Association of low serum anticholinergic levels and cognitive impairment in elderly presurgical patients

Cognitive Dysfunction in Repeat Expansion Diseases: A Review

With the development of the sequencing technique, more than 40 repeat expansion diseases (REDs) have been identified during the past two decades. Moreover, the clinical features of these diseases show some commonality, and the nervous system, especially the cognitive function was affected in part by these diseases. However, the specific cognitive domains impaired in different diseases were inconsistent. Here, we survey literature on the cognitive consequences of the following disorders presenting cognitive dysfunction and summarizing the pathogenic genes, epidemiology, and different domains affected by these diseases. We found that the cognitive domains affected in neuronal intranuclear inclusion disease (NIID) were widespread including the executive function, memory, information processing speed, attention, visuospatial function, and language. Patients with C9ORF72-frontotemporal dementia (FTD) showed impairment in executive function, memory, language, and visuospatial function. While in Huntington's disease (HD), the executive function, memory, and information processing speed were affected, in the fragile X-associated tremor/ataxia syndrome (FXTAS), executive function, memory, information processing speed, and attention were impaired. Moreover, the spinocerebellar ataxias showed broad damage in almost all the cognitive domains except for the relatively intact language ability. Some other diseases with relatively rare clinical data also indicated cognitive dysfunction, such as myotonic dystrophy type 1 (DM1), progressive myoclonus epilepsy (PME), Friedreich ataxia (FRDA), Huntington disease like-2 (HDL2), and cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). We drew a cognitive function landscape of the related REDs that might provide an aspect for differential diagnosis through cognitive domains and effective non-specific interventions for these diseases.

Serum Anticholinergic Activity and Cognitive and Functional Adverse Outcomes in Older People: A Systematic Review and Meta-Analysis of the Literature

INTRODUCTION

Studies have reported associations between serum anticholinergic activity (SAA) and decline in cognitive performance, delirium, and functional impairment. The aim of this meta-analysis was to explore and quantify associations between SAA and adverse cognitive and functional outcomes in older people.

MATERIALS AND METHODS

A literature search in Ovid MEDLINE, EMBASE, PsycINFO and IPA from 1946-2014 was completed. The primary outcomes of interest were cognitive and functional adverse outcomes associated with SAA in older people aged 55 years and above. The Cochrane Risk-Bias assessment tool was used to assess bias in randomised controlled trials (RCTs). The Newcastle-Ottawa Scale was used to assess the quality of non-RCTs. Meta-analyses were conducted for RCTs and cohort studies separately. Heterogeneity was assessed using I2 tests.

RESULTS

The primary electronic literature search identified a total of 1559 records in the 4 different databases. On the basis of full-text analysis, 33 studies that met the inclusion criteria. The review included 4 RCTs, 5 prospective cohort studies, 3 longitudinal cohort studies, 17 cross-sectional studies, and 4 case-control studies. Twenty-four of the retrieved studies examined an association between SAA and cognitive outcomes, 2 studies examined an association with SAA and functional outcomes and 8 studies examined associations between SAA and both cognitive, and functional outcomes. The meta-analysis on 4 RCTs showed no association with higher SAA and cognitive performance (I2 = 89.38%, H2 = 25.53 and p-value = <0.05) however, the pooled data from 4 observational studies showed elevated SAA was associated with reduced cognitive performance (I2 = 0.00%, H2 = 3.37 and p-value = 0.34).

CONCLUSION

This systematic review summarises the limitations of the SAA on predicting cognitive and functional outcomes in older people. SAA measured by receptor bioassay is flawed and its use in older people with multimorbidity and polypharmacy is questionable.

Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses

Background

Delirium is a common condition in hospitalized seniors that nonetheless often goes undetected by nurses or is delayed in being detected which negatively impacts quality of care and outcomes. We sought to develop a new screening tool for delirium, The Sour Seven Questionnaire, a 7-item questionnaire suitable to be completed from informal or untrained caregiver observation. The study aimed to develop the scoring criteria for a positive delirium screen and assess concurrent validity of the questionnaire against a geriatric psychiatrist’s assessment.

Methods

A pilot study of 80 hospitalized seniors over age 65 recruited from three units (2 medical, 1 orthopedic). Participants were assessed using the Confusion Assessment Method (CAM) with a brief cognitive screen and the Sour Seven Questionnaire posed to the appointed informal caregiver (family member) or untrained nurse for up-to 7 days. Subjects testing positive on the CAM and a random sample of negatively CAM screened subjects were assessed by the geriatric psychiatrist.

Results

From 80 participants, 21 screened positive for delirium on the CAM. 18 of the 21 CAM positive screens were diagnosed to have delirium by the geriatric psychiatrist, and 17 of the 18 randomly assigned negative CAM screens were confirmed as not having delirium. From the questionnaires on these 39 participants, weighted scoring for each of the 7 questions of the Sour Seven Questionnaire was developed based on their relative risks for correctly predicting delirium when compared to the geriatric psychiatrist’s clinical assessment. Total scoring of the questionnaire resulted in the following positive predictive values for delirium: 89 % with a total score of 4 (sensitivity 89.5 %, specificity 90 %), and 100 % with a total score of 9 (sensitivity 63.2 %, specificity 100 %). Comparison between scoring on questionnaires posed to informal caregivers versus untrained nurses showed no differences.

Conclusion

A weighted score of 4 in the Sour Seven Questionnaire has concurrent validity as a screening tool for delirium and a score of 9 is diagnostic for delirium. The Sour Seven Questionnaire is the first screening tool for delirium shown to be suitable for use by informal caregivers and untrained nurses in hospitalized seniors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0217-2) contains supplementary material, which is available to authorized users.

Demonstrating the Role of Anticholinergic Activity in a Mood Disorder

We report a case of a 54-year-old woman presenting with amnesia, apathy, work-related difficulties and mental stress. At presentation, her Mini-Mental State Examination score was 27 and her serum anticholinergic activity (SAA) was positive without medication or recent physical illnesses. In addition, magnetic resonance imaging revealed mild atrophy of the frontal and temporal lobes, with a relatively intact hippocampus. Consequently, we diagnosed mild cognitive impairment due to Alzheimer's disease and prescribed a cholinesterase inhibitor (donepezil, 10 mg/day); her SAA fully disappeared and clinical symptoms partially resolved. Addition of duloxetine coupled with environmental adjustments caused her cognitive function to return to a normal level, so we diagnosed pseudodementia due to depression. In this case, we believe that the simultaneous cholinergic burden and mental stress led to positive SAA, which made it reasonable to prescribe a cholinesterase inhibitor to ameliorate the associated acetylcholine hypoactivity. We believe that it is essential to recognize the importance of prescribing a cholinesterase inhibitor for specific patients, even those with pseudodementia, to control their clinical symptoms. Moreover, SAA might be a useful biomarker for identifying this subgroup of patients. We propose that anticholinergic activity appears endogenously in mood disorders (depression and bipolar disorder) and set out our rationalization for this hypothesis.

Serum anticholinergic activity: a possible peripheral marker of the anticholinergic burden in the central nervous system in Alzheimer's disease

We review the utility of serum anticholinergic activity (SAA) as a peripheral marker of anticholinergic activity (AA) in the central nervous system (CAA). We hypothesize that the compensatory mechanisms of the cholinergic system do not contribute to SAA if their system is intact and that if central cholinergic system deteriorates alone in conditions such as Alzheimer's disease or Lewy body dementia, CAA and SAA are caused by way of hyperactivity of inflammatory system and SAA is a marker of the anticholinergic burden in CNS. Taking into account the diurnal variations in the plasma levels of corticosteroids, which are thought to affect SAA, it should be measured at noon or just afterward.

Longitudinal assessment of serum anticholinergic activity in delirium of the elderly

BACKGROUND

Delirium, a frequently occurring, devastating disease, is often underdiagnosed, especially in dementia. Serum anticholinergic activity (SAA) was proposed as a disease marker as it may reflect delirium's important pathogenetic mechanism, cholinergic deficiency. We assessed the association of serum anticholinergic activity with delirium and its risk factors in a longitudinal study on elderly hip fracture patients.

METHOD

Consecutive elderly patients admitted for hip fracture surgery (n = 142) were assessed longitudinally for delirium, risk factors, and serum markers (IL-6, cortisol, and SAA). Using a sophisticated statistical design, we evaluated the association between SAA and delirium in general and with adjustments, but also the temporal course, including the events fracture, surgery, and potential delirium, individual confounders, and a propensity score.

