The occurrence and duration of symptoms in elderly patients with delirium

Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients

BACKGROUND

Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults.

METHODS

Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers.

RESULTS

A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden.

CONCLUSIONS

Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.

Individualized Summary Assessment of Detailed Neuropsychological Testing for the Etiological Diagnosis of Newly Detected Cognitive Impairment in Hospitalized Geriatric Patients

BACKGROUND

Neuropsychological testing (NPT) of geriatric inpatients can be affected by the acute illness and/or the hospitalization.

OBJECTIVE

To test individualized interpretation of detailed NPT for the differentiation between primary 'neurodegenerative' etiologies (predominantly Alzheimer's disease) and 'other' etiologies (including cerebrovascular disease) of newly detected cognitive impairment in geriatric inpatients without and with delirium in remission.

METHODS

96 geriatric inpatients (81.9±5.6 years, 64.6% females) with clinically uncertain cognitive impairment were included. 31.3% had delirium in remission that was not considered the primary cause of the cognitive impairment. Categorization of the most likely etiology as 'neurodegenerative' or 'other' was established retrospectively by a study neuropsychologist based on individualized summary assessment of detailed NPT compiled in a standardized vignette. The etiological diagnosis based on FDG-PET served as gold standard (54.2% 'neurodegenerative', 45.8% 'other').

RESULTS

Individualized summary assessment by the study neuropsychologist was correct in 80 patients (83.3%, 8 false positive, 8 false negative). The impact of delirium in remission was not significant (p = 0.237). Individualized summary assessment by an independent neuropsychologist resulted in more false positive cases (n = 22) at the same rate of false negative cases (n = 8). Automatic categorization with a decision tree model based on the most discriminative NPT scores was correct in 68 patients (70.8%, 14 false positive, 14 false negative).

CONCLUSION

Individualized summary assessment of detailed NPT in the context of relevant clinical information might be useful for the etiological diagnosis of newly detected cognitive impairment in hospitalized geriatric patients, also in patients with delirium in remission, but requires task-specific expertise.

Intranasal insulin for treatment of delirium in older hospitalised patients: study protocol for a randomised controlled trial

INTRODUCTION

Delirium is one of the most common conditions diagnosed in hospitalised older people and is associated with numerous adverse outcomes, yet there are no proven pharmacological treatments. Recent research has identified cerebral glucose hypometabolism as a pathophysiological mechanism offering a therapeutic target in delirium. Insulin, delivered via the intranasal route, acts directly on the central nervous system and has been shown to enhance cerebral metabolism and improve cognition in patients with mild cognitive impairment and dementia. This trial will determine whether intranasal insulin can reduce the duration of delirium in older hospitalised patients.

METHODS AND ANALYSIS

This is a prospective randomised, placebo-controlled, double-blind study with 6 months follow-up. One hundred patients aged 65 years or older presenting to hospital with delirium admitted under geriatric medicine will be recruited. Participants will be randomised to intranasal insulin detemir or placebo administered twice daily until delirium resolves, defined as Confusion Assessment Method (CAM) negative for 2 days, or discharge from hospital. The primary outcome measure will be duration of delirium using the CAM. Secondary outcome measures will include length of hospital stay, severity of delirium, adherence to treatment, hospital complications, new admission to nursing home, mortality, use of antipsychotic medications during hospital stay and cognitive and physical function at 6 months postdischarge.

ETHICS AND DISSEMINATION

This trial has been approved by the South Eastern Sydney Human Research and Ethics Committee. Dissemination plans include submission to a peer-reviewed journal for publication and presentation at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618000318280.

Impact of Tobacco Smoking on Outcomes After Posterior Decompression Surgery in Patients With Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study

STUDY DESIGN

This was a case-control study.

OBJECTIVE

The objective of this study was to clarify the surgical outcomes after cervical posterior decompression in patients who smoked.

SUMMARY OF BACKGROUND DATA

Smoking is associated with poor outcomes in the field of spinal surgery. However, the impact of tobacco smoking on the outcomes after posterior decompression surgery has not been fully evaluated in patients with cervical spondylotic myelopathy.

MATERIALS AND METHODS

In this retrospective multicenter study, 587 patients with cervical spondylotic myelopathy were enrolled at 17 institutions in Japan. Patients underwent cervical laminoplasty or laminectomy and were followed up for at least 1 year after surgery. Outcome measures were: preoperative smoking status, perioperative complications, the Japanese Orthopedic Association scale, and the Visual Analog Scale for neck pain. After adjusting for age and sex by exact matching, smoking and nonsmoking groups were compared using an unpaired t test for continuous variables or a χ test for categorical variables.

RESULTS

There were 182 (31%) current smokers and 405 (69%) nonsmokers including previous smokers. After matching, 158 patients were extracted from each group. Demographic data and surgical information were almost the same between the groups. Regarding postoperative complications, there was no significant difference in the rate of surgical site infection, cerebrospinal fluid leakage, hematoma, segmental motor paralysis, or neurological deficit. However, smokers showed a significantly higher risk for delirium (3.8% vs. 0.0%, P=0.039). Smokers and nonsmokers showed comparable changes in functional recovery according to Japanese Orthopedic Association scores (3.2±2.1 vs. 3.0±2.1, P=0.425) and in neck pain reduction using the Visual Analog Scale (-1.7±3.1 vs. -1.4±2.8, P=0.417) at the final follow-up.

