Delirium. Advances in diagnosis, pathophysiology, and treatment

Factors Associated With Postoperative Delirium After Thoracic Surgery

BACKGROUND

Postoperative delirium is an acute confusional state characterized by fluctuating consciousness and is associated with increased morbidity and mortality. We analyzed the incidence and risk factors of delirium following thoracic surgery.

METHODS

All patients (n = 432) who underwent thoracotomy or sternotomy from 1996 to 2003 were analyzed retrospectively. The diagnosis of postoperative delirium was based on Diagnostic and Statistical Manual of Mental Disorders- IV criteria.

RESULTS

Postoperative delirium developed in 23 patients (5.32%) between postoperative days 2 to 12 (mean, 4.4 +/- 2.6 days). There were 15 males and 8 females, with a mean age of 59.4 years (24 to 77 years). The delirium group was older (59.4 +/- 14.6 vs 51.3 +/- 15.5 years, p < 0.01) and had a longer operation time than the nondelirious group (5.34 +/- 1.58 vs 4.38 +/- 1.6 hours, p = 0.005). Morbidity and mortality rates were not significantly different between the two groups (56.5% vs 47.1%; 13.0% vs 3.66%, respectively). Univariate analysis showed that the older age, markedly abnormal postoperative levels of sodium, potassium, or glucose, sleep deprivation, operation time, and diabetes mellitus were risk factors (p < 0.05). According to multivariate analyses, four factors were selected as predictive risk factors: (1) markedly abnormal postoperative levels of sodium, potassium, or glucose (p = 0.038); (2) sleep deprivation (p = 0.05); (3) age (p = 0.033); and (4) operation time (p = 0.041).

CONCLUSIONS

Postoperative delirium may cause higher morbidity and mortality rates after thoracic surgery. Close postoperative follow-up and early identification of predisposing factors such as older age, sleep deprivation, abnormal postoperative levels of sodium, potassium, or glucose, and longer operation time can prevent occurrence of postoperative delirium.

The role of rehabilitation medicine and palliative care in the treatment of patients with end-stage disease

Rehabilitation medicine and palliative care share many common goals. They strive to maximize physical function and emotional well-being to the highest extent possible given the nature of the underlying disease process. Many patients with end-stage disease experience symptoms and functional losses that diminish their quality of life. This article outlines the benefits that active rehabilitation therapy can provide to patients in the terminal stages of their disease and some of the ethical and practical issues faced in the planning and provision of this care.

Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study

Little is known concerning the natural history of psychiatric morbidity, postoperative delirium, cognitive decline and health-related quality of life (HRQOL) in cardiac surgery patients and the impact of neurocognitive dysfunction on HRQOL after cardiac surgery with cardiopulmonary bypass (CPB). In a prospective study, we followed up for 1 year 30 of the original 34 patients who had undergone cardiac surgery with CPB. Patients were assessed preoperatively, before discharge, and at 1 year after surgery with the Structural Clinical Interview for DSM-IV and a series of neuropsychological tests. Psychometric scales were administered to evaluate cognitive functioning (Syndrom Kurztest), depressive symptomatology (Montgomery-Asberg Depression Rating Scale), posttraumatic stress symptoms (Posttraumatic Stress Syndrome 10-Questions Inventory) and HRQOL (SF-36 Health Status Questionnaire). Delirium Rating Scale (DRS) was used daily over the course of intensive care unit treatment. Postoperative delirium developed in 11 of the 34 patients (mean DRS rating scale score+/-S.D.: 20.36+/-6.22, range: 14-31). Short-term consequences of cardiac surgery included adjustment disorder with depressed features (n=11), posttraumatic stress disorder (n=6), major depression (n=6) and clinically relevant cognitive deficits (n=13). At 12 months, the severity of depression and anxiety disorders improved and returned to the preoperative level, and 6 out of the 30 followed-up patients displayed cognitive deficits. Our patients' HRQOL SF-36 self-reports significantly improved compared with baseline quality of life data. However, 1-year overall lower cognitive function scores were associated with lower HRQOL. Cardiac surgery with CPB is associated with improvements in HRQOL relative to the preoperative period, but the presence of cardiac surgery-related cognitive decline impairing HRQOL is a complication for a subgroup of cardiac surgical patients in the long-term outcome.

End-of-life care in geriatric psychiatry

Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.

