Schlesinger, et al. (1999). "Delirium: a symptom of how hospital
care is failing older persons and a window to improve quality of hospital care." American
Journal of Medicine 106(5): 565-73.
Delirium, or acute confusional state, which often results from hospital-related
complications or inadequate hospital care for older patients, can serve as a
marker of the quality of hospital care. By reviewing five pathways that can lead to
a greater incidence of delirium--iatrogenesis, failure to recognize delirium in its
early stages, attitudes toward the care of the elderly, the rapid pace and
technological focus of health care, and the reduction in skilled nursing staff--we
identify how future trends and cost-containment practices may exacerbate the
problem. Examining delirium also provides an opportunity to improve the quality
of hospital care for older persons. Interventions to reduce delirium would need to
occur at the local and national levels. Local strategies would include routine
cognitive assessment and the creation of systems to enhance geriatric care,
such as incentives to change practice patterns, geriatric expertise, case
management, and clinical pathways. National strategies might include providing
education for physicians and nurses to improve the recognition of delirium and
the awareness of its clinical implications, improving quality monitoring systems
for delirium, and creating environments to facilitate the provision of high-quality
geriatric care. [References: 103]
Justic, M. (2000). "Does "ICU psychosis" really exist?[see comment]." Critical Care
Nurse 20(3): 28-37; quiz 38-9.
In summary, ICU psychosis does not develop in all patients. Instead, many
patients are at risk for hypoactive, hyperactive, or mixed hypoactive and
hyperactive delirium. Prevention of delirium should always be foremost, including
recognition of patients at high risk, minimal use of causative medications, and
treatment of physiological conditions that are often unrelated to a patient's
admitting diagnosis. When prevention fails, early diagnosis and treatment can
make a marked difference in patients' outcomes. The potential adverse outcomes
of delirium are well documented. These include increased mortality; increased
length of stay; reduced level of functioning in the elderly, which often leads to
placement in a nursing home; and stress response syndrome after
hospitalization. The value of nursing in preventing delirium is evident when
nurses apply their knowledge of potential causes and develop strategies to avoid
these causes in their patients. Nurses provide early detection and coordinate with
other members of the healthcare team to initiate a plan of care that includes
prompt treatment of delirium to reduce the signs and symptoms, duration, and
potential adverse sequelae of this disorder. Nursing interventions are designed to
enhance patients' cognitive status, sense of security, safety, and comfort. Nurses
are instrumental in providing appropriate choices, doses, and administration of
medications and in recognizing side effects. Use of medications ordered to treat
delirium is often left to nurses' discretion because the orders specify that the
drugs should be given as needed. Finally, nurses are the ones who recognize the
need for additional assistance via psychiatric consultations or for more intensive
observation and management of patients to ensure quality care. [References: 48]
Kennedy, R. E., R. Nakase-Thompson, et al. (2003). "Use of the cognitive test for
delirium in patients with traumatic brain injury." Psychosomatics 44(4): 283-9.
The sensitivity and specificity of the Cognitive Test for Delirium, which was
originally developed for use in intensive care units, were tested in a group of
patients with traumatic brain injury who were admitted to a neurorehabilitation
center. Sixty-five consecutive patients were evaluated weekly by using the DSMIV criteria for delirium and the Cognitive Test for Delirium. Complete ratings were
available for 249 of 304 weekly observations. Analysis of the receiver operating
characteristic curve suggested an optimum cutoff score of less than 22 for
identification of delirium by using the Cognitive Test for Delirium, with a sensitivity
of 72% and a specificity of 71% compared with the DSM-IV diagnosis. The
results suggest that the Cognitive Test for Delirium provides an acceptable level
of differentiation between delirious and nondelirious patients with traumatic brain
injury.
Kunkel, E. J. and O. Aliu (2000). "Management of the agitated patient." Delaware
Medical Journal 72(11): 473-8.
Unfortunately, although delirium is common in the general hospital, the diagnosis
is frequently missed. As delirium often indicates a serious, sometimes lifethreatening, medical or surgical condition, successful management and
subsequent prevention of morbidity and mortality require prompt recognition and
early intervention. Failure to recognize, diagnose, and treat delirium and the
underlying pathology can result in death. This article presents current thinking on
the management of delirium and related agitation in the general medical hospital.