CONCLUSIONS

Smokers exhibited functional restoration and neck pain reduction after cervical posterior decompression. Attention is required, however, for the postoperative complication of delirium, which could be caused by the acute cessation of tobacco smoking after admission.

LEVEL OF EVIDENCE

Level III.

Brain FDG PET for the Etiological Diagnosis of Clinically Uncertain Cognitive Impairment During Delirium in Remission

BACKGROUND

Positron emission tomography (PET) of the brain with 2-[F-18]-fluoro-2-deoxy-D-glucose (FDG) is widely used for the etiological diagnosis of clinically uncertain cognitive impairment (CUCI). Acute full-blown delirium can cause reversible alterations of FDG uptake that mimic neurodegenerative disease.

OBJECTIVE

This study tested whether delirium in remission affects the performance of FDG PET for differentiation between neurodegenerative and non-neurodegenerative etiology of CUCI.

METHODS

The study included 88 patients (82.0±5.7 y) with newly detected CUCI during hospitalization in a geriatric unit. Twenty-seven (31%) of the patients were diagnosed with delirium during their current hospital stay, which, however, at time of enrollment was in remission so that delirium was not considered the primary cause of the CUCI. Cases were categorized as neurodegenerative or non-neurodegenerative etiology based on visual inspection of FDG PET. The diagnosis at clinical follow-up after ≥12 months served as ground truth to evaluate the diagnostic performance of FDG PET.

RESULTS

FDG PET was categorized as neurodegenerative in 51 (58%) of the patients. Follow-up after 16±3 months was obtained in 68 (77%) of the patients. The clinical follow-up diagnosis confirmed the FDG PET-based categorization in 60 patients (88%, 4 false negative and 4 false positive cases with respect to detection of neurodegeneration). The fraction of correct PET-based categorization did not differ between patients with delirium in remission and patients without delirium (86% versus 89%, p = 0.666).

CONCLUSION

Brain FDG PET is useful for the etiological diagnosis of CUCI in hospitalized geriatric patients, as well as in patients with delirium in remission.

Latent class analysis of the multivariate Delirium Index in long-term care settings

ABSTRACTBackground:A few studies examine the time evolution of delirium in long-term care (LTC) settings. In this work, we analyze the multivariate Delirium Index (DI) time evolution in LTC settings.

METHODS

The multivariate DI was measured weekly for six months in seven LTC facilities, located in Montreal and Quebec City. Data were analyzed using a hidden Markov chain/latent class model (HMC/LC).

RESULTS

The analysis sample included 276 LTC residents. Four ordered latent classes were identified: fairly healthy (low "disorientation" and "memory impairment," negligible other DI symptoms), moderately ill (low "inattention" and "disorientation," medium "memory impairment"), clearly sick (low "disorganized thinking" and "altered level of consciousness," medium "inattention," "disorientation," "memory impairment" and "hypoactivity"), and very sick (low "hypoactivity," medium "altered level of consciousness," high "inattention," "disorganized thinking," "disorientation" and "memory impairment"). Four course types were also identified: stable, improvement, worsening, and non-monotone. Class order was associated with increasing cognitive impairment, frequency of both prevalent/incident delirium and dementia, mortality rate, and decreasing performance in ADL.

CONCLUSION

Four ordered latent classes and four course types were found in LTC residents. These results are similar to those reported previously in acute care (AC); however, the proportion of very sick residents at enrolment was larger in LTC residents than in AC patients. In clinical settings, these findings could help identify participants with a chronic clinical disorder. Our HMC/LC approach may help understand coexistent disorders, e.g. delirium and dementia.

A Comparison of the Severe Cognitive Impairment Rating Scale With the Mini-Mental State Examination and Delirium Rating Scale-Revised-98 for Delirium: A Cross-sectional Study

BACKGROUND

Cognitive impairment including attention deficits, disorientation, memory impairment, language disturbance, and impaired visuospatial ability are core symptoms of delirium. The Severe Cognitive Impairment Rating Scale (SCIRS) was developed to assess cognition in patients with severe dementia, but may also be useful in elderly people with delirium.

OBJECTIVE

We investigated the use of the SCIRS to assess cognition in elderly patients with delirium.

METHODS

We recruited 147 participants, aged ≥65 years, referred for psychiatric consultation at a tertiary-care university hospital. The diagnosis and severity of delirium were assessed using the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). Cognitive function was assessed using the SCIRS and the Mini-Mental State Examination (MMSE) in the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Assessment Packet (MMSE-KC).

RESULTS

There was a strong correlation of SCIRS scores with K-DRS-98 cognition domain (r = -0.796), severity scores (r = -0.742), total scores (r = -0.734), and the MMSE-KC (r = 0.905). Analysis of variance incorporating the severity of delirium suggested that while the MMSE showed a floor effect, the SCIRS could discriminate between moderate and severe delirium.

CONCLUSION

The SCIRS is a useful instrument to assess cognitive function in elderly patients with moderate to severe delirium.

Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

Spine surgeries in elderly patients have increased in recent years due to aging of society and recent advances in surgical techniques, and postoperative complications have become more of a concern. Postoperative delirium is a common complication in elderly patients that impairs recovery and increases morbidity and mortality. The objective of the study was to analyze postoperative delirium associated with spine surgery in patients aged 80 years or older with cervical, thoracic, and lumbar lesions.

METHODS

A retrospective multicenter study was performed in 262 patients 80 years of age or older who underwent spine surgeries at 35 facilities. Postoperative complications, incidence of postoperative delirium, and hazard ratios of patient-specific and surgical risk factors were examined.

RESULTS

Postoperative complications occurred in 59 of the 262 spine surgeries (23%). Postoperative delirium was the most frequent complication, occurring in 15 of 262 patients (5.7%), and was significantly associated with hypertension, cerebrovascular disease, cervical lesion surgery, and greater estimated blood loss (P < .05). In multivariate logistic regression using perioperative factors, cervical lesion surgery (odds ratio = 4.27, P < .05) and estimated blood loss ≥300 mL (odds ratio = 4.52, P < .05) were significantly associated with postoperative delirium.

CONCLUSIONS

Cervical lesion surgery and greater blood loss were perioperative risk factors for delirium in extremely elderly patients after spine surgery. Hypertension and cerebrovascular disease were significant risk factors for postoperative delirium, and careful management is required for patients with such risk factors.

Longitudinal patterns of delirium severity scores in long-term care settings

BACKGROUND

The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents.

METHODS

A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores.

RESULTS

During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks.

CONCLUSIONS

The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

Delirium in older adults: a chronic cognitive disorder?

Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).

Frequency of full, partial and no recovery from subsyndromal deliriumin older hospital inpatients

OBJECTIVES

To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium.

METHODS

SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium.

RESULTS

Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium.

CONCLUSION

Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients.

The interface between delirium and dementia in elderly adults

Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.

Prospective observational study of delirium recovery trajectories and associated short-term outcomes in older adults admitted to a specialized delirium unit

OBJECTIVES

To describe the recovery trajectories of delirium and to determine factors predicting the course of recovery and adverse outcome.

DESIGN

A prospective observational study.

SETTING

Geriatric monitoring unit (GMU), a five-bed unit specializing in managing older adults with delirium.

PARTICIPANTS

Individuals admitted to the GMU between December 2010 and August 2012 (N = 234; mean age 84.1 ± 7.4).

MEASUREMENTS

Information was collected on demographic characteristics; comorbidities; severity of illness; functional status; and daily cognitive, Delirium Rating Scale, Revised-98 (DRS-R98) severity, and functional scoring. Resolution of delirium, and thus GMU discharge, was determined according to clinical assessment. The primary outcome was residual subsyndromal delirium (SSD) (DRS-R98 severity ≥13) upon GMU discharge. Univariate and multivariate methods were used to determine the predictors of residual SSD and adverse outcomes (inpatient mortality and incident nursing home admission upon discharge).

RESULTS

Participants with residual SSD had a slower recovery in terms of delirium severity, cognition, and functional status than those with no residual SSD. Residual SSD predictors included underlying dementia, admission DRS-R98 severity, DRS-R98 severity on Day 1 minus Day 3 of GMU stay, and admission modified Barthel Index. Only presence of residual SSD at discharge predicted adverse outcomes (odds ratio = 5.27, 95% confidence interval = 1.43-19.47).

CONCLUSION

Individuals with residual SSD had prolonged recovery trajectory of delirium. These new insights into the recovery trajectories of delirium may help formulate early discharge planning and provide the basis for future research on delirium treatment.

Diagnostic and treatment practices of delirium in a general hospital

BACKGROUND

Despite the increase in research on delirium, it remains underdiagnosed and difficult to manage, and the outcome is poor especially in older people.

AIMS

To identify the clinically diagnosed rates of delirium, the possible aetiologies, to describe treatment, number and type of psychotropic medication used and to investigate the reasons for referral to a liaison psychiatric team.

METHODS

Retrospective study of medical records of inpatients admitted to Sligo Regional Hospital during an 18-month period.

RESULTS

One hundred and fifty-six files had a documentation of delirium (time prevalence 2%). Mean age of the sample was 82 years (SD = 7.2), 66 (42%) were male. Sixty-nine (44.2%) of the total sample had a previous history of dementia, and 57 (36.5%) had a previous history of delirium. In 67 (43.2%) samples, the cause was infection, while in 4, no specific cause was identified. Ninety (58%) were referred to the liaison service, but only in 26 (28.9 %), the reason for referral was "acute confusion" or "delirium". In a majority of referrals, the reason was an affective disorder more often depression. There were no significant differences between delirium subtypes and referrals (χ(2) = 3.868, df 3, p = 0.28). Examination of the amount of antipsychotics prescribed before, during and after delirium shows that there was a significant increase in use during the delirium (χ(2) = 17.512, df 8, p = 0.025) and decrease in z-hypnotics medication (zopiclone/zolpidem), (χ(2) = 20.114, df 4, p < 0.001), while benzodiazepines and antidepressants remained the same.

CONCLUSIONS

Delirium is often misdiagnosed and unrecognized in hospital settings; however, when identified the pharmacological management is appropriate.

The Mini-Mental State Examination as a diagnostic and screening test for delirium: systematic review and meta-analysis

OBJECTIVE

To analyse the evidence concerning the accuracy of the Mini-Mental State Examination (MMSE) as a diagnostic and screening test for the presence of delirium in adults.

METHOD

Two authors searched MEDLINE, PsychINFO and EMBASE from inception till March 2014. Articles were included that investigated the diagnostic validity of the MMSE to detect delirium against standardised criteria. A diagnostic validity meta-analysis was conducted.

