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

Drug therapy for delirium in terminally ill adults

BACKGROUND

Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004.

OBJECTIVES

To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries.

SELECTION CRITERIA

We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older).

DATA COLLECTION AND ANALYSIS

We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables.

MAIN RESULTS

We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported.

SECONDARY OUTCOMES

use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE.

AUTHORS' CONCLUSIONS

We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.

Post-traumatic Stress Disorder Following Acute Delirium

Delirium is a significant medical condition that is common in hospitalized patients. Beyond the increased risk of mortality, patients who experience an episode of delirium often go on to develop long-term psychiatric disturbance, including symptoms of post-traumatic stress disorder (PTSD). While there is a growing interest in understanding the complex relationship between delirium and PTSD, the existing literature is sparse and lacking harmony. Thus, this review seeks to develop a unified and thorough description of the cognitive and psychiatric underpinnings of post-delirium PTSD with the aims of promoting awareness of this condition amongst clinicians in medical settings, improving patient care, and sparking further research on this topic. While specific underlying mechanisms are yet unclear, PTSD was found to be associated with delirium in that delirious patients may have decreased factual recall of hospital events and increased hallucinations/delusions of a traumatic nature. Several potential interventions were identified, as well as suggestions for future research and clinical practice.

Outcome Differences by Delirium Motor Subtype in Patients with Ischemic Stroke

OBJECTIVE

This study evaluated the outcomes of ischemic stroke patients according to delirium motor subtype.

METHODS

This study included patients who were admitted to the stroke unit between August 2017 and March 2019 and met the DSM-5 diagnostic criteria for delirium. Patients were assessed twice weekly throughout their delirium episodes using the Korean version of the Delirium Motor Subtype Scale (K-DMSS) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). The clinical characteristics and short-term outcomes of the patients were also assessed.

RESULTS

A total of 943 stroke patients were included; the rate of incident delirium was 10.18%. Of the 95 delirium patients, 34 were classified as the hyperactive subtype, 30 as the mixed subtype, 25 as the hypoactive and six as no subtype. Among the subtype groups, the hypoactive subtype had the highest initial scores on the National Institutes of Health Stroke Scale (NIHSS; 6.72±4.75, p=0.02) and the modified Rankin Scale (mRS; 3.96±1.24, p<0.01). Additionally, the mixed and hypoactive subtypes had longer durations (p<0.01) and more severe symptoms of delirium (p=0.03) than the other motor subtypes, and the hypoactive subtype group had a significantly longer hospital stay (36.88±27.71 days, p<0.01) than the other subtype groups. After adjusting for baseline covariates in a multiple linear regression analysis, these differences remained significant.

CONCLUSION

The present results suggest that the motor subtype of delirium is associated with different characteristics and outcomes in ischemic stroke patients.

Impact of intraoperative blood pressure, blood pressure fluctuation, and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study

AIM

Postoperative delirium (PD) is a frequent complication of hip fracture surgery, but its pathophysiology remains poorly understood. We investigated the impact of a single episode of intraoperative hyper/hypotension, blood pressure (BP) fluctuation (ΔMAP), and pulse pressure (PP) on hyper/hypoactive PD in elderly patients undergoing surgery for hip fracture. We also assessed the effect of PD on clinical outcomes.

METHODS

This was a prospective 1-year follow-up study of patients over 60 years of age with a primary diagnosis of acute low-energy hip fracture. Perioperative delirium was assessed using the Confusion Assessment Method (CAM); the development of PD and the type, hyperactive or hypoactive PD, were recorded. Cognitive assessment was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ). The lowest and highest BP values were extracted from the patients' anaesthesia charts. Postoperative complications, reinterventions and 1-month mortality were recorded.

RESULTS

PD occurred in 148 (53%) patients during the first postoperative week, with 75% of the cases diagnosed as hypoactive PD. Patients developing PD of any type were older, had a lower body mass index, higher SPMSQ and Charlson scores, more severe systemic diseases, a lower lowest intraoperative BP, a higher ΔMAP, a lower PP, and a higher postoperative pain score. They also took more drugs and received more blood transfusion intraoperatively. Multivariate logistic regression analyses showed that a higher MAP min had a protective effect on the occurrence of any type of PD, as well as hypoactive and hyperactive. PD had negative effect on outcomes.

CONCLUSION

Our results provide evidence of an association between maximal hypotension, the lowest intraoperative mean blood pressure (MAP), ΔMAP, PP, and PD. A progressive decrease in MAP during surgery was associated with the increased odds of developing either type of PD.

Delirium motor subtypes and prognosis in hospitalized geriatric patients - A prospective observational study

OBJECTIVE

Delirium is common and associated with poor outcomes. Hypoactive motor subtype may predict worse outcome than no-subtype, hyperactive and mixed delirium, but uncertainty remains due to heterogeneity of results and subtyping tools. Other prognostic aspects across delirium motor subtypes are understudied. We investigated differences in one-year mortality, length of stay and institutionalization at discharge and after one year, across delirium motor subtypes in geriatric patients.

METHODS

We conducted a prospective observational study, included 311 patients ≥75 years acutely admitted to a geriatric ward, diagnosed delirium using Diagnostic and Statistical Manual of Mental Disorder (5th ed.) criteria and used the Delirium Motor Subtype Scale for subtyping. Differences in mortality across subtypes were investigated using Cox proportional-hazard regression analyses, unadjusted and adjusted for age, comorbidity and delirium severity. We investigated differences in length of stay and institutionalization using the Kruskal-Wallis test and Pearson's chi-squared test with subsequent Hommel-adjusted pairwise comparisons.

