Maeve Leonard

Delirium in an adult acute hospital population: predictors, prevalence and detection

Background To date, delirium prevalence and incidence in acute hospitals has been estimated from pooled findings of studies performed in distinct patient populations. Objective To determine delirium prevalence across an acute care facility. Design A point prevalence study. Setting A large tertiary care, teaching hospital. Patients 311 general hospital adult inpatients were assessed over a single day. Of those, 280 had full data collected within the studys time frame (90%). Measurements Initial screening for inattention was performed using the spatial span forwards and months backwards tests by junior medical staff, followed by two independent formal delirium assessments: first the Confusion Assessment Method (CAM) by trained geriatric medicine consultants and registrars, and, subsequently, the Delirium Rating Scale-Revised-98 (DRS-R98) by experienced psychiatrists. The diagnosis of delirium was ultimately made using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. Results Using DSM-IV criteria, 55 of 280 patients (19.6%) had delirium versus 17.6% using the CAM. Using the DRS-R98 total score for independent diagnosis, 20.7% had full delirium, and 8.6% had subsyndromal delirium. Prevalence was higher in older patients (4.7% if <50 years and 34.8% if >80 years) and particularly in those with prior dementia (OR=15.33, p<0.001), even when adjusted for potential confounders. Although 50.9% of delirious patients had pre-existing dementia, it was poorly documented in the medical notes. Delirium symptoms detected by medical notes, nurse interview and patient reports did not overlap much, with inattention noted by professional staff, and acute change and sleep-wake disturbance noted by patients. Conclusions Our point prevalence study confirms that delirium occurs in about 1/5 of general hospital inpatients and particularly in those with prior cognitive impairment. Recognition strategies may need to be tailored to the symptoms most noticed by the detector (patient, nurse or primary physician) if formal assessments are not available.

A longitudinal study of motor subtypes in delirium: Relationship with other phenomenology, etiology, medication exposure and prognosis

OBJECTIVE Motor subtypes have promise as a means of identifying clinically relevant delirium subgroups. Little is known about their relationship to etiologies, medication exposure, and outcomes. METHODS Consecutive cases of DSM-IV delirium in palliative care patients were assessed twice-weekly throughout their delirium episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Etiology Checklist (DEC) and Delirium Rating Scale Revised-98 (DRS-R98). RESULTS 100 patients [mean age 70.2 ± 10.5] were assessed on 303 visits [range 2-9]. Over the entire episode, mean DRS-R98 Severity scores were 16.2 ± 5.7. The mean number of etiologies per case was 3.4 ± 1.2. Motor subtypes were no subtype throughout (6%), hypoactive subtype throughout (28%), mixed subtype throughout (18%), hyperactive subtype throughout (10%) and variable subtype (38%). DRS-R98 Total and Severity scales differed significantly across categories (highest in mixed) but only motor, sleep-wake cycle, perceptual and language disturbance items differed. The Generalized Estimating Equations (GEE) approach was used to explore the relationship between subtype profile and symptoms, medication exposure and etiology. This showed that apart from motor items, only delusions, affective lability, metabolic disturbance and CVA related to any subtype. Cross-sectional assessments indicated greater use of benzodiazepine and antipsychotics in hyperactive patients but GEE analyses did not identify major associations between motor subtype and medication exposure. Patients with sustained hypoactive subtype were significantly more likely to die within one month of study entry. CONCLUSIONS Motor profile in delirium is relatively consistent over episode course and relates more closely to delirium phenomenology than to etiology or medication exposure. Motor subtypes have comparable disturbance of key diagnostic features such as cognitive and thought process abnormalities. Although mixed subtype is the most phenomenologically intense, hypoactives have the poorest prognosis.

The delirium experience: A review

While the adverse medical complications and consequences of delirium has been well studied, the same is not true of the psychological morbidity associated with the condition. A better understanding of what it is like to be delirious has the potential to improve recognition, management and treatment of delirium. This article examines the literature relating to the experience of delirium from the perspective of patients, families, and staff. Finally, suggestions for further work that might advance might advance our understanding of these issues are outlined.

A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls

Purpose Delirium and dementia have overlapping features that complicate differential diagnosis. Delirium symptoms overshadow dementia symptoms when they co-occur, but delirium phenomenology in comorbid cases has not been compared to both conditions alone. Methods Consecutive adults with DSM-IV delirium, dementia, comorbid delirium-dementia and cognitively intact controls were assessed using the Revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Results Delirium and comorbid delirium-dementia groups had comparable DRS-R98 and CTD total scores, which were greater than in dementia or control groups. On the DRS-R98, multiple non-cognitive symptoms, inattention and disorientation were more severe in delirium groups compared with dementia-alone. Patients with dementia differed from both delirium groups on the CTD test of attention. Spatial span backwards was significantly lower in all patients with cognitive impairment (delirium, comorbid delirium-dementia, dementia alone) compared to controls, whereas spatial span forwards distinguished delirium groups from dementia. Conclusions Delirium phenomenology is similar with or without comorbid dementia. A wide range of neuropsychiatric symptoms distinguish delirium from dementia. Spatial span forward is disproportionately diminished in delirium suggesting usefulness as a differentiating screening test.

Delirium phenomenology: What can we learn from the symptoms of delirium?