RESULTS

Thirteen studies were included representing 2017 patients in medical settings of whom 29.4% had delirium. The meta-analysis revealed the MMSE had an overall sensitivity and specificity estimate of 84.1% and 73.0%, but this was 81.1% and 82.8% in a subgroup analysis involving robust high quality studies. Sensitivity was unchanged but specificity was 68.4% (95% CI = 50.9-83.5%) in studies using a predefined cutoff of <24 to signify a case. In high-risk samples where delirium was present in 25% of patients, then the Positive predictive value and Negative predictive value would be 50.9% (48.3-66.2%) and 93.2% (90.0-96.5%).

CONCLUSION

The MMSE cannot be recommended as a case-finding confirmatory test of delirium, but may be used as an initial screen to rule out high scorers who are unlikely to have delirium with approximately 93% accuracy.

Delirium in the hospitalised elderly: An audit of NCHD prescribing practice

Objectives: This study was carried out to determine the prescribing of psychotropic medication of non-consultant hospital doctors in the management of delirium and to compare this with best practice guidelines.

Method: A structured questionnaire was forwarded to all non-consultant hospital doctors (n = 95) working at St Vincent's University Hospital and data was collected over a six month period. The questionnaire addressed type, dose and route of psychotropic medication use in delirium as well as adjunctive measures used to manage delirium.

Results: There was a 55% response rate (n = 52). Haloperidol and lorazepam were the two most frequently prescribed psychotropic agents used and over one third of respondents (n = 20) reported the use of risperidone. There was wide variation in doses used and a substantial proportion of NCHDs used higher than recommended starting doses for elderly patients with delirium. In addition, the intramuscular route was reported as the commonest route of administration with a majority of respondents reporting infrequent intravenous route of administration.

Conclusions: The drug choice reported by respondents followed best practice guidelines. However, the wide variation in drug doses used and frequency of parenteral route of administration (particularly intramuscular) indicate the need for increasing awareness of best practice international guidelines. Guidance and clarification regarding the use of atypical antipsychotic medication is required following concerns about their use in dementia.

Prognosis of delirium in hospitalized elderly: worse than we thought

BACKGROUND

Despite treatment of the associated condition, delirious persons do not always recover for unknown reasons. We sought to determine early prognostic indicators of poor recovery following an episode of delirium in older medical in-patients.

METHODS

Between October 2009 and July 2011, consecutively admitted older (≥70 years old) medical in-patients at the London Health Sciences Centre (Ontario) were screened for delirium. Delirious patients were followed. The primary outcome was poor recovery, in delirious patients, defined by death, long-term institutionalization, or functional decline (decreased activities of daily living), at discharge or 3 months after discharge, elicited from the medical chart or post-discharge caregiver telephone interviews.

RESULTS

One thousand two hundred thirty-five in-patients (mean age 82.6 years, 42% men) were screened, delirium occurred in 355 (29%). Follow-up data was known on 342 (96%), and 237 (69%) had poor recovery: 55 died (54 in hospital and one after discharge), 136 were permanently institutionalized (86 directly from hospital and 50 after discharge), and 46 had functional decline (at a median of 103 days after discharge). Poor recovery was associated in the derivation sample with advanced age, lower baseline function, hypoxia, higher delirium severity scores, and acute renal failure; this was predictive of poor recovery in the validation sample (receiver operating characteristic area 0.68, 95% confidence interval: 0.57-0.79); however, even individuals with "low" risk had high (50%) poor recovery rates.

INTERPRETATION

Poor recovery after delirium is common and associated with certain characteristics. However, even "lower risk" delirious individuals do poorly. More research is needed to understand prognostic factors in delirium.

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

OBJECTIVE

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

METHODS

Subsyndromal delirium was defined as the presence of one or more symptoms of delirium, not meeting criteria for delirium and not progressing to delirium. MEDLINE, EMBASE, PsycINFO and the Web of Science were searched for potentially relevant articles published from 1996 to June 2011. The bibliographies of relevant articles were searched for additional references. Twelve studies met the inclusion criteria. The validity of included studies was assessed according to Evidence-Based Medicine criteria. Information about the study population and methods, age, gender, proportion with dementia, diagnostic criteria, period and frequency of observation, and the topics above was systematically abstracted, tabulated and synthesized using standard meta-analysis techniques.

RESULTS

The combined prevalence of SSD was 23% (95% CI, 9-42%); the combined incidence was 13% (95% CI, 6-23%). Risk factors were similar to those for delirium. Episodes lasted up to 133 days and were often recurrent. Outcomes were poor and often intermediate between those of older people with or without delirium. Of note, there was significant unexplained heterogeneity in the results of studies of prevalence, incidence and some risk factors.

CONCLUSIONS

SSD in older people may be a frequent and clinically important condition that falls on a continuum between no symptoms and full delirium. Because of significant unexplained heterogeneity in the results of studies of SSD, however, the results of this review must be interpreted cautiously. Further research is necessary.

Subsyndromal delirium in old age: conceptual and methodological issues

Delirium is a cognitive disorder characterized by acute onset, fluctuating course, altered level of consciousness, inattention, disorganized thinking, disorientation, memory impairment, and perceptual and motor disturbances (American Psychiatric Association, 2000; World Health Organization, 2010). It occurs in hyperactive, hypoactive, or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006) and 70% of older long-term care residents (McCusker et al., 2011). In both settings, delirium is independently associated with poor outcomes (Siddiqi et al., 2006; McCusker et al., 2010; Witlox et al., 2010).