[References: 17]
Laurila, J. V., K. H. Pitkala, et al. (2004). "Impact of different diagnostic criteria on
prognosis of delirium: a prospective study." Dementia & Geriatric Cognitive Disorders
18(3-4): 240-4.
A 2-year follow-up study was performed to compare the prognosis of delirium
defined according to 4 different diagnostic classifications (DSM-III, DSM-III-R,
DSM-IV and ICD-10 clinical criteria) among 425 elderly geriatric hospital patients
and nursing home residents. The proportion of delirium varied from 24.9% (DSMIV) to 10.1% (ICD-10). The prognoses were similar particularly according to all
DSM classifications: 31.3-36.3% of the delirious patients died within 1 year and
57.8-62.5% within 2 years. The number of subjects diagnosed as delirious
according to the ICD-10 was small, and their prognosis did not differ significantly
from the others either. The DSM-IV has simplified the criteria of delirium. It
identifies new, acutely ill and relatively nondependent subjects as delirious who
share the poor prognosis of patients diagnosed with the previous criteria. 2004 S.
Karger AG, Basel
Lendvai, I., S. M. Saravay, et al. (1999). "Creutzfeldt-Jakob disease presenting as
secondary mania." Psychosomatics 40(6): 524-5.
Makker, R. and W. Yanny (2000). "Postoperative delirium mimicking
epilepsy.[comment]." Anaesthesia 55(6): 601.
O'Keeffee, S. T. (1999). "Delirium in the elderly." Age & Ageing 28 Suppl 2: 5-8.
Onishi, H., C. Kawanishi, et al. (2004). "Successful treatment of Wernicke
encephalopathy in terminally ill cancer patients: report of 3 cases and review of the
literature." Supportive Care in Cancer 12(8): 604-8.
Although Wernicke encephalopathy has been reported in the oncological
literature, only one terminally ill cancer patient with Wernicke encephalopathy
has been reported. Wernicke encephalopathy, a potentially reversible condition,
may be unrecognized in terminally ill cancer patients. In this communication, we
report three terminally ill cancer patients who developed Wernicke
encephalopathy. Early recognition and subsequent treatment resulted in
successful palliation of delirium. Two of the three patients did not show the
classical triad of Wernicke encephalopathy. Common clinical symptoms were
delirium and poor nutritional status. Intravenous thiamine administration
dramatically improved the symptoms of delirium in all three patients. In terminally
ill cancer patients, clinicians must remain aware of the possibility of Wernicke
encephalopathy when patients with a poor nutritional status present with
unexplained delirium. Early intervention may correct the symptoms and prevent
irreversible brain damage and the quality of life for the patient may improve.
Papathanasopoulos, P., K. Mallioris, et al. (2000). "Febrile Hashimoto's
encephalopathy." Journal of Neurology, Neurosurgery & Psychiatry 68(6): 795.
Pestka, E. L., R. R. Billman, et al. (2002). "Acute medical crises masquerading as
psychiatric illness." Journal of Emergency Nursing 28(6): 531-5.
Popplewell, P. and P. Phillips (2002). "Is it dementia? Which one?" Australian Family
Physician 31(4): 319-21.
BACKGROUND: People fear losing their identity or no longer being themselves.
It can be devastating to see someone who spent their life with you turn into
someone who looks like your loved one but who no longer recognises you and
may be frightened, suspicious, hostile or violent. OBJECTIVE: This article gives
practical guidelines with a recognition, definition and differential diagnosis of
dementia. DISCUSSION: Dementia may not be obvious to the individual, the
family or their family doctor and should not be simply attributed to 'Alzheimer's'.
Dementias can be confused with delirium or depression and the different
dementias have different prognoses and different interventions.
Rahkonen, T., H. Makela, et al. (2000). "Delirium in elderly people without severe
predisposing disorders: etiology and 1-year prognosis after discharge." International
Psychogeriatrics 12(4): 473-81.