OBJECTIVES This review focuses on phenomenological studies of delirium, including subsyndromal and prodromal concepts, and their relevance to other elements of clinical profile. METHODS A Medline search using the keywords delirium, phenomenology, and symptoms for new data articles published in English between 1998 and 2008 was utilized. The search was supplemented by additional material not identified by Medline but known to the authors. RESULTS Understanding of prodromal and subsyndromal concepts is still in its infancy. The characteristic profile can differentiate delirium from other neuropsychiatric disorders. Clinical (motoric) subtyping holds potential but more consistent methods are needed. Studies are almost entirely cross-sectional in design and generally lack comprehensive symptom assessment. Multiple assessment tools are available but are oriented towards hyperactive features and few have demonstrated ability to distinguish delirium from dementia. There is insufficient evidence linking specific phenomenology with etiology, pathophysiology, management, course, and outcome. CONCLUSIONS Despite the major advancements of the past decade in many aspects of delirium research, further phenomenological work is crucial to targeting studies of causation, pathophysiology, treatment, and prognosis. We identified eight key areas for future studies.

Reversibility of delirium in terminally ill patients and predictors of mortality

In this study, factors related to reversibility and mortality in consecutive cases of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) delirium [n = 121] occurring in palliative care patients were evaluated. Delirium was assessed with the revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Patients were followed until recovery from delirium or death. In all, 33 patients (27%) recovered from delirium before death. Mean time until death was 39.7 ± 69.8 days in patients with reversible delirium [n = 33] versus 16.8 ± 10.0 days in those with irreversible delirium [n = 88; P < 0.01]. DRS-R98 and CTD scores were higher in irreversible delirium (P < 0.001) with greater disturbances of sleep, language, long-term memory, attention, vigilance and visuospatial ability. Irreversible delirium was associated with greater disturbance of CTD attention and higher DRS-R98 visuospatial function. Survival time was predicted by CTD score (P < 0.001), age (P = 0.01) and organ failure (P = 0.01). Delirium was not necessarily a harbinger of imminent death. Less reversible delirium involved greater impairment of attention, vigilance and visuospatial function. Survival time is related to age, severity of cognitive impairment and evidence of organ failure.

Features of subsyndromal and persistent delirium

BACKGROUND Longitudinal studies of delirium phenomenology are lacking. AIMS We studied features that characterise subsyndromal delirium and persistent delirium over time. METHOD Twice-weekly evaluations of 100 adults with DSM-IV delirium using the Delirium Rating Scale-Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). The generalised estimating equation method identified symptom patterns distinguishing full syndromal from subsyndromal delirium and resolving from persistent delirium. RESULTS Participants (mean age 70.2 years (s.d. = 10.5)) underwent 323 assessments (range 2-9). Full syndromal delirium was significantly more severe than subsyndromal delirium for DRS-R98 thought process abnormalities, delusions, hallucinations, agitation, retardation, orientation, attention, and short- and long-term memory items, and CTD attention, vigilance, orientation and memory. Persistent full syndromal delirium had greater disturbance of DRS-R98 thought process abnormalities, delusions, agitation, orientation, attention, and short- and long-term memory items, and CTD attention, vigilance and orientation. CONCLUSIONS Full syndromal delirium differs from subsyndromal delirium over time by greater severity of many cognitive and non-cognitive symptoms. Persistent delirium involves increasing prominence of recognised core diagnostic features and cognitive impairment.

Attention! A good bedside test for delirium?

Background Routine delirium screening could improve delirium detection, but it remains unclear as to which screening tool is most suitable. We tested the diagnostic accuracy of the following screening methods (either individually or in combination) in the detection of delirium: MOTYB (months of the year backwards); SSF (Spatial Span Forwards); evidence of subjective or objective ‘confusion’. Methods We performed a cross-sectional study of general hospital adult inpatients in a large tertiary referral hospital. Screening tests were performed by junior medical trainees. Subsequently, two independent formal delirium assessments were performed: first, the Confusion Assessment Method (CAM) followed by the Delirium Rating Scale-Revised 98 (DRS-R98). DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria were used to assign delirium diagnosis. Sensitivity and specificity ratios with 95% CIs were calculated for each screening method. Results 265 patients were included. The most precise screening method overall was achieved by simultaneously performing MOTYB and assessing for subjective/objective confusion (sensitivity 93.8%, 95% CI 82.8 to 98.6; specificity 84.7%, 95% CI 79.2 to 89.2). In older patients, MOTYB alone was most accurate, whereas in younger patients, a simultaneous combination of SSF (cut-off 4) with either MOTYB or assessment of subjective/objective confusion was best. In every case, addition of the CAM as a second-line screening step to improve specificity resulted in considerable loss in sensitivity. Conclusions Our results suggest that simple attention tests may be useful in delirium screening. MOTYB used alone was the most accurate screening test in older people.

What Do We Really Know About the Treatment of Delirium with Antipsychotics? Ten Key Issues for Delirium Pharmacotherapy

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

Symptoms of Depression and Delirium Assessed Serially in Palliative-Care Inpatients

Background: Delirium occurs in approximately 1 in 5 general hospital admissions and up to 85% of patients with terminal illness, but can be difficult to differentiation from other disorders, such as depression. Objective: The authors assessed and compared mood states as they relate to onset of delirium. Method: Symptoms of depression and delirium were assessed in 100 consecutive palliative-care admissions immediately after admission and 1 week later. Results: Overall, 51% experienced either major depression or delirium. Most patients with syndromal delirium also met criteria for major depressive illness, and 50% of those with depression had delirium or subsyndromal delirium (SSD). Delirium symptoms were less common in patients with major depression than depressive symptoms in patients with delirium or SSD. Discussion: Delirium should be considered in patients with altered mood states, and screening for depression should initially rule out delirium. Sustained alterations in mood may be more frequent in delirium than previously recognized. (Psychosomatics 2009; 50:506 –514)