The course of delirium in older long-term care residents

OBJECTIVE

The purpose of this study was to determine the course of delirium in older long-term care (LTC) residents.

METHODS

A prospective cohort study of 279 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. The Mini Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. Information on medical problems and medication was abstracted from resident charts. Data were analyzed using descriptive statistics, Cox proportional hazard regression, and logistic regression.

RESULTS

Of the 279 residents, 41 (14.7%) had 61 CAM-defined incident episodes of delirium: 28 (10%) had one episode and 13 (4.7%) had two or more episodes. Episode duration was 7-63 days, mean, 11.3 (SD, 10.1) days. The mean episode DI score was 11.5 (SD, 3.5). Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2% 77.1%, and 80.3%, respectively. Most episodes were preceded or followed by one or more CAM core symptoms of delirium, sometimes lasting many weeks.

CONCLUSIONS

Confusion Assessment Method-defined incident episodes of delirium in older LTC residents appear to last longer than episodes in acute care hospital patients, but rates of recovery at 4 and 24 weeks are similar. Notably, most episodes were preceded or followed by one or more CAM core symptoms of delirium. These findings have implications for clinical practice and research in LTC settings.

Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review

OBJECTIVES

To examine evidence of the efficacy of antipsychotics in the treatment of delirium in older hospitalized adults.

DESIGN

Systematic literature review.

SETTING

Hospital.

PARTICIPANTS

Older adults with delirium.

MEASUREMENTS

The MEDLINE (January 1980-December 2010) and Cochrane Databases were searched using the keywords "delirium" and "antipsychotics." References of review articles were reviewed to identify additional studies. Study selection criteria included prospective design, more than 10 participants (in treatment arms), mean age 60 and older, standardized criteria for diagnosing delirium, and validated delirium rating scales for reporting outcomes.

RESULTS

Thirteen articles met selection criteria: six single-agent and seven comparison studies. Of these, eight (62%) had fewer than 25 participants in treatment arms, 10 (77%) recruited participants from psychiatry referrals, and eight (62%) did not clearly describe their screening methods. All single-agent studies were open-label studies. Of the comparison studies, five (71%) used randomization, but only one of these (a placebo-controlled study) used adequate allocation concealment methods, and only one other study (comparing two antipsychotics) described a double-blind method in detail. In the only placebo-controlled study (which was stopped early), no statistically significant differences in mean delirium severity scores were found at individual time points (Days 2, 3, 4, 7, 10). The other 12 studies reported improvements in delirium severity or resolution of delirium based on cutoff scores of the scales, but it is not clear from any of these studies what the natural course of delirium would have been without use of antipsychotics.

CONCLUSION

Because of severe methodological limitations, the studies in this review do not support the use of antipsychotics in the treatment of delirium in older hospitalized adults. Additional well-designed randomized placebo-controlled trials are needed.

The importance of delirium: economic and societal costs

Although a number of studies have documented the negative clinical and economic consequences of delirium, interventions to prevent and treat delirium are infrequently implemented. The importance of delirium may continue to be underestimated until its societal and economic effects are documented. The current article outlines the existing literature related to long-term sequelae and costs associated with delirium and stresses the importance of such research in prompting recognition, prevention, and treatment efforts that could reduce the effect of delirium and improve quality of life for older adults and their caregivers.

Treatment characteristics of delirium superimposed on dementia

BACKGROUND

The course of delirium in patients with dementia who are undergoing management of delirium with antipsychotics has not previously been studied. In order to investigate the treatment characteristics of patients with delirium superimposed on dementia in contrast to delirium in the absence of dementia we performed a secondary analysis of our delirium database.

METHODS

We collected sociodemographic data and medical variables in addition to using the systematic rating scales of the Memorial Delirium Assessment Scale (MDAS) and Karnofsky Scale of Performance Status (KPS). These data were recorded in the delirium database. For this analysis we extracted all data pertaining to patients with delirium and dementia (DD) and compared them to those with delirium without dementia (i.e. non-demented with delirium; NDD).

RESULTS

Out of 111 cases with a diagnosis of delirium we acquired 22 cases with a diagnosis of DD and 89 cases with NDD. The mean age was significantly different with 77.1 years for DD and 62.7 years for NDD. The MDAS scores at baseline were significantly higher in DD (21.1) compared to NDD (17.6). Over the course of treatment, MDAS scores were significantly higher in DD with 11.7 at T3 compared with 7.0 in NDD. After three days of management, delirium resolution rates were significantly lower in DD with 18.2% compared to 53.9% in NDD, and at seven days delirium resolution rates were 50% and 83% respectively. At the endpoint of the observation period, DD had a significantly more pronounced disturbance of consciousness and impairment in the cognitive domain. KPS scores were not significantly different between DD and NDD.

CONCLUSION

In our sample of patients with delirium superimposed on dementia the delirium resolution rates were lower than in patients without dementia at one week of treatment. The data suggest that when delirium is superimposed on dementia the delirium may resolve at a slower rate.

