James Fitzgerald

Delirium: A disturbance of circadian integrity?

Delirium is a serious neuropsychiatric syndrome of acute onset that occurs in approximately one in five general hospital patients and is associated with serious adverse outcomes that include loss of adaptive function, persistent cognitive problems and increased mortality. Recent studies indicate a three-domain model for delirium that includes generalised cognitive impairment, disturbed executive cognition, and disruption of behaviours that are under circadian control such as sleep-wake cycle and motor activity levels. As a consequence, attention has focused upon the possible role of the circadian timing system (CTS) in the pathophysiology of delirium. We explored this possibility by reviewing evidence that (1) many symptoms that occur in delirium are influenced by circadian rhythms, (2) many features of recognised circadian rhythm disorders are similar to characteristic features of delirium, (3) common risk factors for delirium are known to disrupt circadian systems, (4) physiological disturbances of circadian systems have been noted in delirious patients, and (5) positive effects in the treatment of delirium have been demonstrated for melatonin and related agents that influence the circadian timing system. A programme of future studies that can help to clarify the relevance of circadian integrity to delirium is described. Such work can provide a better understanding of the pathophysiology of delirium while also identifying opportunities for more targeted therapeutic efforts.

Development of an abbreviated version of the delirium motor subtyping scale (DMSS-4)

BACKGROUND Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Identification of clinical subtypes can allow for more targeted clinical and research efforts. We sought to develop a brief method for clinical subtyping in clinical and research settings. METHODS A multi-site database, including motor symptom assessments conducted in 487 patients from palliative care, adult and old age consultation-liaison psychiatry services was used to document motor activity disturbances as per the Delirium Motor Checklist (DMC). Latent class analysis (LCA) was used to identify the class structure underpinning DMC data and also items for a brief subtyping scale. The concordance of the abbreviated scale was then compared with the original Delirium Motor Subtype Scale (DMSS) in 375 patients having delirium as per the American Psychiatric Associations Diagnostic and Statistical Manual (4th edition) criteria. RESULTS Latent class analysis identified four classes that corresponded closely with the four recognized motor subtypes of delirium. Further, LCA of items (n = 15) that loaded >60% to the model identified four features that reliably identified the classes/subtypes, and these were combined as a brief motor subtyping scale (DMSS-4). There was good concordance for subtype attribution between the original DMSS and the DMSS-4 (κ = 0.63). CONCLUSIONS The DMSS-4 allows for rapid assessment of clinical subtypes in delirium and has high concordance with the longer and well-validated DMSS. More consistent clinical subtyping in delirium can facilitate better delirium management and more focused research effort.

Concordance between the delirium motor subtyping scale (DMSS) and the abbreviated version (DMSS-4) over longitudinal assessment in elderly medical inpatients.

BACKGROUND Delirium is a common neuropsychiatric syndrome that includes clinical subtypes identified by the Delirium Motor Subtyping Scale (DMSS). We explored the concordance between the DMSS and an abbreviated 4-item version in elderly medical inpatients. METHODS Elderly general medical admissions (n = 145) were assessed for delirium using the Revised Delirium Rating scale (DRS-R98). Clinical subtype was assessed with the DMSS (which includes the four items included in the DMSS-4). Motor subtypes were generated for all patient assessments using both versions of the scale. The concordance of the original and abbreviated DMSS was examined. RESULTS The agreement between the DMSS and DMSS-4 was high, both at initial and subsequent assessments (κ range 0.75-0.91). Intraclass Correlation Coefficient (ICC) for all three raters for the DMSS was high (0.70) and for DMSS-4 was moderate (0.59). Analysis of the agreement between raters for individual DMSS items found higher concordance in respect of hypoactive features compared to hyperactive. CONCLUSIONS The DMSS-4 allows for rapid assessment of clinical subtype in delirium and has high concordance with the longer and well-validated DMSS, including over longitudinal assessment. There is good inter-rater reliability between medical and nursing staff. More consistent clinical subtyping can facilitate better delirium management and more focused research effort.

Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups

Delirium is prevalent and serious, yet remains under‐recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six‐item cognitive impairment test (6‐CIT), clock‐drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT).

The first survey of attitudes of medical students in Ireland towards termination of pregnancy

Background Since the UK Abortion Act (1967), women have travelled from Ireland to the UK for legal abortion. In 2011 >4000 women did so. Knowledge and attitudes of medical students towards abortion have been published, however, this is the first such report from Ireland. Objective To investigate medical students’ attitudes towards abortion in Ireland. Methods All medical students at the University of Limerick, and physicians who graduated from the university within the previous 12 months, were invited via email to complete an anonymous online survey. The questionnaire comprised 17 questions. Quantitative and qualitative analyses were performed. Results Response rate was 45% (n=169; 55% women; 88.2% <30 years of age; 66.7% Irish; 29.2% North American). Outcomes were: abortion should not be legally available (7.1%), abortion should be allowed in limited circumstances only (35.5%), abortion should be legally available upon request (55%). 72.8% of respondents were moderately/strongly prochoice (74% of women/71% of men/72% and 76% of Irish and North American respondents, respectively). Students aged >30 years were less likely to be prochoice (55%). While 95.2% believed that education on abortion should be offered within medical school curricula, 28.8% stated that they would decline to terminate pregnancies even if legally permitted. While 58.8% indicated that they might perform legal abortions once qualified, 25.7% would do so under limited circumstances only. Conclusions The majority of participants wanted education regarding abortion. Despite being predominantly prochoice, considerably fewer students, irrespective of nationality, indicated that they would perform abortions.

Sleep-wake cycle disturbances in elderly acute general medical inpatients: Longitudinal relationship to delirium and dementia

Sleep disturbances in elderly medical inpatients are common, but their relationship to delirium and dementia has not been studied.

193Rates of Refusal of Cognitive Screening Tests in Older Medical Inpatients

Niamh O’Regan, Katrina Maughan, James Fitzgerald, Dimitrios Adamis, David Meagher, Suzanne Timmons Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada School of Applied Psychology, University College Cork, Cork, Ireland Graduate Entry Medical School, University of Limerick, Limerick, Ireland Sligo Mental Health Services, Sligo, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland

192Can we Assess Visuospatial Function Verbally in Older Medical Inpatients

Niamh O’Regan, Katrina Maughan, James Fitzgerald, Dimitrios Adamis, David Meagher, Suzanne Timmons Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada School of Applied Psychology, University College Cork, Cork, Ireland Graduate Entry Medical School, University of Limerick, Limerick, Ireland Sligo Mental Health Services, Sligo, Ireland Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland