A factor analytic study of the Delirium Rating Scale-Revised-98 in untreated patients with delirium

Delusions and Hallucinations Are Associated With Greater Severity of Delirium

BACKGROUND

The 3 core domains of delirium (cognitive, higher level thinking, circadian) do not include the less common noncore psychotic symptoms. However, psychosis might inform about perturbations of neural circuitry, outcomes, or suggest tailored clinical management.

OBJECTIVE

We assessed for the first time the relationships between psychosis and other characteristics of delirium in patients without confounders for delirium phenotype, such as dementia or antipsychotics treatment.

METHODS

Cross-sectional analysis of 366 adults with delirium per the Delirium Rating Scale Revised-98, whose items distinguish hallucinations and delusions from other types of misperceptions and abnormal thought content, assessed during the preceding 24 hours to capture symptom severity fluctuation. The relationship of psychosis with other delirium characteristics was assessed using bivariate comparisons and analysis of variance as appropriate for groups with no psychosis and any psychosis (hallucinations and/or delusions), and subgroups with only hallucinations, only delusions, or both. A discriminant logistic model assessed variables associated with presence of any psychotic features versus none.

RESULTS

Delirium with any psychotic features occurred in 44.5% (163 of 366). Of the 366, 119 (32.5%) had only hallucinations (Hall), 14 (3.8%) had only delusions (Del), and 30 (8.2%) had both (Both). In the psychotic group (n = 163), 73.0% were Hall, 8.6% Del, and 18.4% Both. All psychotic patient groupings had significantly greater delirium severity on the Delirium Rating Scale Revised-98. Delusions and hallucinations were discordant for occurring together. The discriminant model found increased odds of having psychosis as 3 symptom severities increased (visuospatial ability, thought process, and sleep-wake cycle) where these each represented a delirium core domain. The noncore symptom of lability of affect had high odds ratio for psychosis, while motor retardation reduced odds of psychosis in this model.

CONCLUSIONS

Consistent with prior reports, psychosis occurred in less than half of delirious patients with delusions being infrequent, and an association with affective lability was found. We are the first to report that psychotic features are a marker for more severe delirium affecting all core domains. Given that previous functional magnetic resonance imaging research found a correlation between neural network dysconnectivity with greater severity of delirium, psychotic symptoms might be a clinical marker for greater underlying cerebral cortical neural circuitry dysfunction.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients

OBJECTIVES

To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology.

DESIGN

Cross-sectional study.

SETTING

International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings.

PARTICIPANTS

1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV).

PRIMARY AND SECONDARY OUTCOME MEASURES

Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory.

RESULTS

Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001).

CONCLUSIONS

This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

Phenomenological examinations of delirium in advanced cancer patients: exploratory structural equation modelling and latent profile analysis

Background

This study examined phenomenological manifestations of delirium in advanced cancer patients by examining the factor structure of the Delirium Rating Scale-Revised-98 (DRS-R-98) and profiles of delirium symptoms.

Methods

Ninety-three patients with advanced cancer admitted to inpatient palliative care units in South Korea were examined by psychiatrists using the DRS-R-98 and the Confusion Assessment Method (CAM). The factor structure of the DRS-R-98 was examined by exploratory structural equation modelling analysis (ESEM) and profiles of delirium were examined by latent profile analysis (LPA).

Results

CAM-defined delirium was present in 66.6% (n = 62) of patients. Results from the ESEM analysis confirmed applicability of the core and noncore symptom factors of the DRS-R-98 to advanced cancer patients. LPA identified three distinct profiles of delirium characterizing the overall severity of delirium and its core and noncore symptoms. Class 1 (n = 55, 59.1%) showed low levels of all delirium symptoms. Class 2 (n = 17, 18.3%) showed high levels of core symptoms only, whereas Class 3 (n = 21, 22.6%) showed high levels of both core and noncore symptoms except motor retardation.

Conclusions

Clinical care for delirium in advanced cancer patients may benefit from consideration of the core and noncore symptom factor structure and the three distinct phenomenological profiles of delirium observed in the present study.

Association of Cognitive and Noncognitive Symptoms of Delirium: A Study from Consultation-liaison Psychiatry Set-up

Aims:

This study aims to evaluate the cognitive functions of patients with delirium using Hindi Mental Status Examination (HMSE), to study the correlation of cognitive functions assessed by HMSE with noncognitive symptoms as assessed using Delirium Rating Scale-Revised 1998 (DRS-R-98) and to study the association of cognitive functions assessed using HMSE and DRS-R98.