Frequency, risk factors, and prognosis of prolonged delirium in elderly patients after hip fracture surgery

BACKGROUND

Delirium in elderly patients after hip fracture surgery is believed to be a transient event, although it frequently lasts for more than 4 weeks.

QUESTIONS/PURPOSES

We determined the incidence, risk factors, morbidity, and mortality of prolonged delirium in elderly patients after hip fracture surgery.

PATIENTS AND METHODS

We evaluated 232 elderly patients (older than 65 years) (232 hips) who underwent hip fracture surgery for the development and duration of delirium and categorized them into three groups; nondelirium group, transient (≤ 4 weeks) delirium group, and prolonged (> 4 weeks) delirium group. Patients underwent a global geriatric evaluation, which included postoperative complications, mortality, and functional and mental status evaluations. The three groups were compared with respect to these variables.

RESULTS

Seventy patients (30.2%) had delirium develop, and among these, 14 (20%) had prolonged delirium with a total incidence of 6%. Multivariate analysis showed preinjury dementia was a risk factor of prolonged delirium. At the final followup, five (62.5%) of the eight patients who were ambulatory outdoors in the prolonged delirium group became housebound, whereas only 18 (16.4%) of the 110 patients who were ambulatory outdoors in the nondelirium group became housebound. Survival at 40 months was 81.0% (95% confidence interval, 72.6%-89.3%) in the nondelirium group and 63.6% (95% confidence interval, 35.2%-92.1%) in the prolonged delirium group.

CONCLUSIONS

Prolonged delirium was found to be associated with a poor functional outcome and increased mortality.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Neuropsychiatric and cognitive profile of patients with DSM-IV delirium referred to an old age psychiatry consultation-liaison service

BACKGROUND

The phenomenology of delirium is understudied, including how the symptom profile varies across populations. The aim of this study was to explore phenomenology occurring in patients with delirium referred to an old age psychiatry consultation-liaison setting and compare with delirium occurring in palliative care patients.

METHODS

Consecutive cases of DSM-IV delirium were assessed with the Delirium Rating scale Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD).

RESULTS

Eighty patients (mean age 79.3 ± 7.7 years; mean DRS-R98 total score 21.7 ± 4.9 and total CTD score 10.2 ± 6.3) were included. Forty patients (50%) with comorbid dementia were older, had a longer duration of symptoms at referral, and more severe delirium due to greater cognitive impairments. Inattention (100%) was the most prominent cognitive disturbance, while sleep-wake cycle disturbance (98%), altered motor activity (97%), and thought process abnormality (96%) were the most frequent DRS-R98 non-cognitive features. Inattention was associated with severity of other cognitive disturbances on both the DRS-R98 and CTD, but not with DRS-R98 non-cognitive items. The phenomenological profile was similar to palliative care but with more severe delirium due to greater cognitive and non-cognitive disturbance.

CONCLUSION

Delirium is a complex neuropsychiatric syndrome with generalized cognitive impairment and disproportionate inattention. Sleep-wake cycle and motor-activity disturbances are also common. Comorbid dementia results in a similar phenomenological pattern but with greater cognitive impairment and later referral.

Insulin-like growth factor I and the pathogenesis of delirium: a review of current evidence

Delirium is a frequent complication in medically ill elderly patients that is associated with serious adverse outcomes including increased mortality. Delirium risk is linked to older age, dementia, and illness that involves activation of inflammatory responses. IGF-I is increasingly postulated as a key link between environmental influences on body metabolism with a range of neuronal activities and has been described as the master regulator of the connection between brain and bodily well-being. The relationships between IGF-I and ageing, cognitive impairment and inflammatory illness further support a possible role in delirium pathogenesis. Five studies of IGF-I in delirium were identified by a systematic review. These conflicting findings, with three of the five studies indicating an association between IGF-1 and delirium occurrence, may relate to the considerable methodological differences in these studies. The relevance of IGF-I and related factors to delirium pathogenesis can be clarified by future studies which account for these issues and other confounding factors. Such work can inform therapeutic trials of IGF-I and/or growth hormone administration.

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Integration of Research Methods and Outcome Measures: Comprehensive Care for the Frail Elderly

Les instruments de recherche peuvent être intégrées dans les soins de routine si ceux-ci sont utiles aux pourvoyeurs de soins. Ainsi, ils sont utiles s'ils facilitent la prestation de soins et si ce qu'ils mesurent reflètent des résultats qui importent aux patients. Bon nombre de mesures actuelles sont moins utiles parce qu'elles ne peuvent servir dans le quotidien ou mesurent de façon inadéquate les résultats pertinents. Au plan des soins auprès des personnes âgées frêles, qui ont des besoins complexes, ces défis sont particulièrement difficiles à relever. Les techniques d'évalutation gériatrique complète et l'établissement d'une échelle de l'atteinte des objectifs (Goal Attainment Scaling — GAS) sont proposées comme des moyens d'englober la complexité des besoins des personnes âgées frêles et de mesurer l'efficacité des interventions spécialisées. L'échelle GAS est conforme à la définition de la qualité de la vie de l'instrument Health-Related Quality of Life. Ce qui suggère que son utilisation dans le quotidien offre des avantages tant au niveau de la gestion que de la mesure des résultats.