RESULTS

Ninety-three patients (30%) had delirium; 12 (13%) had no-subtype, 27 (29%) hyperactive, 30 (32%) hypoactive and 24 (26%) mixed delirium. There were no group differences regarding mortality (p = .61) or length of stay (p = .32). Analyses indicated group differences regarding discharge to an institution (p = .028), but pairwise comparisons showed no differences (smallest p = .071, no-subtype 45% vs hypoactive 85%). There were no group differences in institutionalization after one year (p = .26).

CONCLUSION

There were no significant differences in one-year mortality, length of stay or institutionalization across delirium motor subtypes in geriatric patients, although the study may indicate better prognosis in the no-subtype group.

Impact of an educational workshop upon psychiatrists' attitudes towards delirium care

OBJECTIVES

Improving knowledge about delirium care is a key target for health care. We describe the implementation of a four-part workshop focusing upon key aspects of delirium care.

METHODS

Attitudes towards and understanding of delirium diagnosis and management amongst psychiatrists were surveyed before and immediately after an educational workshop.

RESULTS

There were 62 participants. Pre-workshop, delirium was rated highly relevant to psychiatry. Overall level of confidence in diagnosis was modest, with the behavioural and psychological symptoms of dementia considered the most challenging differential diagnosis. Only nine participants (15%) correctly identified DSM-5 delirium criteria. Preferred assessment of attention varied with six different approaches endorsed. Confidence was higher for managing hyperactive compared with hypoactive delirium (p&lt;0.001). Pharmacotherapy was more frequently endorsed for hyperactive compared with hypoactive presentations, with haloperidol the most popular agent (p&lt;0.001). A total of 41 (66%) participants completed post-workshop assessments. Post-workshop, there were significant increases to the perceived relevance of delirium (p = 0.003), confidence in overall diagnosis (p&lt;0.001) accuracy of awareness of DSM-5 criteria (p&lt;0.001), and confidence in treating different presentations (p&lt;0.001). The Months Backward Test was the preferred bedside test of attention (38/40 respondents).

CONCLUSIONS

This interactive educational intervention impacted positively upon knowledge and attitudes amongst psychiatrists towards key aspects of delirium care. Further investigation can examine the impact upon longer term knowledge and behaviour.

Delirium and Dementia

Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.

Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study

Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology.

Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics.

Participants: Fifty patients were included in the study.

Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology.

Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.

Motor activity across delirium motor subtypes in geriatric patients assessed using body-worn sensors: a Norwegian cross-sectional study

OBJECTIVES

It remains unclear if geriatric patients with different delirium motor subtypes express different levels of motor activity. Thus, we used two accelerometer-based devices to simultaneously measure upright activity and wrist activity across delirium motor subtypes in geriatric patients.

DESIGN

Cross-sectional study.

SETTINGS

Geriatric ward in a university hospital in Norway.

PARTICIPANTS

Sixty acutely admitted patients, ≥75 years, with DSM-5-delirium.

OUTCOME MEASURES

Upright activity measured as upright time (minutes) and sit-to-stand transitions (numbers), total wrist activity (counts) and wrist activity in a sedentary position (WAS, per cent of the sedentary time) during 24 hours ongoing Delirium Motor Subtype Scalesubtyped delirium.

RESULTS

Mean age was 86.7 years. 15 had hyperactive, 20 hypoactive, 17 mixed and 8 had no-subtype delirium. We found more upright time in the no-subtype group than in the hypoactive group (119.3 vs 37.8 min, p=0.042), but no differences between the hyperactive, the hypoactive and the mixed groups (79.1 vs 37.8 vs 50.1 min, all p>0.28). The no-subtype group had a higher number of transitions than the hypoactive (54.3 vs 17.4, p=0.005) and the mixed groups (54.3 vs 17.5, p=0.013). The hyperactive group had more total wrist activity than the hypoactive group (1.238×10⁴ vs 586×10⁴ counts, p=0.009). The hyperactive and the mixed groups had more WAS than the hypoactive group (20% vs 11%, p=0.032 and 19% vs 11%, p=0.049).

CONCLUSIONS

Geriatric patients with delirium demonstrated a low level of upright activity, with no differences between the hyperactive, hypoactive and mixed groups, possibly due to poor gait function. The hyperactive and mixed groups had more WAS than the hypoactive group, indicating true differences in motor activity across delirium motor subtypes, also in geriatric patients. Wrist activity appears more suitable than an upright activity for both diagnostic purposes and activity monitoring in geriatric delirium.

Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients

ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology.

OBJECTIVES

We sought to determine how delirium subtyped by etiology affected six-month function and cognition.

DESIGN

Prospective cohort study.

SETTING

Tertiary care, academic medical center.

PARTICIPANTS

A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED).

MEASUREMENTS

The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition.

RESULTS

In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = -2.9 points, 95%CI: -0.3 to -5.6) and organ dysfunction (β coefficient = -4.3 points, 95%CI: -7.2 to -1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20).

CONCLUSIONS

Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.

Clinical Assessment and Management of Delirium in the Palliative Care Setting

Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.

Delirium's Arousal Subtypes and Their Relationship with 6-Month Functional Status and Cognition

OBJECTIVE

We sought to determine how delirium subtyped by arousal affected 6-month function and cognition in acutely ill older patients.

METHODS

This was secondary analysis of a prospective cohort study which enrolled hospitalized patients ≥65 years old. Delirium and arousal were ascertained daily in the emergency department and the first 7 days of hospitalization using the modified Brief Confusion Assessment Method and Richmond Agitation Sedation Scale, respectively. For each day, patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Preillness and 6-month functional status were determined using the Older American Resources and Services activities of daily living scale which ranges from 0 (completely dependent) to 28 (completely independent). Preillness and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly which ranges from 1 (markedly improved cognition) to 5 (severe cognitive impairment). Multiple linear regression was performed adjusted for preillness Older American Resources and Services activities of daily living and Informant Questionnaire on Cognitive Decline in the Elderly and other relevant confounders.

