Characteristics and outcome of delirium in psychiatric inpatients

Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study

INTRODUCTION

Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI).

METHODS

We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI.

RESULTS

The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92).

CONCLUSIONS

The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.

Delirium during psychiatric admission increases mortality in psychiatric patients during and after hospitalization. A nationwide study from 1995 through 2012

OBJECTIVE

Delirium is a common acute neuropsychiatric disorder caused by a variety of physical insults. It is commonly associated with a variety of serious adverse outcomes, including elevated mortality. There are few studies of delirium occurring in psychiatric patients, including its mortality. The aim was to determine the psychiatric diagnostic profile of Danish psychiatric inpatients diagnosed with delirium and to compare standardized mortality ratio (SMR) in this group with the Danish population and general psychiatric inpatients from 1995 through 2012.

METHODS

All first time ICD-10 diagnoses of delirium among psychiatric inpatients were identified in the nationwide Danish Psychiatric Central Research Register (DPCRR) from 1995 through 2012.

RESULTS

A total of 7179 persons diagnosed with delirium were identified in the DPCRR between 1995 and 2012. Of these patients 40.8% had more than one diagnosis of delirium during the period. We identified three distinct groups, based on the first delirium-diagnosis; unspecified delirium (76.9%), comorbid delirium-dementia (19.8%), and drug-related delirium (3.3%). Use of sedative-hypnotics was noted in 46% of those with drug-related delirium. The SMR of delirious psychiatric inpatients compared to all psychiatric inpatients was stable at 1.7 throughout the time period.

CONCLUSION

Delirium occurring in psychiatric inpatients is associated with elevated mortality. Sedative-hypnotic agents are commonly involved in drug-related delirium. Particular preventative effort is warranted for patients with a previous history of delirium, as we found approximately 40% with more than one episode of delirium.

A nationwide study on delirium in psychiatric patients from 1995 to 2011

OBJECTIVES

Delirium shares symptoms with some mental illnesses. This may lead to misdiagnosis of delirium in psychiatric patients and a risk of inadequate management. Moreover, literature on delirium in psychiatric patients is sparse. The aim was to analyse possible changes in the diagnostic incidence of delirium in psychiatric patients from 1995 to 2011, and to investigate the patients with regard to sex, age, and type of patient.

METHODS

All first time ever diagnoses of delirium among psychiatric patients were identified in the nationwide Danish Psychiatric Central Research Register (DPCRR) from 1995 to 2011. The delirium diagnoses include (1) delirium unspecified, (2) delirium with dementia, and (3) drug-related delirium, all in accordance with International Classification of Diseases-10. The incidence rates were age standardised.

RESULTS

A total of 15 680 persons diagnosed with delirium for the first time were identified in the DPCRR between 1995 and 2011. The total incidence rate of delirium has decreased, reaching 8.4/1000 person-years in 2011. In 2011, 2.6% of the demented patients were diagnosed with delirium with dementia. Diagnosis of delirium is significantly more common in men, and the three groups of delirium showed a characteristic age distribution.

CONCLUSION

Our incidences were markedly lower when compared with previous studies. This suggests a possible underdiagnosis of delirium in psychiatric hospitals and should be investigated further, as delirium is a serious state and identifying the syndrome is important for sufficient treatment.

Study on the efficacy and tolerability of amisulpride in medical/surgical inpatients with delirium admitted to a general hospital

PURPOSE

To evaluate the efficacy and safety of amisulpride in medical inpatients who present with delirium.

METHOD

Open label prospective study with 7-day follow-up. Forty hospital inpatients with delirium were recruited, seven of whom died and two of whom refused medication. The average dose of amisulpride for delirium treatment was 200-300 mg/day. Daily assessments were performed with Delirium Rating Scale (DRS), Positive Subscale of the Positive and Negative Syndrome Scale (PANSS-P), Mini Mental State Examination (MMSE), Neurological Subscale of the UKU side effect rating scale. Variance analysis was performed through repeated measurements, with the general linear model with paired comparisons and Bonferroni correction for each measured variable.

RESULTS

Patients showed significant improvement on the DRS from the first day of treatment DRS = 17.55 until day 7 DRS = 7.26 (F = 92.485; p < 0.001), psychotic symptoms improved from first day PANSS-P = 18.26 to last day PANSS-P = 9.35 (F = 144.83; p < 0.001). Cognitive status showed a significant improvement from day 2 MMSE = 18.71 until day 7 MMSE = 24.06 (F = 96.56; p < 0.001), and the neurological subscale of the UKU side effect rating scale showed a significant improvement the last day with respect to baseline pretreatment level (F = 7.539; p = 0.01).

CONCLUSIONS

These results suggest a good response to amisulpride in the acute phase of delirium, although further randomized controlled studies must be performed.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium)

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.

Characteristics of patients with organic brain syndromes : A cross-sectional 2-year follow-up study in Kuala Lumpur, Malaysia

BACKGROUND: Organic Brain Syndromes (OBS) are often missed in clinical practice. Determining their varied presentations may help in earlier detection, better management, and, assessing prognosis and outcome. We described the in-patient referrals of patients suffering from the psychiatric effects of organic states and compared the symptomatology and mortality between those with the Acute and Chronic varieties. METHODS: 59 patients referred to our Consultation-Liaison (C-L) Psychiatry services and given a clinical diagnosis of OBS were selected over a 6-month period. Psychiatric and cognitive abnormalities and treatment regimes were recorded and fatality rates determined. Information regarding their condition 24 months after their index hospitalization was recorded. All data were entered into a proforma and analyzed after exclusion. RESULTS: The mean duration of detecting the symptoms by the physician was 3.52 days. The presence of a premorbid psychiatric illness had no influence on the clinical presentation but did on the mortality of patients with OBS (p = 0.029).Patients with the Acute syndrome had significantly more symptom resolution as compared to those with the Chronic syndrome (p = 0.001) but mortalityrates did not differ. Elderly patients and those with symptom resolution upon discharge did not show statistically significant higher mortality rates. The most popular combination of treatment was that of a low-dose neuroleptic and a benzodiazepine (34.7%). The need for maintenance treatment was not significantly different in any group, even in those with a past history of a functional disorder. CONCLUSION: Other than the Acute group having a significantly better outcome in terms of symptom resolution, our findings suggest that there was no significant difference in the clinical presentation between those with Acute or Chronic OBS. Mortality-wise, there was also no difference between the Acute and Chronic syndromes, nor was there any difference between the elderly and the younger group. There was also no significant difference in the need for continued treatment in both groups.

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.

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.