RESULTS

Among elderly hip fracture patients 51% developed delirium, these showed more risk factors (p < 0.001), and complications (p < 0.05). Uncontrolled SAA levels (463 samples) were significantly higher in the delirium group (4.2 vs. 3.4 pmol/ml) and increased with delirium onset, but risk factors absorbed the effect. Using mixed-modeling we found a significant increase in SAA concentration (7.6% (95%CI 5.0-10.2, p < 0.001)) per day, which was modified by surgery and delirium, but this effect was confounded by cognitive impairment and IL-6 values. Confounder control by propensity scores resulted in a disappearance of delirium-induced SAA increase.

CONCLUSIONS

Delirium-predisposing factors are closely associated with changes in the temporal profile of serum anticholinergic activity and thus neutralize the previously documented association between higher SAA levels and delirium. An independent relationship of SAA to delirium presence is highly questionable.

Prescribing Practices of Anticholinergic Medications and Their Association With Cognition in an Extended Care Setting

The current study examined prescribing patterns of anticholinergic (AC) medications and their association with cognitive function in 450 nondemented and nondelirious older adults hospitalized in a postacute extended care center. Participants completed a brief neuropsychological battery that included measures of general mental status, memory, judgment, and executive functioning as part of standard clinical care. An AC burden score was calculated for each participant based on medications taken the day of the testing using the Anticholinergic Drug Scale. Although use of AC medications was common, the majority of participants were taking medications with only minimal AC properties. AC burden and total number of AC medications were negatively correlated with age. AC burden was not associated with lower performance on any of the cognitive measures. In sum, current prescribing practices of AC medications are not associated with negative cognitive effects in a sample of older adults hospitalized in an extended care center.

Delirium scales: A review of current evidence

OBJECTIVES

Delirium is a common neuropsychiatric condition with many adverse outcomes in elderly populations including death. Despite this, it is often misdiagnosed and mistreated. A number of scales can be used to detect delirium. We review scales that have been used in delirium studies and report their psychometric properties.

METHOD

An extensive MEDLINE database search and subsequent examination of reference lists was conducted to identify the various delirium scales that have been designed, primarily for use in the elderly.

RESULTS

Twenty-four scales were identified. Delirium instruments differed according to the classification system they were based on, length of time to administer, the rater and whether they were screening scales or measured symptom severity. The psychometric properties of each scale is reported.

CONCLUSION

A large number of scales exist, but not all are properly evaluated in terms of psychometric properties, and there is not unanimity about which scale is the best. However, a small number of scales may be considered already to be robust and useable: the CAM, the DRS, the MDAS and the NEECHAM.

Anticholinergic activity of commonly prescribed medications and neuropsychiatric adverse events in older people

This study sought to determine whether the presence of in vitro anticholinergic activity (AA) among different drugs is associated with reporting of neuropsychiatric adverse events (NPAEs) and whether age affects this relationship. Retrospective case/noncase analyses using Australia's spontaneous Adverse Drug Reaction System (ADRS) database containing 150 475 reports determined crude and adjusted reporting odds ratios (RORs) for NPAEs for 23 drugs with various reported in vitro AA. Covariates were age (treated as a dichotomous variable [> or =65 years]), gender, and concomitant use of antipsychotics, benzodiazepines, tricyclic antidepressants, and drugs with recognized inherent anticholinergic properties (anticholinergic drugs). The interaction effect between these covariates and each drug exposure category was examined. Age (> or =65 years) has a significant association with greater odds relative to younger age for reporting NPAEs. Drugs with reported significant AA in vitro were not always associated with RORs greater than 1 for reporting NPAEs, highlighting a dissonance between the in vitro AA index and ADRS observations. Significant interactions were observed between age (> or =65 years) and exposure to cimetidine, anticholinergic drugs, antipsychotics, and tricyclic antidepressants in modifying odds for reporting NPAEs, reinforcing the need for cautious use and monitoring of drugs with AA in older people.

The cognitive impact of anticholinergics: a clinical review

Context:

The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes.

Objective:

Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults.

Data sources:

We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies.

Study selection:

Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles.

Data extraction:

We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes.

Results:

Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia.

Conclusions:

Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.

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.

Serum anticholinergic activity and cerebral cholinergic dysfunction: an EEG study in frail elderly with and without delirium

Background

Delirium increases morbidity, mortality and healthcare costs especially in the elderly. Serum anticholinergic activity (SAA) is a suggested biomarker for anticholinergic burden and delirium risk, but the association with cerebral cholinergic function remains unclear. To clarify this relationship, we prospectively assessed the correlation of SAA with quantitative electroencephalography (qEEG) power, delirium occurrence, functional and cognitive measures in a cross-sectional sample of acutely hospitalized elderly (> 80 y) with high dementia and delirium prevalence.