RESULTS

In 228 older patients, delirium with normal arousal was the only subtype independently associated with poorer 6-month function and cognition. For every day spent in this subtype, the 6-month Older American Resources and Services activities of daily living decreased by 0.84 points (95% confidence interval: -1.59 to -0.09) and the patient's 6-month Informant Questionnaire on Cognitive Decline in the Elderly significantly increased by 0.14 points (95% confidence interval: 0.06-0.23).

CONCLUSIONS

Delirium with normal arousal, as opposed to delirium with decreased or increased arousal, was the only arousal subtype significantly associated with worsening 6-month function and cognition. Subtyping delirium by arousal may have important prognostic value.

Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions

OBJECTIVE

The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions.

METHODS

Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories.

RESULTS

Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]).

CONCLUSION

Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.

Environmental factors and risk of delirium in geriatric patients: an observational study

Background

Patients with delirium have increased risk of death, dementia and institutionalization, and prognosis differs between delirium motor subtypes. A few studies have identified associations between environmental factors like room-transfers and time spent in the emergency department (ED) and delirium, but no studies have investigated if environmental factors may influence delirium motor subtypes. We wanted to explore if potentially stressful events like ward-transfers, arriving ED at nighttime, time spent in ED and nigthttime investigations were associated with development of delirium (incident delirium) and delirium motor subtypes.

Methods

We used the DSM-5 criteria to diagnose delirium and the Delirium Motor Subtype Scale for motor subtyping. We defined hyperactive and mixed delirium as delirium with hyperactive symptoms, and hypoactive and no-subtype delirium as delirium without hyperactive symptoms. We registered ward-transfers, time of arrival in ED, time spent in ED and nighttime investigations (8 p.m. to 8 a.m.), and calculated Global Deterioration Scale (GDS) and Cumulative Illness Rating Scale (CIRS) to adjust for cognitive impairment and comorbidity. We used logistic regression analyses with incident delirium and delirium with hyperactive symptoms as outcome variables, and ward-transfers, arriving ED at nighttime, time spent in ED and nighttime investigations as exposure variables, adjusting for age, GDS and CIRS in the analyses for incident delirium.

Results

We included 254 patients, mean age 86.1 years (SD 5.2), 49 (19.3%) had incident delirium, 22 with and 27 without hyperactive symptoms. There was a significant association between nighttime investigations and incident delirium in both the unadjusted (odds ratio (OR) 2.22, 95% confidence interval (CI) 1.17 to 4.22, p = 0.015) and the multiadjusted model (OR 2.61, CI 1.26 to 5.40, p = 0.010). There were no associations between any other exposure variables and incident delirium. No exposure variables were associated with delirium motor subtypes.

Conclusions

Nighttime investigations were associated with incident delirium, even after adjusting for age, cognitive impairment and comorbidity. We cannot out rule that the medical condition leading to nighttime investigations is the true delirium-trigger, so geriatric patients must still receive emergency investigations at nighttime. Hospital environment in broad sense may be a target for delirium prevention.

Detection and management of hyperactive and hypoactive delirium in older patients during hospitalization: a retrospective cohort study evaluating daily practice

OBJECTIVES

The objectives of the study are to study daily hospital practice regarding detection and management and to study hyperactive and hypoactive delirium of older patients during their hospitalization.

METHODS

A retrospective cohort study evaluating care as usual for older hospitalized patients with delirium at Maastricht University Medical Center+, a university hospital in the Netherlands, was performed. Inclusion criteria were older hospitalized patients (65+ years), diagnosed with delirium between 1 January and 31 December 2014. Data were retrieved from the patients' medical files. Delirium was categorized as hyperactive or hypoactive. Primary outcome measures were prevalence and management (pharmacological, reorientation, screening for delirium and delirium consultations, and physical restraints). Secondary outcomes were short-term adverse outcomes.

RESULTS

Prevalence of delirium was 5% (N = 401), of which 77% (n = 307) was hyperactive and 23% (n = 94) was hypoactive. Significantly, more patients with a hyperactive delirium received medication to manage the delirium than patients with a hypoactive delirium (89% vs. 77%, respectively, p = 0.004). No other significant differences between the subtypes were found.

CONCLUSION

There was probably a strong under-recognition of delirium. Drugs were the main intervention of choice, especially for patients with hyperactive delirium. The two subtypes did not differ on non-pharmacological management. The retrospective nature of this study sheds light on the status quo of recognition, management, and care as usual for the different delirium subtypes in daily hospital practice, which may help in forming new guidelines and protocols for the detection and treatment of delirium for older patients in hospitals.

Do the Phenotypes of Symptom Fluctuation Differ Among Motor Subtypes in Patients With Delirium?

CONTEXT

Fluctuation in symptoms is a core feature of delirium. However, it is not well known whether the fluctuating nature would differ or not among the delirium subtype groups.

OBJECTIVE

This study compared phenotypes of diurnal fluctuation among different delirium subtypes using a prospective design.

METHODS

The motor subtypes of delirium patients were determined using the Delirium Motor Subtype Scale, fluctuations in consciousness levels were monitored with the Richmond Agitation-Sedation Scale (RASS), and symptom severity was assessed with the Nursing Delirium Screening Scale (Nu-DESC). All scales were administered at three time points over 24 hours; fluctuations in and phenotypes of symptoms were compared according to subtype of delirium using repeated-measures analysis of variance after adjustment for covariates.