Admission characteristics of trauma patients in whom delirium develops

BACKGROUND

The purpose of this study was to describe the admission characteristics of trauma victims that are predictive of the development of delirium during hospitalization.

METHODS

In this case-control study, data (demographics, injury type, medical histories, admission laboratory values, medications, and outcomes) were obtained from the records of 120 patients in whom delirium developed and 145 in whom it did not after admission for traumatic injury. Odds ratios were employed to identify significant predictors used in a stepwise logistic regression analysis.

RESULTS

Admission characteristics, retained after stepwise logistic regression, that were independently predictive of delirium were age more than 45 years, positive admission blood alcohol, and an elevated mean corpuscular volume. Those in whom delirium developed had longer hospital and intensive care unit lengths of stay than in whom it did not.

CONCLUSIONS

Older patients and alcoholics are at increased risk for delirum. Therapies directed at prevention have the potential to improve care and decrease lengths of stay.

Delirium, depression, and anxiety

Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.

Use of the cognitive test for delirium in patients with traumatic brain injury

The sensitivity and specificity of the Cognitive Test for Delirium, which was originally developed for use in intensive care units, were tested in a group of patients with traumatic brain injury who were admitted to a neurorehabilitation center. Sixty-five consecutive patients were evaluated weekly by using the DSM-IV criteria for delirium and the Cognitive Test for Delirium. Complete ratings were available for 249 of 304 weekly observations. Analysis of the receiver operating characteristic curve suggested an optimum cutoff score of less than 22 for identification of delirium by using the Cognitive Test for Delirium, with a sensitivity of 72% and a specificity of 71% compared with the DSM-IV diagnosis. The results suggest that the Cognitive Test for Delirium provides an acceptable level of differentiation between delirious and nondelirious patients with traumatic brain injury.

Identification and management of delirium in the critically ill patient with cancer

Rather than a specific entity, delirium is at the midpoint on a spectrum of potential mental status changes that ranges from full consciousness to deep coma. The extremes are relatively easy to recognize, but other points along the spectrum may go unrecognized or be misdiagnosed. If recognized and treated expeditiously, delirium may be reversed in some patients. It is imperative that those caring for critically ill patients with cancer have the knowledge and tools necessary to identify and manage delirium appropriately. Although all critically ill patients are at risk for delirium, cancer presents additional assaults to the central nervous system via direct tumor invasion or iatrogenic provocations. This article describes delirium in cancer, and addresses diagnostic and management issues across the course of the disease.

Southwestern Internal Medicine Conference. Etiology and management of delirium

Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.

Acute postoperative delirium: definitions, incidence, recognition, and interventions

Emergence excitement or delirium is a common postanesthesia complication. Often, the emergence excitement resolves quickly, and the patient's continued recovery is uneventful. Although the initial period of excitement may be short lived and resolve without long-term sequela, some patients may experience acute postoperative delirium, a phenomenon that is more difficult to assess and of potentially longer duration. Although patients are spending less time in the hospital after surgical procedures, concern over the potential development of acute postoperative delirium remains. Patients at risk present in ambulatory surgery centers and inpatient perianesthesia settings daily. Identification of at-risk patients is crucial to avoiding the development of delirium in the acute postanesthesia care setting. The purpose of this selective review is to define acute postoperative delirium and its incidence, discuss assessment and recognition, describe interventions, and identify future considerations related to this phenomenon.

Delirium: an important (but often unrecognized) clinical syndrome

Delirium is a clinical syndrome characterized by the acute onset of a disturbance in consciousness accompanied by a reduced ability to focus, sustain, or shift attention. It may foreshadow impending death in as many as 25% of hospitalized inpatients and may be a source of significant morbidity in those who present with this syndrome. The disorder may go unrecognized by hospital staff as well as those close to an affected individual, and this oversight may lead to poorer outcomes including longer lengths of stay in acute care hospitals, the need for nursing home placement, prolonged cognitive disturbances, and protracted disability. This paper will address this complex condition, focusing on its history, definition, epidemiology, pathophysiology, recognition, risk factors, and clinical quantification. Its prevention and treatment will be covered elsewhere in this journal.

Use of neuroleptics in a general hospital

BACKGROUND

This study investigates the clinical use of neuroleptics within a general hospital in acutely ill medical or surgical patients and its relation with dementia three months after admission compared with control subjects.