Methods

61 consecutively admitted patients over 80 years underwent an extensive clinical and neuropsychological evaluation. SAA was determined by using radio receptor assay as developed by Tune, and standard as well as quantitative EEGs were obtained.

Results

15 patients had dementia with additional delirium (DD) according to expert consensus using DSM-IV criteria, 31 suffered from dementia without delirium (D), 15 were cognitively unimpaired (CU). SAA was clearly detectable in all patients but one (mean 10.9 ± 7.1 pmol/ml), but was not associated with expert-panel approved delirium diagnosis or cognitive functions. Delirium-associated EEG abnormalities included occipital slowing, peak power and alpha decrease, delta and theta power increase and slow wave ratio increase during active delirious states. EEG measures correlated significantly with cognitive performance and delirium severity, but not with SAA levels.

Conclusion

In elderly with acute disease, EEG parameters reliable indicate delirium, but SAA does not seem to reflect cerebral cholinergic function as measured by EEG and is not related to delirium diagnosis.

Delirium detection in clinical practice and research: critique of current tools and suggestions for future development

Delirium is underrecognized clinically. Many tools have been developed to assist with the diagnosis of delirium, and they vary greatly in purpose, quality, and administration time. It is suggested that future development of delirium assessment instruments be guided by a dichotomization of raters into expert and nonexpert groups. Careful consideration of the needs of the two groups suggests that assessment instruments designed for nonexperts should be entirely objective, whereas those instruments developed for experts should include the full range of constructs associated with the syndrome. This conceptualization is explored in detail, and existing assessment instruments are considered briefly in light of this position.

Pathophysiology of delirium in the intensive care unit

Delirium, or acute brain dysfunction, is a life-threatening global disturbance in cognitive functioning that frequently manifests in critically ill patients. This review examines the current status of knowledge regarding the pathophysiology of delirium in the ICU, in particular, evaluating the role of iatrogenic factors such as sedatives and analgesic administration in brain dysfunction. This hypothesis is considered along with several other plausible mechanisms of ICU delirium, including sepsis, postoperative cognitive dysfunction, and changes in biomarkers and neurotransmitters. The review concludes by highlighting potential future directions in molecular genetics for the elucidation of delirium and its long-term consequences.

EEG changes and serum anticholinergic activity measured in patients with delirium in the intensive care unit

The aim of this study was to examine whether serum anticholinergic activity (SAA) is a reliable indicator of delirium in the ICU, and whether there is a significant correlation between SAA and quantitative electroencephalographic (EEG) data in delirious patients. In a prospective cohort study, we assessed ICU patients diagnosed with delirium (n = 37). EEG measurements and blood analysis including SAA were performed 48 h following ICU admission. The presence of delirium was evaluated using the Confusion Assessment Method for critically ill patients in ICU (CAM-ICU). The SAA level was measured using a competitive radioreceptor binding assay for muscarinergic receptors and quantitative EEG was measured using the CATEEM system. We found that, under comparable conditions, patients in the delirium group showed a higher relative EEG theta power and a reduced alpha power (n = 17) than did the non-delirious patients (n = 20). No difference in measured SAA levels were seen; therefore, there was no correlation between SAA and EEG measurements in delirious patients. We conclude that, in contrast to the EEG, the SAA level cannot be proposed as a tool for diagnosing delirium in ICU patients.

Serum anticholinergic activity and motor performance in elderly persons

BACKGROUND

Medications prescribed to elderly persons often have an anticholinergic effect, as do many commonly used over-the-counter drugs. Anticholinergic medications are known to produce psychomotor slowing, especially in older persons.

METHODS

The present study examined whether the cumulative anticholinergic load present in the serum of community volunteers was associated with decrements on tests of psychomotor performance (gait speed and simple manual response time) known to predict falls in elderly persons.

RESULTS

Serum anticholinergic activity (SAA) was relatively low in this group; however, an elevated SAA was associated with a significant slowing in both gait speed and simple response time.

CONCLUSION

Cumulative anticholinergic burden may be one of the factors contributing to an increased risk of falls in the older population.