Methods:

A total of 76 consecutive patients fulfilling the diagnosis of delirium were evaluated on DRS-R-98, HMSE, and Short Informant Questionnaire on Cognitive Decline in the Elderly (retrospective IQCODE).

Results:

The mean DRS-R-98 score 33.9 (standard deviation [SD] - 7.2) and the mean DRS-R-98 severity score was 25.9 (SD - 7.2). The mean score on HMSE was 19.3 (7.98). There were significant correlations of all the domains of HMSE with DRS-R-98 total score, DRS-R-98 severity score, DRS-R-98 cognitive subscale score, DRS-R-98 noncognitive domain subscale score, and DRS severity score without attention score. When the association of each item of DRS-R-98 and HMSE was evaluated, except for the items of delusions, lability of affect and motor retardation, there were significant negative association between all the items of DRS-R-98 and HMSE, indicating that higher severity of cognitive symptoms as assessed on HMSE is associated with higher severity of all the cognitive symptoms and most of the noncognitive symptoms as assessed by DRS-R-98.

Conclusion:

The present study suggests that attention deficits in patients with delirium influence the severity of cognitive and noncognitive symptoms of delirium. Further, the present study suggests an increase in the severity of cognitive symptoms in other domains is also associated with an increase in the severity of noncognitive symptoms of delirium.

The Probability That Catatonia in the Hospital has a Medical Cause and the Relative Proportions of Its Causes: A Systematic Review

OBJECTIVE

The objective of this review is to determine the probability that catatonia in the hospital has a secondary cause ("medical catatonia") and to calculate the relative proportions of these causes stratified by hospital setting.

METHODS

PRISMA systematic review of PubMed.

RESULTS

Eleven studies were included. Hospital-wide, 20% of catatonia was medical. In acute medical and surgical settings, medical catatonia comprised more than half of cases. At least 80% of older adults seen by consult psychiatry and critically ill patients had a medical cause. Two thirds of medical catatonia involved CNS-specific disease including encephalitis, neural injury, developmental disorders, structural brain pathology, or seizures.

CONCLUSIONS

Patients in acute medical and surgical settings with catatonia deserve a medical workup that prioritizes CNS etiologies.

Delirium in Intensive Care Unit: Phenomenology, Subtypes, and Factor Structure of Symptoms

AIM

This study aimed to explore the phenomenology, motor subtypes, and factor structure of symptom profile of delirium in patients admitted to the intensive care unit (ICU).

METHODS

Consecutive patients aged ≥16 years admitted in an ICU were screened daily for delirium using confusion assessment method-ICU. Patients diagnosed to have delirium as per Diagnostic and Statistical Manual fourth revision, text revision (DSM-IVTR) criteria were assessed with Delirium Rating Scale-Revised 98 (DRS-R 98) and Memorial Delirium Assessment Scale (MDAS). Motor subtypes of delirium were assessed with amended Delirium Motor Symptom Scale.

RESULTS

Sixty-six patients were evaluated for delirium, of which 45 (68%) patients developed delirium at point of their ICU stay. All patients had sleep-wake cycle disturbances, followed by motor symptoms (retardation - 80%; agitation - 73.3%). As per MDAS assessment, all the subjects had disturbances in the consciousness and sleep-wake cycle disturbances, and a substantial majority also had attention difficulties (93.3%) and motor symptoms (93.3%). Hypoactive subtype (47%) was the most common motoric subtype of delirium. Factor analysis revealed three-factor model for DRS-R 98, MDAS, and combining items of the two.

CONCLUSION

Phenomenology of delirium in ICU setting is similar to that of the non-ICU settings. The factor analysis consistently demonstrated a three factor solution, with a robust attention-arousal factor, and overlapping cognitive (core vs. non-core) motor factors.

The Relationship Between Sleep-Wake Cycle Disturbance and Trajectory of Cognitive Recovery During Acute Traumatic Brain Injury

OBJECTIVE

Following traumatic brain injury, both sleep dysfunction and cognitive impairment are common. Unfortunately, little is known regarding the potential associations between these 2 symptoms during acute recovery. This study sought to prospectively examine the relationship between ratings of sleep dysfunction and serial cognitive assessments among traumatic brain injury acute neurorehabilitation admissions.

METHODS

Participants were consecutive admissions to a free-standing rehabilitation hospital following moderate to severe traumatic brain injury (Median Emergency Department Glasgow Coma Scale = 7). Participants were assessed for sleep-wake cycle disturbance (SWCD) and cognitive functioning at admission and with subsequent weekly examinations. Participants were grouped on the basis of presence (SWCD+) or absence (SWCD-) of sleep dysfunction for each examination; groups were equivalent on demographic and injury variables. Individual Growth Curve modeling was used to examine course of Cognitive Test for Delirium performance across examinations.

RESULTS

Individual Growth Curve modeling revealed a significant interaction between examination number (ie, time) and SWCD group (β = -4.03, P < .001) on total Cognitive Test for Delirium score. The SWCD+ ratings on later examinations were predicted to result in lower Cognitive Test for Delirium scores and greater cognitive impairment over time.

CONCLUSIONS

This study has implications for improving neurorehabilitation treatment, as targeting sleep dysfunction for early intervention may facilitate cognitive recovery.

Phenomenology of delirium among patients admitted to a coronary care unit

AIM

To study the phenomenology and motor sub-types of delirium in patients admitted in a Coronary Care Unit (CCU).

METHODS

Three hundred and nine consecutive patients were screened for delirium, and those found positive for the same were evaluated by a psychiatrist on DSM-IVTR criteria to confirm the diagnosis. Those with a diagnosis of delirium were evaluated on the DRS-R-98 to study the phenomenology and on the amended Delirium Motor Symptom Scale (DMSS) to study the motor sub-types.

RESULTS

Eighty-one patients were found to have delirium. Commonly seen symptoms of delirium included: disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Very few patients had delusions. More than half of the participants were categorized as having hyperactive (n = 46; 56.8%) followed by hypoactive sub-type (n = 21; 26%) and mixed sub-type (n = 9; 11.1%) of delirium. There were minor differences in the frequency and severity of symptoms of delirium between incidence and prevalence cases of delirium and those with different motoric sub-types.

CONCLUSION

Delirium in CCU set-up is characterized by the symptoms of disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Hyperactive delirium is more common than hypoactive delirium.

Comparative effectiveness of quetiapine and haloperidol in delirium: A single blind randomized controlled study

AIM

To evaluate the effectiveness of quetiapine and haloperidol in patients of delirium referred to psychiatry consultation liaison services.

METHODS

The study followed a single blind randomised controlled trial design. Thirty-two patients in the haloperidol group and 31 patients in the quetiapine group were assessed at the baseline and 6 consecutive days. Flexible dosing regimen (haloperidol: 0.25-1.25 mg; quetiapine 12.5-75 mg/d) was used. Delirium Rating Scale-Revised-98 (DRS-R-98) and mini mental status examination (MMSE) were the primary and secondary efficacy measures respectively.

RESULTS

Baseline DRS-R-98 severity score and MMSE scores did not differ between the 2 study groups. From baseline to day 6, there was significant reduction in the total DRS-R-98 scores, DRS-R-98 cognitive domain scores, DRS-R-98 non-cognitive domain scores and significant increase in the MMSE scores in both the groups. Both the groups did not differ on any of the assessments in terms of DRS-R98 and MMSE scores. The effectiveness of both the medications was similar in adult and elderly (≥ 60 years) patients. At the end of the trial, 68.75% and 67.74% of subjects in the haloperidol and quetiapine group respectively had mean DRS-R-98 scores below 10. By 6^th day, 12 (37.5%) patients in haloperidol group and 9 (29.03%) patients in the quetiapine group had DRS-R98 score of “0” with no significant difference between the two groups (P = 0.47).

CONCLUSION

Quetiapine is as effective as haloperidol in the management of delirium.

Exploratory and Confirmatory Factor Analyses of Delirium Symptoms in a Sample of Nursing Home Residents

OBJECTIVE

This study examined the latent constructs of delirium symptoms among nursing home (NH) residents in the United States.

METHOD

Cross-sectional NH assessment data (Minimum Data Set 2.0) from the 2009 Medicare Current Beneficiary Survey were used. Data from two independent, randomly selected subsamples of residents ≥65 years were analyzed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

There were 367 and 366 individuals in the EFA and CFA, respectively. Assessment of multiple model fit statistics in CFA indicated that the two-factor structure provided better fit for the data than a one-factor solution. The two factors represented cognitive and behavioral latent constructs as suggested by the related literature. A correlation of .72 between these constructs suggested moderate discriminant validity.