METHODS

Cases were defined as every adult patient to whom a neuroleptic medication was prescribed during their hospitalization in our Hospital from February 1st, to June 30th, 1998. A control matched by age and sex was randomly selected among patients who had been admitted in the same period, in the same department, and had not received neuroleptics drugs (205 cases and 200 controls). Demographic, clinical and complementary data were compared between cases and controls. Crude odds ratios estimating the risk of dementia in non previously demented subjects compared with the risk in non-demented control subjects were calculated.

RESULTS

205 of 2665 patients (7.7%) received a neuroleptic drug. The mean age was 80.0 +/- 13.6 years and 52% were females. They were older and stayed longer than the rest of the population. Only 11% received a psychological evaluation before the prescription. Fifty two percent were agitated while 40% had no reason justifying the use of neuroleptic drug. Three months after neuroleptic use 27% of the surviving cases and 2.6% of the surviving controls who were judged non-demented at admission were identified as demented.

CONCLUSIONS

The most common reason for neuroleptic treatment was to manage agitation symptomatically in hospitalised patients. Organic mental syndromes were rarely investigated, and mental status exams were generally absent. Most of neuroleptic recipients had either recognised or unrecognised dementia.

Deciphering the 4 D's: cognitive decline, delirium, depression and dementia--a review

PURPOSE

The purpose of this paper is to assist advanced practice nurses to recognize, identify, and diagnose cognitive change in older adults.

BACKGROUND/RATIONALE

Optimal cognitive function is important for continued independence, and yet changes in cognition are frequently unrecognized among older adults. Cognitive change in older adults can be observed due to age-related cognitive decline, the development of acute confusion (delirium), depression, dementia and/or a combination of these. When the aetiological source for alterations in cognitive function is delirium or depression, the potential for reversibility mandates that the reason for the cognitive change be identified with steps taken to remedy the situation. Also, early recognition of dementia is an important factor in obtaining timely and appropriate care. These conditions can exist concurrently and may fluctuate making deciphering the reason for the cognitive change problematic.

CONCLUSIONS

It is essential to understand how the 4 'D's' are expressed and to recognize the potential contributing factors to an observable change in cognitive function for diagnosis and treatment. Recommendations for obtaining a person's history are included.

Psychiatric illness and subsequent traumatic brain injury: a case control study

OBJECTIVE

To determine whether psychiatric illness is a risk factor for subsequent traumatic brain injury (TBI).

METHODS

Case control study in a large staff model health maintenance organisation in western Washington State. Patients with TBI, determined by International classification of diseases, 9th revision, clinical modification (ICD-9-CM) diagnoses, were 1440 health plan members who had TBI diagnosed in 1993 and who had been enrolled in the previous year, during which no TBI was ascertained. Three health plan members were randomly selected as control subjects, matched by age, sex, and reference date. Psychiatric illness in the year before the TBI reference date was determined by using computerised records of ICD-9-CM diagnoses, psychiatric medication prescriptions, and utilisation of a psychiatric service.

RESULTS

For those with a psychiatric diagnosis in the year before the reference date, the adjusted relative risk for TBI was 1.7 (95% confidence interval (CI) 1.4 to 2.0) compared with those without a psychiatric diagnosis. Patients who had filled a psychiatric medication prescription had an adjusted relative risk for TBI of 1.6 (95% CI 1.2 to 2.1) compared with those who had not filled a psychiatric medication prescription. Patients who had utilised psychiatric services had an adjusted relative risk for TBI of 1.3 (95% CI 1.0 to 1.6) compared with those who had not utilised psychiatric services. The adjusted relative risk for TBI for patients with psychiatric illness determined by any of the three psychiatric indicators was 1.6 (95% CI 1.4 to 1.9) compared with those without any psychiatric indicator.

CONCLUSION

Psychiatric illness appears to be associated with an increased risk for TBI.

Delirium: moving beyond the clinical diagnosis

Delirium is a common mental disorder that has been associated with increased length of hospital stay and health costs, as well as higher morbidity and mortality rates in later life. To date, psychiatric interventions have mostly been limited to the clinical diagnosis of delirium and treatment of the behavioural and psychological complications of the acute episode, although this seems to have a negligible impact on the course and long-term outcome of patients. This paper reviews the development of recent strategies designed to reduce the incidence and complications of delirium, and proposes that an effective management plan must always include the basic components of primary, secondary and tertiary prevention.