BACKGROUND: The etiologic factors of delirium have been frequently studied in
hospitalized elderly patients who usually have an underlying disorder, i.e., hip
fracture or dementia predisposing to delirium. The etiologic factors of delirium
and prognosis in healthy elderly remain unstudied. The aim of our study was to
detect the primary and additional etiologic factors contributing to delirium among
community-dwelling healthy elderly people without predisposing disorders to
delirium and to evaluate 1-year prognosis after discharge to home. METHOD:
The study subjects consisted of 51 community-dwelling people over 65 years of
age, without severe underlying disorders predisposing to delirium, admitted
consecutively to the hospital because of a delirious state. The diagnosis of
delirium was based on the DSM-III-R criteria. After discharge to home, the
subjects were followed up for 1 year. RESULTS: The most important primary
causes of delirium were infections in 22 cases (43%) and cerebrovascular
attacks in 13 cases (25%). After the 1-year follow-up period, 10 patients (20%)
had been taken into long-term care and 5 patients (10%) had died.
DISCUSSION: The plausible etiologic factor of delirium was detected in all
cases. Among healthy elderly people, infections and cerebrovascular attacks
were the most important etiologic factors for delirium. After discharge to home,
30% of the patients had to be taken into long-term care or had died within 1 year
of the delirium.
Robinson, M. J. (2002). "Probable Lewy body dementia presenting as "delirium"."
Psychosomatics 43(1): 84-6.
Roche, V. (2003). "Southwestern Internal Medicine Conference. Etiology and
management of delirium." American Journal of the Medical Sciences 325(1): 20-30.
Delirium has been recognized for the last 3 millennia and is the most common
complication found in hospitalized patients aged 65 and older in the United
States. However, critical basic science and clinical research did not progress until
the DSM III criteria clearly defined delirium 20 years ago. The term delirium then
replaced many nonspecific entities, such as acute confusion state, acute brain
syndrome, metabolic encephalopathy, and toxic psychosis. This review
discusses the epidemiology, risk factors, interventions, causes, management,
and outcomes of delirium. The pathophysiology of delirium has the potential to
radically alter our management of delirium and is a controversial area of
research. [References: 84]
Rockwood, K. (2003). "Need we do so badly in managing delirium in elderly
patients?[comment]." Age & Ageing 32(5): 473-4.
Samuels, S. C. and M. M. Evers (2002). "Delirium. Pragmatic guidance for managing a
common, confounding, and sometimes lethal condition." Geriatrics 57(6): 33-8; quiz 40.
Virtually any medical illness, intoxication, or medication can precipitate delirium,
an acute confusional state common among older persons. Delirium is associated
with a high risk of morbidity and mortality, thus management requires thorough
assessment and swift but careful action. A range of nonpharmacologic
interventions can aid management of delirium, but in general, emergent, empiric
pharmacotherapy is indicated for acute cases. Key to assessment and diagnosis
is ruling out dementia and depression, determining the presence of delirium, and
establishing an underlying cause. Several screening tools are available to aid this
effort. Vigilance can help reduce the high number of patients discharged with
unresolved symptoms.
Schneider, G., A. Kruse, et al. (2000). "The prevalence and differential diagnosis of
subclinical depressive syndromes in inpatients 60 years and older." Psychotherapy &
Psychosomatics 69(5): 251-60.
BACKGROUND: Depressive syndromes that do not comply with the diagnostic
criteria for specific depressive disorders are designated as 'subclinical' or
'subsyndromal' depressive syndromes. Using our own data from a clinical study,
this paper outlines the significance of subclinical depressive syndromes and
demonstrates the problems of differentiating between depressive and subclinical
depression (SD) syndromes and organic mood disorders especially in an elderly
population with medical comorbidity. METHODS: Two hundred and sixty-two
patients aged 60 years and older in a general hospital were investigated, using a
clinical psychiatric interview, expert ratings and self-report scales after extensive
internal medical diagnostic evaluation. RESULTS: When, without further
differentiation as to their origin, all symptoms required by symptom checklists
according to ICD-10 were considered for the diagnosis of major depression (MD),
35.5% of the study participants fulfilled the diagnostic criteria. After differentiating
for etiology of symptoms, MD was found in only 14.1%, SD was diagnosed in
17.6% and organic mood disorder in 12.2% of the study participants. In another
41 patients (15.6%), symptoms of depression not fulfilling ICD-10 criteria were
classified as being of organic or drug-induced origin. SD patients were in a mean
position between nondepressive and depressive patients with regard to social
isolation and physical impairment; women were overrepresented in the
depressive and subdepressive groups. CONCLUSIONS: SD and organic mood
disorder are common and helpful diagnostic categories in the elderly. The results
show that in old age there is substantial danger of confounding MD, SD and
organic mood disorder, thus leading to erroneously high prevalence rates of MD
and underestimations of organic mood disorder if depressive symptoms are
recorded only by self-report scales or a symptom checklist. Both internal and
psychosomatic-psychotherapeutic competence as well as a liaison service in
general hospitals are necessary for the differential diagnosis of MD, SD and
organic mood disorder in the elderly with medical comorbidity. Copyright 2000 S.