CONCLUSION

This finding emphasizes the importance of health care providers to be attentive to both cognitive and behavioral symptoms when diagnosing, treating, and managing delirium.

Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version

BACKGROUND

The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain.

OBJECTIVE

To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98).

METHOD

A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98.

RESULTS

The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms.

CONCLUSIONS

Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.

Yokukansan, a traditional Japanese medicine, decreases head-twitch behaviors and serotonin 2A receptors in the prefrontal cortex of isolation-stressed mice

ETHNOPHARMACOLOGICAL RELEVANCE

Yokukansan, a traditional Japanese (Kampo) medicine, has recently been used to treat the behavioral and psychological symptoms of dementia (BPSD), including aggressiveness, excitability, and hallucination. The present study was designed to investigate the mechanisms underlying the ameliorative effects of yokukansan on BPSD using animals exhibiting hallucination-like behaviors. For this purpose, we initially examined whether chronic isolation stress increases the frequency of hallucination in response to a psychedelic drug. Using this animal model, we next examined the effects of yokukansan on drug-induced hallucination-like behaviors. Finally, we examined the density and mRNA levels of serotonin 2A (5-HT2A) receptors.

MATERIALS AND METHODS

Male mice were subjected to isolation stress for six weeks. Yokukansan was incorporated into food pellets, and administered to the mice for six weeks. In some experiments, yokukansan and each of seven constituent herbs were administered orally to the mice for the last two weeks during the six-week period of isolation stress. A 5-HT2A receptor agonist, 2,5-dimethoxy-4-iodoamphetamine (DOI, 2.5mg/kg), was injected into the mice, and head-twitch behaviors were quantified. The binding sites of 5-HT2A receptors on the plasma membrane of the prefrontal cortex (PFC) were assessed by a receptor-binding assay using tritium-labeled ketanserin, and the density and affinity were calculated from a Scatchard plot. The level of mRNAs was measured by PCR analyses.

RESULTS

Isolation stress enhanced the frequency of the DOI-induced head-twitch response, and yokukansan treatment by feeding significantly reduced this enhancement. Isolation stress significantly increased the 5-HT2A receptor density in the PFC, and yokukansan treatment by feeding as well as administration significantly down-regulated this increase. Isolation stress and yokukansan did not affect the affinity. Among seven constituent herbs, Bupleurum Root, Uncaria Hook, Japanese Angelica Root, and Glycyrrhiza down-regulated the increase, but statistically not significant, in which their efficacies were over 50% relative to yokukansan. Neither isolation stress nor yokukansan affected mRNA levels of 5-HT2A receptors.

CONCLUSION

Yokukansan attenuated drug-induced hallucination-like behaviors in isolated mice, which is suggested to be mediated by 5-HT2A receptor down-regulation in the PFC. This mechanism may underlie the ameliorative effects of yokukansan on hallucination.

Comparison of symptoms of delirium across various motoric subtypes

AIM

The aim of this study was to determine the correlation between delirium motor subtypes and other symptoms of delirium.

METHODS

Three hundred and twenty-one (n = 321) consecutive patients referred to consultation-liaison psychiatry services were evaluated on Delirium Rating scale-Revised-98 version and amended Delirium Motor Symptom Scale.

RESULTS

Half of the patients had hyperactive subtype (n = 161; 50.15%) delirium. One-quarter of the study sample met the criteria for mixed subtype (n = 79; 24.61%), about one-fifth of the study sample met the criteria for hypoactive delirium subtype (n = 64; 19.93%), and only very few patients (n = 17; 5.29%) did not meet the required criteria for any of these three subtypes and were categorized as 'no subtype'. When the hyperactive and hypoactive subtypes were compared, significant differences were seen in the prevalence of perceptual disturbances, delusions, lability of affect, thought process abnormality, motor agitation and motor retardation. All the symptoms were more common in the hyperactive subtype except for thought process abnormality and motor retardation. Compared to hyperactive subtype, the mixed subtype had significantly higher prevalence of thought process abnormality and motor retardation. Significant differences emerged with regard to perceptual disturbances, delusions, lability of affect and motor agitation when comparing the patients with mixed subtype with those with hypoactive subtype. All these symptoms were found to be more common in the mixed subtype. No significant differences emerged for the cognitive symptoms as assessed on Delirium Rating scale-Revised-98 across the different motoric subtypes.