Monitoring sedation, agitation, analgesia, and delirium in critically ill adult patients

The recent development of valid and reliable assessment tools to monitor agitation, sedation, analgesia, and delirium in the ICU represents an essential first step in the provision of patient comfort and the development of preferred treatment strategies. To make the ICU a more humane healing environment, these assessment tools must be used as part of a comprehensive evaluation of interventional and preventive treatments, pharmacologic and nonpharmacologic. In the spirit of the JCAHO, it may be time to add the evaluation of sedation, agitation, and delirium to that of pain assessment, making all aspects of patient comfort the fifth vital sign for the critically ill.

A survey on the drug therapy for delirium

Delirium, which is experienced by 10-30% of inpatients, is commonly seen in daily practice. A survey was conducted of the delirium medications, and results were obtained from 28 psychiatric departments and related facilities. Haloperidol was used in 67% cases for the treatment of delirium. Ninety-seven per cent of facilities considered haloperidol as the drug of first choice, while 57% thought this drug had few side-effects and was easy to use. However, because the use of this drug is not covered by health insurance in Japan, its use is limited. We expect that this study on medication for the treatment of delirium will be a first step in increasing the approved indications for drugs used for the treatment of delirium, and to reduce off-label use.

Changes in patterns of psychiatric referral in a German general hospital: results of a comparison of two 1-year surveys 8 years apart

The aim of this study was to investigate the issues of changes in patterns of referral and interventions and of consistency of psychiatric diagnoses assigned by a psychiatric consultation-liaison service in a general hospital over an 8-year period. We compared two 1-year surveys 8 years apart. Survey A comprised 713 referrals in 1990, and Survey B included 1025 consecutive new consultations in 1998. Data pertained to demographic characteristics, source of referral, reason for referral, psychiatric diagnosis according to DSM-III-R, and intervention. Our study demonstrated significant changes in diagnostic characteristics and in patterns of referral and intervention over the years. Changes in source of referral and psychiatric diagnoses were associated with the increasing involvement of clinical psychologists and specialists in psychosomatic medicine. Also, surgeons and physicians were increasingly aware of psychiatric morbidity in medical-surgical populations. Modern psychopharmacological treatment approaches resulted in a higher rate of recommendation of psychotropic medication. To ameliorate the provision of psychiatric care for general hospital patients, the need for a biopsychosocial conceptual framework at the interface of psychiatry and medicine in general hospitals should be underscored.

Validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM) for the detection of delirium in the elderly

This study has tested the validity and reliability of the Portuguese version of the Confusion Assessment Method (CAM), a diagnostic assessment instrument for delirium developed by Inouye et al. (1990). The sample was formed by 100 patients with 60 and more years of age, admitted at the emergency service of Santa Casa de São Paulo, in the time periods between July and August, 1996, November and December, 1996 and February and March, 1997. The sensibility was 94.1% and specificity 96.4%. The assessors reliability in a sample of the 24 patients resulted in a kappa = 0.70. We have concluded that CAM is an adequate instrument to assess the presence of delirium, reliable to assess elderly patients at the emergency services.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part 2--Interventions

Delirium, a disorder of consciousness that may afflict over one-half of elderly surgical orthopaedic patients is a common sequela of surgery in the elderly. Agitation, either as an element of the delirium or dimension of a preexisting dementia, is another common behavioral problem that can confront the orthopaedic nurse in acute care. It is time now to tear down the barriers to intelligent and compassionate care of patients with agitation and delirium, including late or missed recognition and diagnosis, biases about what is "normal" and acceptable behavior in the elderly, and lack of familiarity with pharmacologic strategies. In Part 1 (Jan/Feb issue), current thinking about the phenomena was presented, including hypotheses about causation and pathophysiology. That foundation is intended to serve as the basis for the current discussion. The triad of interventions available to manage disorganized behavior in elderly orthopaedic patients is presented in Part 2. They include an extensive selection of pharmacologic options, a discussion of therapeutic use of self and environmental-organizational issues to address and consider on a case-by-case basis. Though it may be impossible to prevent behavioral decompensation during an acute orthopaedic admission, it is certainly possible to improve our performance to date, using a compassionate, intelligent, and inclusive approach with every patient.

Delirium in psychiatric inpatients: a case-control study

OBJECTIVE

To investigate the clinical and pharmacoepidemiological determinants of delirium in a psychiatric inpatient population.