Significant correlation between plasma and CSF anticholinergic activity in presurgical patients

Previous studies have suggested a possible link between cognitive impairment and anticholinergic burden as reflected by high serum anticholinergic activity (SAA). Thus, we hypothesized a close relationship between anticholinergic activity in cerebral spinal fluid (CSF) and blood. However, it has never been convincingly demonstrated that peripheral anticholinergic activity correlates with central anticholinergic levels in presurgical patients. Therefore, anticholinergic activity was measured in blood and CSF from 15 patients with admission scheduled for urological surgery to compare peripheral and central anticholinergic level. Blood and CSF probes were taken after routine premedication and before spinal anesthesia. Anticholinergic activity was determined by competitive radioreceptor binding assay for muscarinergic receptors. Correlation analysis was conducted for peripheral and central anticholinergic levels. The mean anticholinergic levels were 2.4+/-1.7 in the patients' blood and 5.9+/-2.1 pmol/mL of atropine equivalents in CSF. Interestingly, the anticholinergic activity in CSF was about 2.5-fold higher than in patients' blood. A significant linear correlation was detected between blood and CSF levels. Therefore we conclude that SAA levels adequately reflect central anticholinergic activity. When patients receiving or not receiving anticholinergic medication were compared, anticholinergic activity tended to increase in blood and CSF after receiving anticholinergic medication > or =4 weeks (p>0.05).

A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement

OBJECTIVES

This was a pilot, phase 2a study to assess methodological feasibility and the safety and efficacy of donepezil in preventing postoperative delirium after elective total hip replacement surgery in older people without pre-existing dementia. The hypothesis was that donepezil would reduce the incidence of postoperative delirium.

METHODS

A double blind, placebo controlled, parallel group randomized trial was undertaken. Patients were block randomized pre-operatively to receive placebo or donepezil 5 mg immediately following surgery and every 24 h thereafter for a further three days. The main outcome was the incidence of delirium (using the Delirium Symptom Interview). The secondary outcome was length of hospital stay.

RESULTS

Thirty-three patients (mean age 67 years; 17 males, 16 females) completed the study (19 donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p = 0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1 days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78) (t([31]) = 1.73: p = 0.09).

CONCLUSIONS

The experimental paradigm was feasible and acceptable. Donepezil did not significantly reduce the incidence of delirium or length of hospital stay, however for both outcomes there was a consistent trend suggesting possible benefit. The sample size required for a definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.

Evaluation of the memorial delirium assessment scale (MDAS) for the screening of delirium by means of simulated cases by palliative care health professionals

BACKGROUND

Delirium is among the most common neuropsychiatric complications of advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a widely used and validated screening tool for delirium in cancer patients.

OBJECTIVE

The purpose of this study was to assess the use of the MDAS by different palliative care health professionals after receiving formal training and a guiding manual for administration and scoring.

MATERIALS AND METHODS

Thirty-one palliative care health professionals received a training session on the MDAS, including description of the tool, validation, and scoring. Participants also received copies of a proposed standardized manual for completion of the MDAS. Two of the investigators presented three simulated cases to the participants, who independently completed a scoring sheet for each case. The data were then analyzed according to the cases and the profession of the operators.

RESULTS

Thirty-one scoring sheets were analyzed (11 physicians, 12 nurses, and 8 others). A correct diagnosis was achieved by 30 (96.8%) of the 31 participants in case 1 (nondelirious, true score = 5, median = 5, range = 2-15), 28 of 31 (90.3%) in case 2 (severe mixed delirium, true score = 20, median = 18, range = 10-26), and 31 of 31 in case 3 (mild hypoactive delirium, true score = 14, median = 19, range = 13-25). Overall percentage of error was 31% for items 2, 3, and 4 (cognitive) and 45% for all other items (observational) (p < 0.001). The percentage of error did not differ between physicians and nurses and other palliative care professionals (p > 0.99).

CONCLUSIONS

Our preliminary results suggest that adequate training and a guiding manual can enhance the application of MDAS by palliative care health professionals in the teaching settings. Clinical studies to assess the utility of the MDAS as a screening tool are justified to further confirm these findings.

A model of anticholinergic activity of atypical antipsychotic medications

BACKGROUND

Atypical antipsychotics clozapine, olanzapine, and quetiapine have significant affinity for the muscarinic receptors in vitro, while aripiprazole, risperidone, and ziprasidone do not. Dissimilarity in binding profiles may contribute to the reported differences in the anticholinergic effects of these antipsychotics. However, it is difficult with the available data to predict the likelihood of anticholinergic effects occurring with various doses of an atypical antipsychotic.