CONCLUSION

Different motoric subtypes of delirium differ on non-cognitive symptoms.

Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile?

OBJECTIVE

To explore the frequency of different motor subtypes of delirium in children and adolescents and to study the relationship of motor subtypes with other symptoms, etiology and outcome of delirium.

METHODS

Forty-nine consecutive patients, aged 8-19 years, diagnosed as having delirium as per DSM-IV-TR were assessed on Delirium Rating Scale-Revised 98 (DRS-R-98), amended Delirium Motor Symptom Scale (DMSS), delirium etiology checklist and risk factors for delirium. Different motoric subtypes of delirium were compared with each other for symptoms of delirium as assessed by DRS-R-98, risk factors, etiology and outcome.

RESULTS

More than half (53%) of patients were classified as having hyperactive delirium, this was followed by the mixed (26.5%) and the hypoactive (16%) subtype. When the different subtypes were compared with each other, the 3 motor subtypes did not differ from each other in terms of frequency and severity of other symptoms except for minor differences. Hallucinations are more common in patients with hyperactive and mixed subtype. There is no significant difference in the outcome of delirium across different subtypes.

CONCLUSION

Unlike in adults, motoric subtypes of delirium in child and adolescents do not differ from each other with respect to other symptoms, risk factors and outcome.

Symptom profile and outcome of delirium associated with alcohol withdrawal syndrome: a study from India

AIM

To study the profile of delirium associated with alcohol withdrawal syndrome (AWS) in a developing country in terms of symptomatology, associated risk factors/physical complications, and outcome.

METHODOLOGY

Using a prospective design, 112 patients in whom delirium could be attributed to AWS as either the sole or a contributory cause were assessed by Delirium Rating Scale-Revised-98 and the associated etiological factors were assessed by using delirium etiology checklist.

FINDINGS

In all patients, delirium was acute in onset and all patients had disturbance of sleep-wake cycle and inattention. Other common symptoms were: disorientation (99.1%), fluctuation in symptoms (97.3%), motor agitation (94.6%), and short-term memory disturbance (92.9%). In terms of delirium etiology checklist etiological categories, besides alcohol withdrawal, the most common factors were metabolic/endocrine abnormalities (76%), followed by organ insufficiency and infection (37% and 35%, respectively). Most patients (67%) improved or recovered completely from delirium during the short stay of 4 days. During the short stay of mean duration of 4 days 13.4% of the patients died during the hospital stay.

CONCLUSION

Delirium associated with alcohol withdrawal is characterized by an acute onset of symptoms with high prevalence of disturbance of sleep-wake cycle, inattention, disorientation, fluctuation in symptoms, motor agitation, and disturbance in short-term memory. There are certain differences in the symptom profile of delirium associated with alcohol withdrawal and that associated with medical-surgical causes. About one-sixth of the patients developing delirium due to alcohol withdrawal die during the short hospital stay of 4 days.

Relationship between cognitive and non-cognitive symptoms of delirium

AIM

To study relationship between the cognitive and the non-cognitive symptoms of delirium.

METHODS

Eighty-four patients referred to psychiatry liaison services and met DSM-IVTR criteria of delirium were assessed using the Delirium Rating Scale Revised-1998 (DRSR-98) and Cognitive Test for Delirium (CTD).

RESULTS

The mean DRS-R-98 severity score was 17.19 and DRS-R-98 total score was 23.36. The mean total score on CTD was 11.75. The mean scores on CTD were highest for comprehension (3.47) and lowest for vigilance (1.71). Poor attention was associated with significantly higher motor retardation and higher DRS-R-98 severity scores minus the attention scores. There were no significant differences between those with and without poor attention. Higher attention deficits were associated with higher dysfunction on all other domains of cognition on CTD. There was significant correlation between cognitive functions as assessed on CTD and total DRS-R-98 score, DRS-R-98 severity score and DRS-R-98 severity score without the attention item score. However, few correlations emerged between CTD domains and CTD total scores with cognitive symptom total score of DRS-R-98 (items 9-13) and non-cognitive symptom total score of DRS-R-98 (items 1-8).