METHOD

A case-control study design was used. Potential cases and potential controls were identified using hospital discharge data. The clinical record of each subject was reviewed using a validated protocol to confirm case and control status. Subsequently, exposure data were recorded from clinical records.

RESULTS

Subjects admitted to hospital with delirium tended to be older, to have pre-existing cognitive deficits, and to have diagnoses of substance use disorders. Subjects who developed delirium after their admission to hospital were older than control subjects, more likely to have a history of cognitive impairment, and were significantly more likely to be treated during the hospitalization with lithium or anticholinergic antiparkinsonian medications. Antipsychotic medication exposures were also associated with delirium, but only at standard or above-standard dosage levels. Antidepressant and sedative-hypnotic medications were not associated with delirium.

CONCLUSIONS

These findings indicate that using conservative dosages of antipsychotic medications and minimizing the use of anticholinergic medications for parkinsonian symptoms may help to prevent delirium in psychiatric inpatients. Anticonvulsant mood stabilizers may convey less delirium risk than lithium. Antidepressant medications and sedative-hypnotics were not important determinants of delirium in this population.

Acute confusional state in elderly orthopaedic patients: factors of importance for detection in nursing care

OBJECTIVES

The aims of this study were to identify factors of significance in the development of acute confusional state (ACS) and the differences between patients who developed ACS and those who did not.

METHOD AND RESULTS

Assessment, observations and interviews with 505 patients admitted to an orthopaedic clinic revealed that 51 patients developed ACS during their in-hospital stay. Patients admitted for hip fracture had a higher incidence of ACS (20.2%) than patients admitted for elective surgery for coxarthros or gonarthros (3.6%). The highest hazard ratio for ACS was several other physical diseases 15.94 (CI: 4.60-55.31 and p-value <0.00001) and the lowest was age 1.10 (CI: 1.04-1.15 and p-value <0.0002). The ACS lasted from 1 to 9 days, and patients had one (N=42), two (N=8) or three episodes (N=1) of confusion during their stay on the ward. More patients who developed ACS before surgery had two or more confusional episodes and emergency patients developed ACS more rapidly. The ACS lasted longer in patients with a higher score on the OBS scale at admittance and with rapid development of ACS.

CONCLUSIONS

Acuteness in the situation seems an important risk indication for ACS in the elderly. Awareness of factors associated with the development of ACS makes it possible to more systematically identify those at risk, for instance by systematic assessment in the first interview with the patient on admission to hospital.

Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room

The objective of this study was to compare the results of the Confusion Assessment Method (CAM) obtained by a trained non-physician interviewer to those obtained by a geriatrician, among a sample of elderly patients seen in an emergency room. A group of 110 elderly patients (> or =66 years) were evaluated in the emergency room by a lay interviewer. The geriatrician conducted an interview in the presence of the lay interviewer. Subsequently, the geriatrician and the lay interviewer completed a CAM checklist independently. Kappa statistics, sensitivity, specificity, positivity predictive value (PPV), and negative predictive value (NPV) for the geriatrician's and lay interviewer's results with the CAM diagnostic algorithm were compared. The kappa coefficient was 0.91, the sensitivity 0.86, the specificity 1.00, the PPV 1.00, and the NPV 0.97. In conclusion, the CAM used by a trained lay interviewer in the emergency room is sensitive, specific, reliable and easy to use for the identification of patients with delirium. The under-recognition and under-treatment of delirium is a major health issue and has important clinical and financial implications. The implementation of systematic screening in populations at risk could increase the rate of early detection and lead to the appropriate management of delirious patients.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects

Managing behavioral disorders such as delirium and agitation while simultaneously attending to the acute needs of elderly patients is a challenge that confronts orthopaedic nurses on a daily basis. This will only increase in frequency and complexity as the new century dawns. Delirium and agitation affect morbidity, mortality, length of stay, and costs--in short, outcomes. To manage and care for these patients, orthopaedic nurses must first update their knowledge of acute disorders that can disrupt mental status and behavior, and the effects of systemic events on brain function. With the knowledge of the pathophysiology of delirium and agitation, nurses then need to refine their assessment and intervention skills. This article describes the phenomena of agitation and delirium in the elderly acute orthopaedic patient, outlines current perceptions regarding pathophysiology, and offers guidelines for prevention and intervention. An algorithm has been developed that can assist with the identification of at-risk individuals, causes of delirium, and early assessments in the acute care setting.