RESULTS

This study included 224 delirium patients. Of this patients, 144 (64.3%) were classified as hyperactive, 25 (11.2%) as hypoactive, 33 (14.7%) as mixed, and 22 (9.9%) as no subtype. Scores on the RASS and Nu-DESC significantly changed during the evening and/or night and there were significant subtype group × time interaction for the RASS and Nu-DESC (F = 9.66, P < 0.001 and F = 5.11, P < 0.001, respectively). Post hoc analyses revealed that the hyperactive and mixed subtype groups had higher mean RASS scores and greater ranges of fluctuation than the other groups. The mixed subtype group was differentiated from hyperactive and hypoactive subtype groups by the range of fluctuation in psychomotor activity.

CONCLUSIONS

The phenotypes of symptom fluctuation differed among the motor subtypes. These findings further support the rationale that fluctuations are a core feature of delirium and could differentiate delirium subtypes.

Refining Delirium: A Transtheoretical Model of Delirium Disorder with Preliminary Neurophysiologic Subtypes

The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.

Delirium clinical motor subtypes: a narrative review of the literature and insights from neurobiology

INTRODUCTION

Clinical motor subtypes have been long recognised in delirium and, despite a growing body of research, a lack of clarity exists regarding the importance of these motor subtypes. The aims of this review are to (1) examine how the concept of motor subtypes has evolved, (2) explore their relationship to the clinical context, (3) discuss the relationship between the phenomenology of delirium and motor activity, (4) discuss the application of neurobiology to the theory of delirium motor subtypes, and (5) identify methodological issues and provide solutions for further studies.

METHODS

The following databases were searched: PubMed, PsychInfo, EBSCO, Medline, BioMed central and Science Direct. Inclusion criteria specified peer-reviewed research assessing delirium motor subtypes published between 1990 and 2016.

RESULTS

Sixty-one studies met the inclusion criteria. The majority of studies (n = 50) were found to use validated psychometric tools, while the remainder (n = 11) used clinical criteria. The majority of studies (n = 45) were conducted in the medical setting, while the remainder were in the ICU/post-operative setting (n = 17).

CONCLUSION

Although host sensitivities (e.g. frailty) and exogenous factors (e.g. medication exposure) may determine the type of motor disturbance, it remains unclear to what extent motor subtypes are influenced by other features of delirium. The use of more specialised tools (e.g. delirium motor subtyping scale), may enable researchers to develop an approach to delirium that has a greater nosological consistency. Future studies investigating delirium motor subtypes may benefit from enhanced theoretical considerations of the dysfunctional neural substrate of the delirious state.

Prognostic effects of delirium motor subtypes in hospitalized older adults: A prospective cohort study

OBJECTIVES

To investigate the association between delirium motor subtypes and hospital mortality and 12-month mortality in hospitalized older adults.

DESIGN

Prospective cohort study conducted from 2009 to 2015.

SETTING

Geriatric ward of a university hospital in Sao Paulo, Brazil.

PARTICIPANTS

We included 1,409 consecutive admissions of acutely ill patients aged 60 years and over. We excluded admissions for end-of-life care, with missing data on the main variables, length of stay shorter than 48 hours, or when consent to participate was not given.

MAIN OUTCOMES AND MEASURES

Delirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Comprehensive geriatric assessment was performed at admission and included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses used Cox proportional hazards models adjusted for possible confounders.

RESULTS

We included 1,409 admissions, with a mean age of 80 years. The proportion of in-hospital deaths was 19%, with a cumulative mortality of 38% in 12 months. Delirium occurred in 47% of the admissions. Hypoactive delirium was the predominant motor subtype (53%), followed by mixed delirium (30%) and hyperactive delirium (17%). Hospital mortality rates were respectively 33%, 34% and 15%. We verified that hypoactive and mixed delirium were independently associated with hospital mortality, with respective hazard ratios of 2.43 (95%CI = 1.64-3.59) and 2.31 (95%CI = 1.53-3.50). Delirium motor subtypes were not independently predictive of 12-month mortality.

CONCLUSIONS

One in three acutely ill hospitalized older adults who suffered hypoactive or mixed delirium died in the hospital. Clinicians should be aware that hypoactive symptoms of delirium, whether shown exclusively or in alternation with hyperactive symptoms, are indicative of a worse prognosis in this population.

Persistent Delirium in Elderly patients Three Months After Hospital Discharge from a University Clinic

OBJECTIVE

The purpose of the study was to determine the prevalence and characteristics of patients with persistent delirium (PD) at three months after hospital discharge.

METHODOLOGY

Longitudinal descriptive study to assess the prevalence and characteristics of in-patients aged 65 years and older in the Clinica Universitaria Bolivariana who met DSM-5 criteria for delirium at admission, at discharge, and at a 3-month follow up assessment. Socio-demographic features were determined, and CGI-S and DRS-R98 scales used.

RESULTS

A total of 30 patients were evaluated between April and October 2013, but 6 did not fulfil the inclusion criteria. The study included 24 patients, with 9 (37.5%) dying during hospitalisation. Of the 15 surviving patients, five (20.8% of the total sample) had their delirium resolved at discharge, and ten (41.6% of the sample) continued with symptoms. These established the PD group, of whom five of them (20.8%) had full PD, and the other five (20.8%) sub-syndromal PD (SSPD). At the final assessment, only two patients (8.3%) continued with full PD, and another two (8.3%) with SSPD. Among the PD group, 30% had a full delirium at admission (prevalence), and 70% developed full delirium during hospitalization (incidence).

CONCLUSIONS

A significant number of patients did not recover from delirium at leaving hospital, and remained symptomatic three months after discharge. The study findings suggest a course of gradual improvement of delirium, with a persistence of symptoms over time in 40% of the patients, which would have implications for the clinical practice.