METHODS

We developed a model to assess the potential anticholinergic activity (AA) of atypical antipsychotics at therapeutic doses. A radioreceptor assay was used to measure in vitro AA at 6 clinically relevant concentrations of aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone. Using published pharmacokinetic data, in combination with the measured in vitro AA, dose-AA curves were generated.

RESULTS

Clozapine, and to a lesser extent olanzapine and quetiapine showed dose-dependent increases in AA. At therapeutic doses, the AA (in pmol/mL of atropine equivalents) was estimated to range from 27-250, 1-15, and 0-5.4 pmol/mL for clozapine, olanzapine, and quetiapine, respectively. Aripiprazole, risperidone, and ziprasidone did not demonstrate AA at any of the concentrations studied.

CONCLUSIONS

Therapeutic doses of clozapine, olanzapine, and, to a lesser extent, quetiapine are associated with clinically relevant AA.

Delirium subtype identification and the validation of the Delirium Rating Scale--Revised-98 (Dutch version) in hospitalized elderly patients

BACKGROUND

Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. The Dutch version of the Delirium Rating Scale-Revised-98 (DRS-R-98) appears to be a reliable method to classify delirium. The aim of this study was to determine the validity and reliability of the DRS-R-98 and to study clinical subtypes of delirium using the DRS-R-98.

METHODS

Patients received the Dutch version of the DRS-R-98, the Mini-Mental State Examination, the Confusion Assessment Method, and a clinical diagnosis of delirium according to DSM-IV criteria, and their relatives the Informant Questionnaire Cognitive Decline in the Elderly.

RESULTS

The DRS-R-98 validation cohort (n=65) consisted of 23 patients with delirium, 22 patients with dementia, and 20 non-psychiatric comparison patients. For the delirium subtype study, a second cohort comprising 54 delirious patients was investigated. Median DRS-R-98 scores significantly distinguished delirium from dementia and no psychiatric disorder. Inter-rater reliability (intra-class correlation 0.97) and internal consistency (Crohnbach's alpha 0.94) were high. Positive scores of DRS-R-98 item 4 (affect liability) and item 7 (motor agitation) predicted the presence of non-hypoactive delirium, with a specificity of 89% and a sensitivity of 57%.

CONCLUSION

The results show that the Dutch version of the DRS-R-98 is a valid and reliable measure of delirium severity and distinguishes patients with delirium from patients with dementia and comparison patients. Furthermore, the DRS-R-98 is able to exclude hypoactive delirium.

Methods for Assessing Drug-Related Anticholinergic Activity

The geriatric population is a large consumer of both prescription and over-the-counter drugs. Positive outcomes from drugs depend on the delicate interplay between therapeutic and adverse effects. This relationship becomes tortuous with simultaneous administration of several drugs. Numerous concomitant drug therapies may be essential for providing quality patient care but may also increase the possibility of an adverse drug event. Increasing sensitivity to drug effects in the geriatric population also creates concern over adverse effects. Drugs that possess anticholinergic properties are especially worrisome, as these properties may manifest as hazardous physiologic and psychological adverse drug events. Consequently, clinicians strive to minimize total drug exposure to agents possessing anticholinergic properties in elderly patients. A review of the literature revealed four methods that might help clinicians systematically reduce or eliminate potentially offending anticholinergic drugs. Each of the four has merits and limitations, with no ideal evidence-based approach used. Three of the four methods described have research utility; however, only one of the methods is clinically useful.

Inter-Rater Reliability of Delirium Rating Scales

Delirium continues to be under-recognized despite use of rating scales with apparently high inter-rater reliability. We analyzed the inter-reliability data of published rating scales for delirium using a standard questionnaire to evaluate if the inter-rater reliability was assessed rigorously. Most studies employed a heterogeneous group of cognitively disordered elderly, however other aspects of inter-rater reliability estimation were less than rigorous. This suggests that the reported reliability may be spuriously high, which may have implications on the ability of clinicians to discriminate delirium from other causes of cognitive impairment in practice. The methodology of assessing inter-rater reliability of delirium scales needs to improve and reliability should be evaluated when the settings of administration change substantially.