Karger AG, Basel
Schofield, I. and J. Dewing (2001). "The care of older people with a delirium in acute
care settings.[see comment]." Nursing Older People 13(1): 21-5; quiz 26.
This article suggests that nurses should play a major part in the screening,
assessment and management of delirium in older people in acute settings.
Schuurmans, M. J., S. A. Duursma, et al. (2001). "Early recognition of delirium: review
of the literature." Journal of Clinical Nursing 10(6): 721-9.
This review focuses on delirium and early recognition of symptoms by nurses.
Delirium is a transient organic mental syndrome characterized by disturbances in
consciousness, thinking and memory. The incidence in older hospitalized
patients is about 25%. The causes of delirium are multi-factorial; risk factors
include high age, cognitive impairment and severity of illness. The consequences
of delirium include high morbidity and mortality, lengthened hospital stay and
nursing home placement. Delirium develops in a short period and symptoms
fluctuate, therefore nurses are in a key position to recognize symptoms. Delirium
is often overlooked or misdiagnosed due to lack of knowledge and awareness in
nurses and doctors. To improve early recognition of delirium, emphasis should
be given to terminology, vision and knowledge regarding health in ageing and
delirium as a potential medical emergency, and to instruments for systematic
screening of symptoms. [References: 105]
Sturmberg, J. P. and J. Death (2000). "Delirium and confusional states." Australian
Family Physician 29(11): 1063-5.
Timmermans, M. and J. Carr (2004). "Neurosyphilis in the modern era." Journal of
Neurology, Neurosurgery & Psychiatry 75(12): 1727-30.
OBJECTIVE: To review the nature of the presentation of neurosyphilis, the value
of diagnostic tests, and the classification of the disease. METHODS: A
retrospective review was carried out of the records of patients who had been
identified as possible cases of neurosyphilis by a positive FTA-abs test in the
CSF. The review extended over 10 years at a single hospital which served a
population of mixed ancestry in a defined catchment area in the Western Cape
province of South Africa. Patients were placed in predefined diagnostic
categories, and clinical, radiological, and laboratory features were assessed.
RESULTS: 161 patients met diagnostic criteria for neurosyphilis: 82 presented
with combinations of delirium and dementia and other neuropsychiatric
conditions, and the remainder had typical presentations such as stroke (24),
spinal cord disease (15), and seizures (14). The average age of presentation
ranged from 35.9 to 42.6 years in the different categories of neurosyphilis. Of
those followed up, 77% had residual deficits from their initial illness.
Cerebrospinal fluid (CSF) VDRL was positive in 73% of cases. CONCLUSIONS:
The diagnosis of neurosyphilis can be made with reasonable certainty if there is
an appropriate neuropsychiatric syndrome associated with a positive CSF VDRL.
If the VDRL is negative, a positive FTA-abs in an appropriate clinical setting,
associated with raised CSF cell count, protein, or IgG index, is a useful method
of identifying neurosyphilis. Tabes dorsalis has become uncommon, but this is
likely to be the only manifestation of neurosyphilis that has been altered during
the antibiotic era.
van Zyl, L. T. and P. R. Davidson (2003). "Delirium in hospital: an underreported event
at discharge." Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie
48(8): 555-60.
OBJECTIVE: Delirium, an important event in hospital, is associated with
significant mortality and morbidity. Most patients with delirium recover fully;
however, when left untreated, delirium may progress to stupor, coma, or death.
