Martin G. Cole

Delirium risk factors in elderly hospitalized Patients

OBJECTIVE: Delirium is frequent in elderly hospitalized patients. Many studies have examined its risk factors, but results have been quite variable. Thus, the goal of this study is to identify through systematic literature review the risk factors associated with the development of delirium in hospitalized geriatric patients.MEASUREMENTS AND MAIN RESULTS: First, MEDLINE/CURRENT contents databases were screened for relevant articles published from 1966 to December 1995, and from bibliographies of identified articles additional reports were selected. Second, the reports were screened by two different investigators and retained only if meeting the five following criteria: (1) original research in French or English; (2) prospective study; (3) patients over age 50; (4) minimum of one risk factor examined; (5) acceptable definition of delirium. Third, the methodology of each study was graded according to specific criteria for risk factor studies. Fourth, risk factors were identified and tabulated, unadjusted odds ratios (ORs) were computed, and where appropriate a combined OR with the Mantel-Haenszel estimator was calculated. Twenty-seven articles were retained meeting all of the above criteria. Among these studies, 11 were done on medical patients, 9 on surgical patients, 2 on medical and surgical patients, and 5 on psychiatric patients. In total 1,365 subjects with delirium were studied. Sixty-one different risk factors were examined, the five most common being dementia, medication, medical illness, age, and male gender. Mantel-Haenszel estimator was calculated for 10 risk factors, the most strongly associated being dementia (OR 5.2; 95% confidence interval [CI] 4.2, 6.3), medical illness (OR 3.8; 95% CI 2.2, 6.4), alcohol abuse (OR 3.3; 95% CI 1.9, 5.5), and depression (OR 1.9; 95% CI 1.3, 2.6). Methodologic weaknesses were present in many studies.CONCLUSIONS: Despite methodologic limitations, certain risk factors for delirium seem to be consistent and could help identify high-risk patients. These risk factors include dementia, advanced age, and medical illness. Other risk factors appear to play a contributory role in the development of delirium in elderly hospitalized patients.

Recognition of Depression by Non-psychiatric Physicians—A Systematic Literature Review and Meta-analysis

BACKGROUNDDepression, with up to 11.9% prevalence in the general population, is a common disorder strongly associated with increased morbidity. The accuracy of non-psychiatric physicians in recognizing depression may influence the outcome of the illness, as unrecognized patients are not offered treatment for depression.OBJECTIVESTo describe and quantitatively summarize the existing data on recognition of depression by non-psychiatric physicians.METHODSWe searched the following databases: MEDLINE (1966–2005), Psych INFO (1967–2005) and CINAHL (1982–2005). To summarize data presented in the papers reviewed, we calculated the Summary receiver operating characteristic (ROC) and the summary sensitivity, specificity and odds ratios (ORs) of recognition, and their 95% confidence intervals using the random effects model.MEASUREMENTS AND MAIN RESULTSThe summary sensitivity, specificity, and OR of recognition using the random effects model were: 36.4% (95% CI: 27.9–44.8), 83.7% (95% CI: 77.5–90.0), and 4.0 (95% CI: 3.2–4.9), respectively. We also calculated the Summary ROC. We performed a metaregression analysis, which showed that the method of documentation of recognition, the age of the sample, and the date of study publication have significant effect on the summary sensitivity and the odds of recognition, in the univariate model. Only the method of documentation had a significant effect on summary sensitivity, when the age of the sample and the date of publication were added to the model.CONCLUSIONThe accuracy of depression recognition by non-psychiatrist physicians is low. Further research should focus on developing standardized methods of documenting non-psychiatric physicians’ recognition of depression.

Environmental Risk Factors for Delirium in Hospitalized Older People

To evaluate the relationship of environmental risk factors in hospitals to changes over time in delirium symptom severity scores.

A new hierarchic approach to the measurement of dementia: Accurate results within 15 to 30 minutes

Abstract The Hierarchic Dementia Scale is a new instrument for assessing cognitive impairment, based on Piagetian concepts, neuropsychological findings, and the hierarchic nature of decline in mental function. Performance of 20 specific functions such as orienting reflexes and comprehension can be rapidly pinpointed over a wide range of impairment. Scale reliability and validity, tested in 50 demented patients, was high. Study with the scale of the course of Alzheimers disease in 13 patients defined a variety of patterns in their mental decline.