The cost of delirium in the surgical patient

The authors identified the added cost attributable to postoperative delirium in patients undergoing elective surgery. The authors evaluated patients (n = 500) before their elective surgery, assessing cognitive functioning, medical conditions, medication usage, and other information regarding their health status. Using DSM-IV criteria, the authors assessed patients for delirium on Postoperative Days 1-4. Medical record review provided laboratory, radiological, and pharmaceutical information. The authors analyzed length of stay (LOS), comprehensive cost data collected through the hospital, and a group practice financial database to determine differences among those developing delirium. Of the 500 patients assessed, 57 (11.4%) developed delirium during the study. Delirium is an extremely costly disorder, both to the patient in terms of morbidity and mortality and to the medical facility. A prolonged LOS increases charges to third party payors and reduces return to physicians and hospitals when delirium develops. Careful presurgical screening and targeted postoperative interventions may help contain LOS and costs while affording greater physical, emotional, and cognitive health to patients hospitalized for elective surgery.

Delirium

Delirium is a true medical emergency that can masquerade as chronic dementia or functional psychosis and obscure the causative underlying physical or toxic disorder. In most cases, a well-focused history and thorough physical examination can unmask the delirium and reveal the medical or toxic problem. Carefully selected diagnostic testing can be required. Emergency management of the medical or toxic disorder is the same as in nondelirious patients. Control of agitated or aggressive behavior with pharmacologic or physical restraints and special support measures are required to facilitate ED care. Delirious patients whose symptoms do not totally resolve in the ED must be admitted.

Outcomes associated with delirium in acutely hospitalized acquired immune deficiency syndrome patients

The study demonstrates that delirium in acquired immune deficiency syndrome (AIDS) patients is associated with mortality, the need for long-term care, and an increased length of hospitalization. Data were collected prospectively on human immunodeficiency virus (HIV)/AIDS patients admitted to a teaching hospital from January 1996 through December 1996. The data included demographic characteristics of the participants, medical diagnoses, CD4 cell count, Karnofsky functional assessment, mortality during admission, length of stay, and discharge placement. Participants were evaluated throughout their hospital stay for evidence of delirium. The presence of delirium was determined using DSM-IV diagnostic criteria. There were no significant differences between delirious and nondelirious patients with respect to demographic characteristics or markers of medical morbidity. Patients with delirium were more likely to die during admission (chi-square [chi2] = 39.1, df = 1, P<.0010), to stay longer in hospital (t = 3.50, df = 12.9, P<.0041), or to need long-term care if discharged alive (chi2 = 12.8, df = 2, P<.0021). Delirium is associated with adverse outcomes in hospitalized AIDS patients. More research is needed to characterize the nature of this association.

Delirium and Agitation

Delirium is a syndrome of altered state of consciousness and global cognitive impairment with diverse causes. It is common in the medically or surgically compromised patient and is associated with significant morbidity and mortality. The primary goal of treatment is to identify and correct the underlying cause of the delirium. Treatment includes protecting the patient from accidental self-harm, initiating pharmacotherapy to manage disruptive and dangerous behavior and symptoms of psychosis, and providing supportive and educational therapy for the patient and family. Physical restraints may need to be used for patients at immediate risk of injuring themselves or someone else until pharmacologic management can be initiated. Antipsychotics such as haloperidol with or without lorazepam are the treatment of choice. Environmental factors that may exacerbate delirium also need to be controlled. Patients should be reoriented and may benefit by having familiar or favorite objects present, such as family pictures. Sleep-wake disturbances must be corrected, and visual and auditory impairments must be addressed. Because family members can have a calming effect, provide frequent reorientation, and give the patient a sense of safety, family should be encouraged to be present if at all possible.

Medical assessment of patients presenting with psychiatric symptoms in the emergency setting

Psychiatrists in the emergency department (ED) are often asked to evaluate patients with disturbances of affect, behavior, and cognition. The first and most crucial step in the evaluation process is to eliminate possible medical causes for a patient presenting psychiatric symptoms. Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality.