Persistent delirium in older hospital patients

PURPOSE OF REVIEW

There are two contradictory views on the prognosis of delirium in older hospital patients. On one hand, the Diagnostic and Statistical Manual, 4th Text Revision (DSM-IV-TR), describes delirium as a transient cognitive disorder, the majority of affected individuals having a full recovery. On the other hand, longitudinal studies of delirium in this population report that the outcomes are poor. This review proposes to reconcile these two contradictory views.

RECENT FINDINGS

In older hospital patients, delirium appears to persist in 44.7% of patients at discharge and in 32.8, 25.6 and 21% of patients at 1, 3 and 6 months, respectively. The outcomes (cognition, function, nursing home placement, mortality) of patients with persistent delirium are consistently worse than the outcomes of patients who recover from delirium.

SUMMARY

The majority of older hospital patients with delirium may recover but the persistence of delirium in a substantial minority of patients may account, in large part, for the poor outcomes of delirium in this population. This proposal has potentially important implications for clinical practice and research.

Fractures after nursing home admission: incidence and potential consequences

SUMMARY

Fracture rates were examined in residents newly admitted to nursing homes. The risk of a fracture was highest during the first months after admission and declined thereafter. This risk pattern was observed independently of fracture site, gender or degree of care need.

INTRODUCTION AND HYPOTHESIS

Residents of nursing homes are a high-risk group for fractures. The aim of the study was to analyse fracture rates as a function of time from admission to nursing home.

METHODS

Fractures of the upper limb, femur, pelvis and lower leg, time to first and subsequent fractures, age, gender and care needs at admission were measured in 93,424 women and men aged 65 years and over and newly admitted to nursing homes in Bavaria between 2001 and 2006.

RESULTS

Fracture incidence was highest during the first months after admission to nursing homes and declined thereafter. This pattern was observed for all fracture sites, in women and men and in residents with different care needs. For example, fracture rates of the upper limb declined from 30.0 to 13.5/1,000 person-years in the first 9 months after admission and for all fracture sites from 135.3 to 69.4/1,000 person-years in a corresponding time period.

CONCLUSION

Newly admitted residents have the highest fracture risk. The pattern of risk is similar across all fractures, suggesting a generic causal pathway. Implementation of effective fracture prevention efforts should be a priority at the time of admission to nursing homes.

Improving the outcomes of delirium in older hospital inpatients

Delirium is a cognitive disorder characterized by acute onset, fluctuating course and disturbances in consciousness, orientation, memory, thought, perception and behavior (American Psychiatric Association, 2000). It occurs in hyperactive, hypoactive or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006), many with pre-existing dementia (Fick et al., 2002).

Medication Sleuth: An Important Role for Pharmacists in Determining the Etiology of Delirium

Delirium is characterized by disturbances of consciousness, attention, cognition, and perception and is the most common reason for acute cognitive dysfunction in hospitalized elderly patients. Causes of delirium can be multifactorial, and a careful medical and medication history can help determine the underlying cause of behavioral disturbances. A 65-year-old patient with a history of chronic pain, insomnia, and multiple medical problems, who presented with altered mental status and aggressive behavior, is described. The patient had taken an overdose of zolpidem prior to admission, and she required chemical and physical restraints and one-on-one care for safety. With time and washout of the zolpidem, the patient's behavior did not improve. On the second day of admission, medication reconciliation of this patient's medication profile helped to reveal a medication cause for this patient's delirium. A pharmacist should be included early in the process of obtaining a medication history. Recommendations for the management of chronic pain and insomnia in the elderly are presented.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

Assessment scales for delirium

Delirium is a severe psychiatric syndrome that is highly prevalent in elderly general hospital patients. However, the diagnosis of delirium is often missed. The use of rating scales can be helpful in detecting and measuring delirium symptom severity. This article reviews recent developments regarding psychometric qualities, measurement goals, content and rating procedures of some of the available rating scales in clinical practice. Literature from the Medline files up to 2008 were collected, using the following search entries: delirium, (acute) confusion, assessment/rating scale and screening. Articles were selected if their title or summary were related to the development or applicability of delirium rating scales. The reference lists of relevant articles were searched for additional references. The rating scales were split up according to their purposes, screening or severity rating and were discussed for the following aspects: content (theoretical background, rating domains and items), interview (duration, format and assessors’ expertise) and psychometric qualities (reliability and validity). There were eight screening scales (Confusion Assessment Method [CAM], CAM for the Intensive Care Unit [CAM-ICU], Intensive Care Delirium Screening Checklist [ICDSC], Delirium Symptom Interview [DSI], NEECHAM Confusion Scale [NEECHAM], Cognitive Test for Delirium [CTD], Delirium Observation Screening [DOS] and Nursing Delirium Screening Scale [Nu-DESC]) and seven severity rating scales (Delirium Rating Scales [DRS], Memorial Delirium Assessment Scales [MDAS], Confusional State Evaluation [CSE], Delirium Severity Scales [DSS], Delirium Index [DI], Delirium-O-Meter [DOM] and Delirium Detection Scale [DDS] ) selected for further research. The CAM, NEECHAM and DOS and the CAM-ICU for the ICU appear to be the most suitable as screening instruments, depending on the type of rater (trained) physician or nurse. The (revised) Delirium Rating Scale (DRS-R-98) and the DOM appear to be particularly useful for measuring delirium severity or monitoring change.

Delirium resolution in hospitalized older patients with cancer

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.