Validation of the Korean Version of the Delirium Motor Subtype Scale

OBJECTIVE

The Delirium Motor Subtype Scale (DMSS) is a validated and reliable instrument developed from various methods previously used to assess delirium motor subtypes. It focuses on pure motor disturbances with a relative specificity for delirium. The aim of this study was to investigate the validity and reliability of a Korean version of the DMSS (K-DMSS).

METHODS

We recruited 145 patients who were older than 60 years and had been referred for psychiatric consultation for delirium. These patients were evaluated using the K-DMSS, Liptzin & Levkoff criteria, and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-R98) to compare delirium motor subtypes.

RESULTS

The internal consistency of the K-DMSS in assessing delirium motor subtypes was acceptable (Cronbach's alpha=0.79). Delirium motor subtypes identified with the K-DMSS and K-DRS-R98 showed almost perfect agreement (Cohen's Kappa=0.81), while those identified with the K-DMSS and Liptzin & Levkoff criteria showed substantial agreement (Cohen's Kappa=0.78).

CONCLUSION

Our results suggest that the K-DMSS is a valid and reliable tool for identifying delirium subtypes.

Validation and Psychometric Properties of the German Version of the Delirium Motor Subtype Scale (DMSS)

Objective: Delirium has been characterized into its subtypes—hypoactive, hyperactive, mixed, or no motor subtype—along with the use of the Delirium Motor Symptom Scale (DMSS). The German version of this scale (DMSS-G), however, has not yet been validated. Method: We determined internal consistency, reliability, and validity of the DMSS-G in the surgical intensive care unit, using DSM-IV-TR criteria and the Delirium Rating Scale–Revised–98. Results: In total, 289 patients were included, and out of these, 122 were delirious. The DMSS-G showed excellent internal consistency (Cronbach’s α = 0.92) and interrater reliability (Fleiss κ = 0.83). Additionally, the overall concurrent validity was substantial (Cramer’s V = 0.69); within subtypes, hyperactive, hypoactive, or mixed, the concurrent validity remained at least substantial (Cohen’s κ = 0.73-0.82) and the sensitivity ranged from 60% to 97%. In contrast, in those with no motor subtype, we found the concurrent validity (Cohen’s κ = 0.31) and sensitivity to be low (22%). Overall, specificity for all individual subtypes was high (82% to 100%). The DMSS was very sensitive in both rating hyperactive and hypoactive motor symptoms of delirium. Conclusion: The DMSS-G is a highly reliable and valid instrument for detecting motor symptoms in delirium, which provides an accurate instrument to classify the motor subtypes of delirium.

Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis

BACKGROUND

Delirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess.

OBJECTIVES

To report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units.

METHODS

The Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion.

RESULTS

There was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units.

CONCLUSION

Improving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.

Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study

OBJECTIVE

To date motor subtypes of delirium have been evaluated in single-center studies with a limited examination of the relationship between predisposing factors and motor profile of delirium. We sought to report the prevalence and clinical profile of subtypes of delirium in a multicenter study.

METHODS

This is a point prevalence study nested in the "Delirium Day 2015", which included 108 acute and 12 rehabilitation wards in Italy. Delirium was detected using the 4-AT and motor subtypes were measured with the Delirium Motor Subtype Scale (DMSS). A multinomial logistic regression was used to determine the factors associated with delirium subtypes.

RESULTS

Of 429 patients with delirium, the DMSS was completed in 275 (64%), classifying 21.5% of the patients with hyperactive delirium, 38.5% with hypoactive, 27.3% with mixed and 12.7% with the non-motor subtype. The 4-AT score was higher in the hyperactive subtype, similar in the hypoactive, mixed subtypes, while it was lowest in the non-motor subtype. Dementia was associated with all three delirium motor subtypes (hyperactive, OR 3.3, 95% CI: 1.2-8.7; hypoactive, OR 2.8, 95% CI: 1.2-6.5; mixed OR 2.6, 95% CI: 1.1-6.2). Atypical antipsychotics were associated with hypoactive delirium (OR 0.23, 95% CI: 0.1-0.7), while intravenous lines were associated with mixed delirium (OR 2.9, 95% CI: 1.2-6.9).

CONCLUSIONS

The study shows that hypoactive delirium is the most common subtype among hospitalized older patients. Specific clinical features were associated with different delirium subtypes. The use of standardized instruments can help to characterize the phenomenology of different motor subtypes of delirium.

Clinical Assessment and Management of Delirium in the Palliative Care Setting

Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.

The intensive care delirium research agenda: a multinational, interprofessional perspective

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

Postoperative delirium in elderly citizens and current practice

Postoperative delirium (POD) represents an acute brain dysfunction in the postsurgical period. Perioperative physicians caring for the older adults are familiar with the care of dysfunction of organs such as lungs, heart, liver, or kidney in the perioperative setting, but they are less familiar with management of brain dysfunction. As early detection and prompt treatment of inciting factors are utmost important to prevent or minimize the deleterious outcomes of delirium. The purpose of this review is to prepare perioperative physicians with a set of current clinical practice recommendations to provide optimal perioperative care of older adults, with a special focus on specific perioperative interventions that have been shown to prevent POD. On literature search in EMBASE, CINAHL, and PUBMED between January 2000 and September 2015 using search words delirium, POD, acute postoperative confusion, and brain dysfunction resulted in 9710 articles. Among them, 73 articles were chosen for review, in addition, National Institute for Health and Clinical Excellence guidelines, American Geriatric Society guidelines, hospital elderly life program-confusion assessment method training manual, New York geriatric nursing protocols, World Health Organization's International Classification of Diseases, 10th Revision classification of mental disorders, Food and Drug Administration requests boxed warnings on older class of antipsychotic drugs 2008 and delirium in Miller's text book of anesthesia were reviewed and relevant information presented in this article.

Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management

Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.

Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: a prospective study (DELIRIUM CORDIS)

Background:

Delirium is a frequent in-hospital complication in elderly patients, and is associated with poor clinical outcome. Its clinical impact, however, has not yet been fully addressed in the setting of the cardiac intensive care unit (CICU). The present study is a prospective, two-centre registry aimed at assessing the incidence, prevalence and significance of delirium in elderly patients with acute cardiac diseases.

Methods:

Between January 2014 and March 2015, all consecutive patients aged 65 years or older admitted to the CICU of our institutions were enrolled and followed for 6 months. Delirium was defined according to the confusion assessment method.

Results:

During the study period, 726 patients were screened for delirium. The mean age was 79.1±7.8 years. A total of 111 individuals (15.3%) were diagnosed with delirium; of them, 46 (41.4%) showed prevalent delirium (PD), while 65 (58.6%) developed incident delirium (ID). Patients 85 years or older showed a delirium rate of 52.3%. Hospital stay was longer in delirious versus non-delirious patients. Patients with delirium showed higher in-hospital, 30-day and 6-month mortality compared to non-delirious patients, irrespective of the onset time (overall, ID or PD). Six-month re-hospitalisation was significantly higher in overall delirium and the PD group, as compared to non-delirious patients. Kaplan–Meier analysis showed a significant reduction of 6-month survival in patients with delirium compared to those without, irrespective of delirium onset time (i.e. ID or PD). A positive confusion assessment method was an independent predictor of short and long-term mortality.

Conclusions:

Delirium is a common complication in elderly CICU patients, and is associated with a longer and more complicated hospital stay and increased short and long-term mortality. Our findings suggest the usefulness of a protocol for the early identification of delirium in the CICU. Clinicaltrials.gov: NCT02004665

Exploring Delirium's Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients

OBJECTIVES

To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality.

DESIGN

This was a preplanned secondary analysis of two prospective cohort studies.

SETTING

Academic tertiary care emergency department (ED).

PARTICIPANTS

1,084 ED patients who were 65 years old or older.

MEASUREMENTS

At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation Sedation Score to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality.

RESULTS

Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.3-7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95% CI: 0.9-2.1) and 1.3 (95% CI: 0.3-5.4), respectively.

CONCLUSIONS

Delirious ED patients with normal arousal at initial presentation had a threefold increased hazard of death within 6 months compared with patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study.

The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses

OBJECTIVE

This study aims to investigate the effect of nonpharmacological intervention training on delirium recognition and the intervention strategies of intensive care (ICU) nurses.

METHOD

This is a quasi-experimental study conducted using a pretest-posttest design. The study sample included a total of 95 patients staying in the medical ICU of a university hospital and 19 nurses working in these units. The data were collected using the Patient and Nurse Introduction, Confusion Assessment Method for the ICU, and Delirium Risk Factors, and Non-pharmacological Interventions in Delirium Prevention Forms.

RESULTS

Delirium was identified in 26.5% and 20.9% of the patients in the pre- and posttraining phase, respectively. Patients with delirium had a longer duration of stay in the ICU, lower mean Glasgow Coma Scale score and a higher number of medications in daily treatment (p<0.05). The risk of delirium increased 8.5-fold by physical restriction and 3.4-fold by the presence of hypo/hypernatremia. The delirium recognition rate of nurses increased from 7.7% to 33.3% in the post-training phase.

CONCLUSION

Our study results show that training can increase the efficiency of ICU nurses in the management of delirium.

Delirium: a guide for the general physician

Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.

Brief assessment of delirium subtypes: Psychometric evaluation of the Delirium Motor Subtype Scale (DMSS)-4 in the intensive care setting

OBJECTIVE

The management of and prognosis for delirium are affected by its subtype: hypoactive, hyperactive, mixed, and none. The DMSS-4, an abbreviated version of the Delirium Motor Symptom Scale, is a brief instrument for the assessment of delirium subtypes. However, it has not yet been evaluated in an intensive care setting.

METHOD

We performed a prospective/descriptive cohort study in order to determine the internal consistency, reliability, and validity of the relevant items of the DMSS-4 versus the Delirium Rating Scale-Revised-98 (DRS-R-98) and the original DMSS in a surgical intensive care setting.

RESULTS

A total of 289 elderly, predominantly male patients were screened for delirium, and 122 were included in our sample. The internal consistency of the DMSS-4 items was excellent (Cronbach's α = 0.92), and between the DMSS-4 and DRS-R-98 the overall concurrent validity was substantial (Cramer's V = 0.67). Within individual motor subtypes, concurrent validity remained at least substantial (Cohen's κ = 0.65-0.81) and sensitivity high (69.8 to 82.2%), in contrast to those of the no-motor subtype, with less validity and sensitivity (κ = 0.28, 22%). Similarly, total concurrent validity between the DMSS-4 and the original DMSS reached perfection (Cramer's V = 0.83), as did agreement between the subtypes (κ = 0.83-0.92), while sensitivity remained high (88.2-100%). Only in those with delirium with no-motor subtype was agreement moderate (κ = 0.56) and sensitivity lower (67%). Specificity was high across all subtypes (91.2-99.1%). The DMSS-4 yielded very sensitive ratings, particularly for hypoactive and hyperactive motor symptoms, and interrater agreement was excellent (Fleiss's κ = 0.83).