CONCLUSIONS

Our study suggests that in delirium, cognitive deficits are quite prevalent and correlate with overall severity of delirium. Attention deficit is a core symptom of delirium.

Delirium-related distress in caregivers: a study from a tertiary care centre in India

PURPOSE

To study the caregiver's distress with symptoms of delirium.

DESIGN AND METHODS

Consenting adult caregivers (>18 years of age) of patients with delirium were evaluated for the distress due to symptoms of delirium.

RESULTS

The study included 72 primary caregivers of patients with delirium. Symptoms of delirium that led to severe or very severe distress in more than two thirds of the caregivers included decreased sleep, increased motor activity, attempts to remove intravenous lines, tubings, etc., and attempts to get out of bed when they were actually required to lie down.

CONCLUSIONS

Overall experience of delirium was very distressing for the caregivers.

Symptom profile of delirium in children and adolescent--does it differ from adults and elderly?

OBJECTIVE

The objective was to evaluate the phenomenology, etiology and outcome of delirium in children and adolescents (8-18 years of age) seen in a consultation-liaison psychiatric service in India. Additionally, an attempt was made to compare the phenomenology with adult and elderly patients with delirium.

METHOD

Thirty children and adolescents (age 8-18 years) diagnosed with delirium by the consultation-liaison psychiatry team were rated on the Delirium Rating Scale-Revised-98 (DRS-R-98) and compared with DRS-R-98 data on 120 adults and 109 elderly patients.

RESULTS

The commonly observed symptoms in children and adolescents with delirium were disturbance in attention, orientation, sleep-wake cycle disturbances, fluctuation of symptoms, disturbance of short-term memory and motor agitation. The least commonly seen symptoms included delusions and motor retardation. Compared to adults, children and adolescents had lower frequency of long-term memory and visuospatial disturbances. Compared to the elderly, children and adolescents had higher frequency of lability of affect. For severity of symptoms, compared to adults, the children and adolescents had lower severity of sleep-wake disturbances, abnormality of thought, motor agitation, orientation, attention, short-term memory, long-term memory and visuospatial abilities. When compared to elderly patients, children and adolescents had higher severity of lability of affect and lower severity of language disturbances, short-term memory and visuospatial abilities.

CONCLUSIONS

In general, phenomenology, of delirium in children and adolescents (age 8-18 years) is similar to that seen in adults and elderly patients.

Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India

OBJECTIVE

To evaluate the incidence, prevalence, risk factors and outcome of delirium in the respiratory intensive care unit of a tertiary care hospital.

METHODS

Consecutive patients admitted to an eight-bed respiratory intensive care unit were screened for presence of delirium by a psychiatrist. Patients found to have delirium were evaluated using univariate techniques for their clinical profiles, risk factors for delirium, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, duration of stay (in days) and outcome at discharge from intensive care unit besides evaluation on Delirium Rating Scale-Revised 98 version (DRS-R-98).

RESULTS

Incidence and prevalence rate of delirium were 24.4% and 53.6% respectively. Univariate analyses revealed that the prevalence of delirium was higher (64%) in mechanically ventilated patients. The predisposing risk factors identified for delirium in univariate analysis were higher age; higher Glasgow Coma Scale score; increased APACHE II score; hyperuricemia; hypoalbuminemia; presence of acidosis; abnormal alkaline transferase levels; use of mechanical ventilation; higher number of total medication received and use of sedative, steroids and insulin. Univariate analysis showed that patients who were diagnosed with delirium had significantly longer duration of intensive care unit (ICU) stay and higher mortality rates. Age, multiple organ failure, hypoactive delirium and higher DRS-R-98 scores were significant risk factors for mortality in patients with delirium.

CONCLUSIONS

Delirium is highly prevalent in the ICU setting and delirium is associated with longer ICU stay and higher mortality.

[Delirium and subsyndromal delirium: prevalence of a disease spectrum]

INTRODUCTION

Subsyndromal delirium (SSD) is a developing concept of disease with a spectrum beyond the diagnostic dichotomy of delirium with standard criteria.

MATERIAL AND METHODS

To study the prevalence and significance of SSD we have conducted a cross-sectional prospective multicenter study of all patients admitted to three Geriatric Departments in tertiary hospitals. The SSD diagnostic criteria used were based on Marcantoniós criteria, and the DRS-R-98 scale was also used as a continuous variable of the degree of delirium.