Delirium is less likely to resolve completely in elderly patients in whom persistent
cognitive deficits commonly occur. The extent to which this information is
available to family doctors after discharge was investigated. METHOD: A total of
31 patients with delirium who were referred to consultation-liaison psychiatry
were assessed using standardized measures. Medical services completed
discharge summaries on these patients; a chart review captured the extent to
which the diagnosis of delirium and the involvement of psychiatry was recorded
in the discharge summaries. RESULTS: In structured discharge summaries, a
reference to delirium occurrence was found in 55% of cases. In unstructured
discharge summaries, the reporting was much lower (16% of cases). Delirium
was more likely to be reported in women than in men, when it was more severe,
or when it was the principal reason for admission, rather than when it occurred
during an admission for some other reason. CONCLUSIONS: Delirium episodes
that occur during a period of hospitalization for treatment of any medical disorder
are underreported, even when specifically diagnosed. Structured discharge
summaries tend to increase the rate of reporting.
Velasco, P. J., M. Manshadi, et al. (1999). "Psychiatric aspects of parathyroid disease."
Psychosomatics 40(6): 486-90.
Parathyroid diseases can present with psychiatric symptoms and can be
recognized through determinations of serum electrolytes, especially the calcium
level. Psychiatric evaluations should include a serum calcium concentration test,
which is also essential in reassessment of patients poorly responsive to mental
illness treatment. A magnesium and a phosphate assay may also be
diagnostically helpful. Abnormality of divalent cation levels may provide evidence
for consideration of, or ruling out, parathyroid disorders. Determinations of
parathyroid hormone are performed if clinically indicated, and if abnormal
divalent cation quantifications are confirmed. If parathyroid disease is identified,
corrective endocrine therapies may diminish or even cure psychiatric aspects of
parathyroid pathology. Failure to recognize a parathyroid disorder leaves an
endocrine-induced mental dysfunction without proper treatment. [References: 12]
Weintraub, D. and S. Lippmann (2001). "Delirious mania in the elderly." International
Journal of Geriatric Psychiatry 16(4): 374-7.
Delirious mania is a clinical syndrome in which the signs and symptoms of
delirium manifest themselves in the context of a manic episode. Though there
have been numerous descriptions and case reports of this syndrome, all have
described mania as the presenting feature, with signs of delirium developing
subsequently, and none of the vignettes have involved elderly patients. We
report two cases of elderly individuals with mania who initially presented as in a
delirium. Both of them experienced clear manic episodes, which were confirmed
by their psychiatric histories and clinical responses to mood stabilizers. Mania
needs to be in the differential diagnosis of elderly people presenting with
confusion, disorientation, and perceptual changes, particularly in those with a
history of bipolar disorder. Copyright 2001 John Wiley & Sons, Ltd.
Wong, C. P., P. K. Chiu, et al. (2005). "Zopiclone withdrawal: an unusual cause of
delirium in the elderly." Age Ageing 34(5): 526-7.
We report a case of an elderly lady who was admitted for congestive heart
failure. She developed delirium during the course of her hospital stay. Multiple
investigations were performed but were unremarkable. Finally, a diagnosis of
abrupt zopiclone withdrawal causing delirium was made. Zopiclone was resumed
at a lower dose and delirium resolved completely.
Yang, C. H., J. P. Hwang, et al. (2000). "The clinical applications of Mini-Mental State
Examination in geropsychiatric inpatients." International Journal of Psychiatry in
Medicine 30(3): 277-85.
OBJECTIVE: This study investigated the association between Mini-Mental State
Examination (MMSE) scores and diagnosis, computerized tomographic scans or
electroencephalogram findings in geropsychiatric inpatients (age > or = 65).
METHOD: We analyzed the MMSE records of patients sixty-five and older who
had been hospitalized in our psychiatric ward during a nine-year period. Case
data were collected by review of chart records. RESULTS: In these patients,
MMSE scores were significantly different among the seven diagnostic groups
included. Demented patients had the lowest MMSE scores. Patients who had
abnormal findings on computerized tomographic scans or electroencephalogram
had lower MMSE than patients with normal findings. CONCLUSION: Our findings
suggest that the MMSE is a useful screening instrument for organicity in the
geropsychiatric inpatients. However, because of the lower average MMSE score
in geropsychiatric inpatients, the optimal cut-offpoint of MMSE for dementia
should be lower than those used in other populations.