SIGNIFICANCE OF RESULTS

We found the DMSS-4 to be a most reliable and valid brief assessment of delirium in characterizing the subtypes of delirium in an intensive care setting, with increased sensitivity to hypoactive and hyperactive motor alterations.

Agitation, Delirium, and Cognitive Outcomes in Intracerebral Hemorrhage

BACKGROUND

Delirium predicts higher long-term cognitive morbidity. We previously identified a cohort of patients with spontaneous intracerebral hemorrhage and delirium and found worse outcomes in health-related quality of life (HRQoL) in the domain of cognitive function.

OBJECTIVE

We tested the hypothesis that agitation would have additional prognostic significance on later cognitive function HRQoL.

METHODS

Prospective identification of 174 patients with acute intracerebral hemorrhage, measuring stroke severity, agitation, and delirium, with a standardized protocol and measures. HRQoL was assessed using the Neuro-QOL at 28 days, 3 months, and 1 year. Functional outcomes were measured with the modified Rankin Scale.

RESULTS

Among the 81 patients with HRQoL follow-up data available, patients who had agitation and delirium had worse cognitive function HRQoL scores at 28 days (T scores for delirium with agitation 20.9 ± 7.3, delirium without agitation 30.4 ± 16.5, agitation without delirium 36.6 ± 17.5, and neither agitated nor delirious 40.3 ± 15.9; p = 0.03) and at 1 year (p = 0.006). The effect persisted in mixed models after correction for severity of neurologic injury, age, and time of assessment (p = 0.0006) and was not associated with medication use, seizures, or infection.

CONCLUSIONS

The presence of agitation with delirium in patients with intracerebral hemorrhage may predict higher risk of unfavorable cognitive outcomes up to 1 year later.

Delirium: a guide for the general physician

Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.

Delirium Frequency and Risk Factors Among Patients With Cancer in Palliative Care Unit

Introductıon: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit.

METHODS

Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria.

RESULTS

The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%.

CONCLUSION

The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.

Psychometric evaluation of the DMSS-4 in a cohort of elderly post-operative hip fracture patients with delirium

BACKGROUND

Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Rapid reliable identification of clinical subtypes can allow for more targeted research efforts.

METHODS

We explored the concordance in attribution of motor subtypes between the Delirium Motor Subtyping Scale 4 (DMSS-4) and the original Delirium Motor Subtyping Scale (DMSS) (assessed cross-sectionally) and subtypes defined longitudinally using the Delirium Symptom Interview (DSI).

RESULTS

We included 113 elderly patients developing DSM-IV delirium after hip-surgery [mean age 86.9 ± 6.6 years; range 65-102; 68.1% females; 25 (22.1%) had no previous history of cognitive impairment]. Concordance for the first measurement was high for both the DMSS-4 and original DMSS (k = 0.82), and overall for the DMSS-4 and DSI (k = 0.84). The DMSS-4 also demonstrated high internal consistency (McDonald's omega = 0.90). The DSI more often allocated an assessment to "no subtype" compared to the DMSS-4 and DMSS-11, which showed higher inclusion rates for motor subtypes.

CONCLUSIONS

The DMSS-4 provides a rapid method of identifying motor-defined clinical subtypes of delirium and appears to be a reliable alternative to the more detailed and time-consuming original DMSS and DSI methods of subtype attribution. The DMSS-4, so far translated into three languages, can be readily applied to further studies of causation, treatment and outcome in delirium.

Delirium diagnosis defined by cluster analysis of symptoms versus diagnosis by DSM and ICD criteria: diagnostic accuracy study

BACKGROUND

Information on validity and reliability of delirium criteria is necessary for clinicians, researchers, and further developments of DSM or ICD. We compare four DSM and ICD delirium diagnostic criteria versions, which were developed by consensus of experts, with a phenomenology-based natural diagnosis delineated using cluster analysis of delirium features in a sample with a high prevalence of dementia. We also measured inter-rater reliability of each system when applied by two evaluators from distinct disciplines.

METHODS

Cross-sectional analysis of 200 consecutive patients admitted to a skilled nursing facility, independently assessed within 24-48 h after admission with the Delirium Rating Scale-Revised-98 (DRS-R98) and for DSM-III-R, DSM-IV, DSM-5, and ICD-10 criteria for delirium. Cluster analysis (CA) delineated natural delirium and nondelirium reference groups using DRS-R98 items and then diagnostic systems' performance were evaluated against the CA-defined groups using logistic regression and crosstabs for discriminant analysis (sensitivity, specificity, percentage of subjects correctly classified by each diagnostic system and their individual criteria, and performance for each system when excluding each individual criterion are reported). Kappa Index (K) was used to report inter-rater reliability for delirium diagnostic systems and their individual criteria.

RESULTS

117 (58.5 %) patients had preexisting dementia according to the Informant Questionnaire on Cognitive Decline in the Elderly. CA delineated 49 delirium subjects and 151 nondelirium. Against these CA groups, delirium diagnosis accuracy was highest using DSM-III-R (87.5 %) followed closely by DSM-IV (86.0 %), ICD-10 (85.5 %) and DSM-5 (84.5 %). ICD-10 had the highest specificity (96.0 %) but lowest sensitivity (53.1 %). DSM-III-R had the best sensitivity (81.6 %) and the best sensitivity-specificity balance. DSM-5 had the highest inter-rater reliability (K =0.73) while DSM-III-R criteria were the least reliable.

CONCLUSIONS

Using our CA-defined, phenomenologically-based delirium designations as the reference standard, we found performance discordance among four diagnostic systems when tested in subjects where comorbid dementia was prevalent. The most complex diagnostic systems have higher accuracy and the newer DSM-5 have higher reliability. Our novel phenomenological approach to designing a delirium reference standard may be preferred to guide revisions of diagnostic systems in the future.