RESULTS

We studied 85 patients, 56% women, Barthel 62 (SD: 32), age 87 (SD: 6), CIRS-G 24 (SD: 6.85). Three quarters (75.3%) of patients had at least one CAM positive item, and half of them with at least 13 points in the DRS-R-98 scale. The prevalence of delirium was 53% and 22.3% for SSD. The degree of delirium-DSS was associated with different geriatric syndromes, levels of malnutrition, and degree of functional and cognitive impairment, with a significant linear trend between groups. Patients without delirium have higher levels than those with subsyndromal delirium, and these in turn are higher than those without diagnosed delirium. There is also a tendency in the degree of delirium measured by the DRS-R-98.

CONCLUSION

Beyond the dichotomous concept of the presence or absence of delirium, this study suggests the probable continuity of cognitive processes and the possibility of more effective and earlier diagnostic and therapeutic measures.

Delirium in elderly people: a study of a psychiatric liaison service in north India

BACKGROUND

Very few studies from India have studied the phenomenology of delirium. The aim of the present study was to study the phenomenology as measured using the Delirium Rating Scale-Revised-98 (DRS-R98), the associated etiologies and the outcome of delirium among the elderly participants seen by the consultation-liaison psychiatric service in India. In addition, an attempt was made to study the factor structure of symptoms using principal components analysis.

METHODS

The case notes of 109 elderly patients referred to psychiatry liaison services were reviewed.

RESULTS

The mean age of the sample was 73.35 years (SD: 7.44; range 65-95 years) and two-thirds of the sample had hospital emergent delirium. The mean DRS-R98 severity score was 18.77 and the DRS-R98 total score was 24.81. In 15 patients the DRS-R98 scores were in the subsyndromal range. Among the various symptoms present, most patients had sleep-wake cycle disturbance, disturbance in orientation, attention and short-term memory impairments, fluctuation of symptoms, temporal onset of symptoms and a physical disorder. Principal components analysis identified three factors which explained 43.5% of variance of symptomatology and it yielded a three-factor structure. Endocrine/metabolic disturbances were the commonest associated etiological category with delirium. The mean hospital stay after being referred to psychiatry referral services was 8.89 days, after which delirium improved in 58.7% of cases. The mortality rate during the inpatient stay was 16.5%.

CONCLUSIONS

Results suggest that the symptoms of delirium as assessed by DRS-R98 separate out into a three-factor structure. Delirium is commonly associated with metabolic endocrine disturbances and about one-sixth of the patients die during the short inpatient stay.

Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium

OBJECTIVE

The objective of the study was to assess the efficacy and safety of second-generation antipsychotics olanzapine and risperidone vs. haloperidol in patients of delirium admitted to medical and surgical wards.

METHODS

Prospective follow-up single-blind randomized controlled trials were performed. Consecutive patients with delirium referred to the consultation-liaison psychiatry team were eligible for the study. The study sample comprised 64 patients, with 20 subjects in the haloperidol group, 21 subjects in the risperidone group and 23 subjects in the olanzapine group. A flexible dose regimen (haloperidol -0.25 to 10 mg; risperidone -0.25 to 4 mg; olanzapine -1.25 to 20 mg) was used. Delirium Rating Scale-Revised-98 (DRS-R98) was used as the primary efficacy measure, and mini mental status examination (MMSE) was used as a secondary efficacy measure.

RESULTS

There was no significant difference in mean baseline DRS-R98 severity scores and MMSE scores between the three groups. However, there were a significant reduction in DRS-R98 severity scores and a significant improvement in MMSE scores over the period of 6 days, but there was no difference between the three groups. Four patients in the haloperidol group, six subjects in the risperidone group and two subjects in the olanzapine group experienced some side effects.

CONCLUSIONS

Risperidone and olanzapine are as efficacious as haloperidol in the treatment of delirium.

State of Consultation-Liaison Psychiatry in India: Current status and vision for future

Over the years Consultation-Liaison (C-L) psychiatry has contributed significantly to the growth of the psychiatry and has brought psychiatry very close to the advances in the medicine. It has also led to changes in the medical education and in the providing comprehensive management to the physically ill. In India, although the General Hospital Psychiatric units were established in 1930s, C-L Psychiatry has never been the main focus of training and research. Hence there is an urgent need to improve C-L Psychiatry services and training to provide best and optimal care to the patients and provide best education to the trainees.