Importance of serum anticholinergic activity in the assessment of elderly patients with delirium

To evaluate the importance of serum anticholinergic activity (SAA) in elderly patients who developed delirium following hospital admission, we performed a cross-sectional study with consecutively referred inpatients in a university geriatric medical ward. Sixty-one patients aged 66 to 95 years (mean age: 79.2+/-11.6; 54% females) were recruited. Delirium was assessed by means of the Confusion Assessment Method, SAA determination, questionnaire for current drug treatment, past medical history and clinical examination, and blood chemistries. Patients were divided into two groups according to the absence (N = 49) or the presence (N = 12) of delirium. Delirious patients showed a significantly higher SAA (23.0 vs 3.9 pmol/mL atropine equivalents, P < .004); they were using antibiotics (P < .05), neuroleptics (P < .002), barbiturates (P < .004), and benzodiazepines (P < .005) more frequently. Subjects with delirium were more likely to have infections and a lower Body Mass Index; they had higher plasma glucose and creatinine. The multivariate analysis identified SAA and use of neuroleptics, and benzodiazepines as the most important features independently associated with delirium. SAA may be a suitable marker for identifying people at risk of developing delirium. Moreover, neuroleptics and benzodiazepines must be carefully used in the elderly because of their relationship with the onset of delirium.

The Delirium Rating Scale. Its use in consultation-liaison research

In addition to diagnostic criteria, delirium research requires standardized instruments to measure symptoms. This article reviews the literature about the Delirium Rating Scale (DRS), the most widely used scale to assess delirium that has been translated into at least seven other languages. The DRS has 10 items and is clinician-rated, but 7- or 8-item subscale adaptations have been used for repeated measurements. It has high scale characteristics, including internal consistency, validity, specificity, sensitivity and interrater reliability. The DRS distinguishes delirious from demented, schizophrenic, and depressed patients and is more accurate than cognitive tests in identifying delirium. Scores are sensitive to treatment of delirium. Principal components analyses find one underlying dimension that can be subdivided into two or three components. The DRS has been used in studies of phenomenology, physiology, treatment, outcome, and at-risk populations. Tables summarize details from various studies. The DRS is used clinically and in research. It is currently being revised to enhance its use in phenomenologic and treatment research.

Delirium: prevention, treatment, and outcome studies

The purpose of this paper was to contribute to a new conceptual understanding of delirium by reviewing evidence related to its prevention, treatment, and outcome. 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, 13 studies on treatment, and 15 studies on outcome. Most studies had methodological limitations. Abroad spectrum of interventions appeared to be modestly effective in preventing delirium in young and old surgical patients but not elderly medical patients; systematic detection and intervention 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; haloperidol, chlorpromazine, and mianserin appeared to be useful in controlling the symptoms of delirium in both surgical and medical patients; and good levels of premorbid function seemed to be related to better outcomes. Although the above findings do not contribute to a new conceptual understanding of delirium, they do suggest directions for further research on the treatment of delirium.

Frequently missed diagnosis in geriatric psychiatry

Older adults are an important segment of the population that has specific health care needs. Their unique biopsychosocial characteristics impact the presentation, evaluation, and management of psychiatric illnesses. This article describes how common psychiatric disorders present in an aging population. Research in this area is relatively new and much more information is still needed. Close attention should be paid to new knowledge as it emerges about this growing population.

Delirium in hospital: does it increase length of stay?

OBJECTIVE

To determine the effect of delirium, as a comorbid diagnosis in hospitalised patients, on patient length of stay (LOS).

METHOD

Prospective study comparing LOS of delirious patients with controls matched by age, gender, principal diagnosis and date of admission. Medical and surgical inpatients of Westmead Hospital with delirium were identified from a Consultation Liaison (CL) psychiatry database and were matched with controls from the hospital medical records.

RESULTS

Delirious patient LOS was found to be significantly longer (2.2-fold; 95% confidence interval 1.5-3.3) than matched controls.

CONCLUSIONS

Delirium, as a comorbid diagnosis in general hospital patients, is associated with an increased use of resources. Its early diagnosis may limit this and morbidity.

Acute delirium as a manifestation of obstructive sleep apnea syndrome

Cognitive deficits and psychiatric manifestations such as depression and psychosis have been associated with obstructive sleep apnea (OSA) syndrome. We report a patient with OSA admitted to our center because of acute delirium of sudden onset at night, during sleep, and which impelled the patient to jump out of the window of his home. After exhaustive study, no other causes were found for the delirium, which resolved when nasal continuous positive airway pressure (nCPAP) was initiated. We believe that it is clinically important to be aware of this association, since it identifies a new, treatable cause of delirium.