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.

Comparison of diagnostic classification systems for delirium with new research criteria that incorporate the three core domains

OBJECTIVE

Diagnostic classification systems do not incorporate phenomenological research findings about the three core symptom domains of delirium (Attentional/Cognitive, Circadian, Higher Level Thinking). We evaluated classification performances of novel Trzepacz, Meagher, and Franco research diagnostic criteria (TMF) that incorporate those domains and ICD-10, DSM-III-R, DSM-IV, and DSM-5.

METHODS

Primary data analysis of 641 patients with mixed neuropsychiatric profiles. Delirium (n=429) and nondelirium (n=212) reference standard groups were identified using cluster analysis of symptoms assessed using the Delirium Rating Scale-Revised-98. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR+, LR-) are reported.

RESULTS

TMF criteria had high sensitivity and specificity (87.4% and 89.2%), more balanced than DSM-III-R (100% and 31.6%), DSM-IV (97.7% and 74.1%), DSM-5 (97.7% and 72.6%), and ICD-10 (66.2% and 100%). PPV of DSM-III-R, DSM-IV, and DSM-5 were <90.0%, while PPV for ICD-10 and TMF were >90%. ICD-10 had the lowest NPV (59.4%). TMF had the highest LR+ (8.06) and DSM-III-R the lowest LR- (0.0). Overall, values for DSM-IV and DSM-5 were similar, whereas for ICD-10 and DSM-III-R were inverse of each other. In the pre-existing cognitive impairment/dementia subsample (n=128), TMF retained its highest LR+ though specificity (58.3%) became less well balanced with sensitivity (87.9%), which still exceeded that of DSM.

CONCLUSIONS

TMF research diagnostic criteria performed well, with more balanced sensitivity and specificity and the highest likelihood ratio for delirium identification. Reflecting the three core domains of delirium, TMF criteria may have advantages in biological research where delineation of this syndrome is important.

Predicting outcome in older hospital patients with delirium: a systematic literature review

OBJECTIVE

Delirium is a serious neuropsychiatric syndrome common in older hospitalised adults. It is associated with poor outcomes, however not all people with delirium have poor outcomes and the risk factors for adverse outcomes within this group are not well described. The objective was to report which predictors of outcome had been reported in the literature.

METHODS

We performed a systematic review by an initial electronic database search of MEDLINE, Embase and PsycINFO using four key search criteria. These were: (1) participants with a diagnosis of delirium, (2) clearly defined outcome measures, (3) a clearly defined variable as predictor of outcomes and (4) participants in the general hospital, rehabilitation and care home settings, excluding intensive care. Studies were then selected in a systematic fashion using specific predetermined criteria by three reviewers.

RESULTS

A total of 559 articles were screened, and 57 full text articles were assessed for eligibility. Twenty seven studies describing 18 different predictors of poor outcome were reported. The studies were rated by the Newcastle-Ottawa Score and were generally at low risk of bias. Four broad themes of predictor were identified; five delirium related predictors, two co-morbid psychiatric illness related predictors, eight patient related predictors and three biomarker related predictors. The most numerously described and clinically important appear to be the duration of the delirium episode, a hypoactive motor subtype, delirium severity and pre-existing psychiatric morbidity with dementia or depression. These are all associated with poorer delirium outcomes.

CONCLUSION

Important predictors of poor outcomes in patients with delirium have been demonstrated. These could be used in clinical practice to focus direct management and guide discussions regarding prognosis. These results also demonstrate a number of key unknowns, where further research to explore delirium prognosis is recommended and is vital to improve understanding and management of this condition.

Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study

OBJECTIVE

The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination.

DESIGN

Prospective, observational study.

SETTING

University hospital.

PARTICIPANTS

The study included 110 patients undergoing cardiac surgery.

INTERVENTIONS

Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit.

MEASUREMENTS AND MAIN RESULTS

The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean±SD, 33.2±26.51 mmHgxh v 23.4±16.13 mmHgxh; p = 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011).

CONCLUSIONS

Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.

Differential Associations Between Delirium and Mortality According to Delirium Subtype and Age: A Prospective Cohort Study

OBJECTIVE

This study investigated the differential associations between delirium and mortality in terminally ill patients according to delirium subtype and age.

METHODS

This was a prospective cohort study of terminally ill patients. Delirium was diagnosed using the confusion assessment method. Delirium subtypes were defined based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria and the Delirium Rating Scale-98-R. A multivariate Cox proportional hazards regression analysis was used to examine predictors of mortality.

RESULTS

Of the 322 cases, 98 patients (30.4%) were diagnosed as having delirium. The median (interquartile range) number of survival days after admission was 17.0 (10.0-36.0) days for patients with delirium and 28.0 (16.0-57.0) days for patients without delirium (p = .002). A multivariate analysis revealed that patients with hypoactive and mixed subtypes of delirium survived for shorter periods compared with patients without delirium (hazard ratio [HR] = 1.65 [95% confidence interval {CI} = 1.05-2.59, p = .029] and HR = 2.30 [95% CI = 1.44-3.69, p = .001], respectively). The hypoactive and mixed delirium subtypes exhibited significant interactions with age: younger age was associated with shorter periods of survival in patients with hypoactive and mixed subtype delirium (HR = 0.95 [95% CI = 0.93-0.98, p < .001] and HR = 0.97 [95% CI = 0.93-1.00, p = .038], respectively).

CONCLUSIONS

The hypoactive and mixed subtypes of delirium were associated with shorter survival periods in terminally ill patients, and these associations interacted significantly with age. These findings support the clinical and academic value of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition specifiers that differentiate the diagnoses of delirium subtypes.