Detection and diagnosis of delirium in the elderly: psychiatrist diagnosis, confusion assessment method, or consensus diagnosis?

The clinical diagnosis of delirium has traditionally been based on an assessment by one or more physicians. Because of the transient, ubiquitous, and fluctuating nature of the symptoms of delirium, however, this approach may be flawed. Therefore, we decided to compare diagnosis based on one assessment by a psychiatrist, diagnosis by a nurse clinician (using the Confusion Assessment Method [CAM] and multiple observation points), and diagnosis by consensus. The study subjects were 87 patients aged 65 and over who were admitted consecutively from the emergency department to the medical wards, and who scored 3 or more on the Short Portable Mental Status Questionnaire. All subjects were assessed independently by one of three psychiatrists (a chart review and clinical examination) and a nurse clinician (using the CAM and multiple observation points). A consensus conference, attended by the three psychiatrists and the nurse clinician, used all available information to reach a consensus diagnosis. Compared to the consensus diagnosis, the clinical diagnosis by a psychiatrist had a sensitivity of .73 (95% confidence interval [CI]: .61-.85), a specificity of .93 (95% CI: .79-1.0), and an agreement kappa coefficient of .58 (95% CI: .41-.74). The nurse clinician diagnosis had a sensitivity of .89 (95% CI: .81-.97), a specificity of 1.00, and an agreement kappa coefficient of .86 (95% CI: .75-.97). These results suggest that one clinical assessment by a psychiatrist may not be the best method for detecting and diagnosing delirium in the elderly. A consensus diagnosis or diagnosis by a trained rater (using the CAM and multiple observation points) may be more sensitive approaches.

Pathway to psychiatric care of the elderly with depression

Goldberg and Huxley describe a pathway to psychiatric care which has five levels and four filters. To explore the application of this pathway to the elderly with depression we searched the relevant literature to estimate median annual rates of moderate‐severe depression at each level of the pathway. Among 27 elderly per thousand each year who had depression, 22 consulted a family physician who detected the disorder in 5.3. Of these, 2.8 were referred to psychiatric services and 1.3 were ultimately admitted to psychiatric units. Thus, only 10% of the elderly with moderate‐severe depression were assessed or treated by a psychiatrist. If confirmed, these findings have implications for geriatric psychiatry services and research.

Prevalence and incidence of delirium in long‐term care

(1) To describe the prevalence and 6‐month incidence of delirium in long‐term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics.

Delirium: effectiveness of systematic interventions.

The purpose of this paper was to review evidence related to the effectiveness of systematic interventions in preventing or detecting and treating delirium. The review process involved a systematic search of the literature on each topic, assessment of the validity of the studies retrieved and examination of their results. The literature search identified 10 studies on prevention and 7 studies on detection and treatment. A broad spectrum of systematic interventions appeared to be modestly effective in preventing delirium in young and old surgical patients but not elderly medical patients. Systematic detection and treatment programs and special nursing care appeared to add large benefits to traditional medical care in young and old surgical patients and modest benefits in elderly medical patients; however, it seemed that the more precise the target of the detection and treatment program, the greater the benefit.

Subsyndromal delirium in older people: a systematic review of frequency, risk factors, course and outcomes

To determine the frequency, risk factors, course and outcomes of subsyndromal delirium (SSD) in older people by systematically reviewing evidence on these topics.

Sleep deprivation in the treatment of elderly depressed patients.

ABSTRACT: Fifteen elderly depressed patients were treated by 36‐hour sleep deprivation (SD). The depression was unipolar in 3 cases, bipolar in 3, and secondary in 4. Nine of the 15 patients responded to SD, and 6 had a remission (1 with SD alone and 5 with SD plus an antidepressant drug). Some of the remaining 6 patients might have responded if the treatment had not been interrupted for various reasons. These favorable results in elderly patients were better than anticipated. SD was well tolerated, although in one patient with bipolar depression a manic attack was precipitated. The effectiveness of SD poses interesting theoretic questions.