Persistent delirium in older hospital patients: a systematic review of frequency and prognosis

BACKGROUND

one explanation for the poor prognosis of delirium among older hospital patients may be that many of these patients do not recover from delirium. We sought to determine the frequency and prognosis of persistent delirium (PerD) in older hospital patients by systematically reviewing original research on this topic.

METHODS

MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews were searched for potentially relevant articles. The bibliographies of relevant articles were searched for additional references. Eighteen reports (involving 1,322 patients with delirium) met the following seven inclusion criteria: original research published in English or French, prospective study design, study population of at least 20 hospital patients, patients aged 50 years or more, follow-up of at least 1 week, acceptable definition of delirium at enrollment and included at least one assessment for PerD at discharge or later. The methods of each study were assessed according to the six criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the sample origin and size, age, proportion with dementia, criteria for delirium, timing of follow-up assessments, criteria for PerD, proportion with PerD and prognosis of PerD was systematically abstracted from each report, tabulated and combined using standard meta-analysis techniques.

RESULTS

the combined proportions with PerD at discharge, 1, 3 and 6 months were 44.7% (95% CI 26.8%, 63.7%), 32.8% (95% CI 18.4%, 47.2%), 25.6% (95% CI 7.9%, 43.4%) and 21% (95% CI 1.4%, 40.6%), respectively. The outcomes (mortality, nursing home placement, function, cognition) of patients with PerD were consistently worse than the outcomes of patients who had recovered from delirium.

CONCLUSION

PerD in older hospital patients is frequent, appears to be associated with adverse outcomes and may account for the poor prognosis of delirium in this population. These findings have potentially important implications for clinical practice and research.

Long-term cognitive outcome of delirium in elderly hip surgery patients. A prospective matched controlled study over two and a half years

OBJECTIVE

To study the outcome of delirium in elderly hip surgery patients.

DESIGN

Prospective matched controlled cohort study. Hip surgery patients (n = 112) aged 70 years and older, who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified using psychiatric interviews. Proportions of patients with dementia/MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during index hospitalization. Other outcomes were mortality rate and rate of institutionalization.

RESULTS

During the follow-up period, 54.9% of delirium patients had died compared to 34.1% of the controls (relative risk = 1.6, 95% CI = 1.0-2.6). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.9% of control patients (relative risk = 1.9, 95% CI = 1.1-3.3). Half of the patients with delirium were institutionalized at follow-up compared to 28.6% of the controls (relative risk = 1.8, 95% CI = 0.9-3.4).

CONCLUSION

The risk of dementia or MCI at follow-up is almost doubled in elderly hip surgery patients with postoperative delirium compared with at-risk patients without delirium. Delirium may indicate underlying dementia.

Delirium phenomenology: what can we learn from the symptoms of delirium?

OBJECTIVES

This review focuses on phenomenological studies of delirium, including subsyndromal and prodromal concepts, and their relevance to other elements of clinical profile.

METHODS

A Medline search using the keywords delirium, phenomenology, and symptoms for new data articles published in English between 1998 and 2008 was utilized. The search was supplemented by additional material not identified by Medline but known to the authors.

RESULTS

Understanding of prodromal and subsyndromal concepts is still in its infancy. The characteristic profile can differentiate delirium from other neuropsychiatric disorders. Clinical (motoric) subtyping holds potential but more consistent methods are needed. Studies are almost entirely cross-sectional in design and generally lack comprehensive symptom assessment. Multiple assessment tools are available but are oriented towards hyperactive features and few have demonstrated ability to distinguish delirium from dementia. There is insufficient evidence linking specific phenomenology with etiology, pathophysiology, management, course, and outcome.

CONCLUSIONS

Despite the major advancements of the past decade in many aspects of delirium research, further phenomenological work is crucial to targeting studies of causation, pathophysiology, treatment, and prognosis. We identified eight key areas for future studies.

Defining delirium for the International Classification of Diseases, 11th Revision

OBJECTIVE

The development of ICD-11 provides an opportunity to update the description of delirium according to emerging data that have added to our understanding of this complex neuropsychiatric syndrome.

METHOD

Synthetic article based on published work considered by the authors to be relevant to the definition of delirium.

RESULTS

The current DSM-IV definition of delirium is preferred to the ICD-10 because of its greater inclusivity. Evidence does not support major changes in the principal components of present definitions but a number of key issues for the updated definition were identified. These include better account of non-cognitive features, more guidance for rating contextual diagnostic items, clearer definition regarding the interface with dementia, and accounting for illness severity, clinical subtypes and course.

CONCLUSION

Development of the ICD definition of delirium can allow for more targeted research and clinical effort.

Misdiagnosed delirium in patient referrals to a university-based hospital psychiatry department

The authors examined the factors associated with referral errors in which the presence of delirium was ostensibly not recognized by medical staff personnel. Medical records of 541 university-hospital patients consecutively referred for psychiatric consultation were scrutinized for extant delirium. The data indicated that a greater likelihood of a missed diagnosis was associated with younger age; referrals outside of family practice service; orientation as to person, place, and time; and a history of bipolar affective disorder or psychosis. The ramifications of failure to diagnose existing delirium include increased morbidity and mortality, longer length of hospital stay, and increased healthcare costs.

One-year health care costs associated with delirium in the elderly population

BACKGROUND

While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium.

METHODS

Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics.

RESULTS

During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year.

CONCLUSIONS

The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.

WITHDRAWN: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus* . The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

AUTHORS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.