Drugs with anticholinergic properties and cognitive performance in the elderly: results from the PAQUID Study

OBJECTIVES

To measure the association between the use of drugs with anticholinergic properties and cognitive performance in an elderly population, the PAQUID cohort.

METHODS

The sample studied was composed of 1780 subjects aged 70 and older, living at home in South western France. Data on socio-demographic characteristics, medical history and drug use were collected using a standardized questionnaire. Cognitive performance was assessed using the following neuropsychological tests: the Mini-Mental State Examination (MMSE) which evaluates global cognitive functioning, the Benton Visual Retention Test (BVRT) which assesses immediate visual memory, and the Isaacs' Set Test (IST) which assesses verbal fluency. For each test, scores were dichotomized between low performance and normal to high performance using the score at the 10th percentile of the study sample as the cut-off point, according to age, gender and educational level. The association between the use of drugs with anticholinergic properties and cognitive performance was examined using logistic regression models, adjusting for several potential confounding factors.

RESULTS

About 13.7% of the subjects used at least one drug with anticholinergic properties. In multivariate analyses, the use of these drugs was significantly associated with low performance in the BVRT [odds ratio (OR) = 1.6; 95% confidence interval (CI) 1.1, 2.3] and in the IST (OR = 1.9; 95% CI 1.3, 2.8). The association found with low performance in the MMSE (OR = 1.4; 95% CI 1.0, 2.1) was barely statistically significant.

CONCLUSION

These findings suggest that the use of drugs with anticholinergic properties is associated with low cognitive performance among community-dwelling elderly people.

Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research

The most commonly encountered clinical conditions presenting with cognitive failure (CF) are delirium, dementia and amnestic disorders. Of these, delirium is probably the most prevalent in palliative care, and it is potentially reversible. Thus, improvement in diagnostics seems warranted. The objectives of this review were to examine the methods for assessment of CF and delirium in palliative care. Twenty-two studies were reviewed: 64% were published in 2000 or later. Twelve reports focused on delirium, six on CF, while the remaining four assessed confusion (2), hallucinations and general psychological morbidity. Median sample size was 100 (20393). Ten different instruments were used: The Mini Mental State Exam was used in 13 studies. Five studies were validation reports of new or existing instruments. The term CF is an imprecise description of a loss in one or more of the cognitive functions. The interchangeable use of CF as a description of specific diagnoses should be avoided, as this contributes to prevalence rates that are not representative. Assessment tools that discriminate between the different diagnostic entities presenting with CF should be used in future studies.

Anaesthesia in Elderly Patients with Neurodegenerative Disorders

Neurodegenerative diseases are increasingly common in elderly patients, who present a particular anaesthetic challenge. The majority of people over the age of 70 years have some degree of cerebral atrophy. The pathogenesis of neurodegenerative diseases is due to alterations in the transport, degradation and aggregation of proteins. Alterations in physiology that occur with advancing age affect both the pharmacokinetics and pharmacodynamics of drugs used in the elderly. Changes in pharmacokinetics result in either increased or reduced drug concentrations depending on the variable contributions of absorption, metabolism and elimination. The distribution of a drug depends on its protein binding, cardiac output and blood volume, which are all altered in the elderly. Metabolism and excretion of drugs are also affected due to changes in hepatic and renal mass and blood flow in the elderly. A number of drugs are used in neurodegenerative disorders including antidepressants, benzodiazepines, antipsychotics, acetylcholinesterase inhibitors and levodopa. Polypharmacy is a common problem, which can lead to adverse drug interactions and an exacerbation of dementia. Levodopa, bromocriptine and tricyclic antidepressants are known to cause orthostatic hypotension in patients with neurodegenerative disease. Elderly patients are liable to excessive sedation from benzodiazepines in both the pre- and postoperative period; therefore these drugs should be prescribed in low doses. For induction of general anaesthesia propofol is a suitable agent in patients with neurodegenerative disease due to its rapid metabolism, but may not be suitable in patients with Parkinson's disease as it can induce spontaneous involuntary movements. Volatile inhalational agents should be administered carefully in the elderly, as they are more sensitive to the depressant cerebral and cardiovascular effects. Levodopa should be avoided in conjunction with halothane, which sensitises the heart to catecholamines. Co-administration of monoamine oxidase inhibitors and opioids should be avoided as it can cause agitation, muscular rigidity, sweating and hyperpyrexia. If an anticholinergic agent is required, then glycopyrronium bromide is the drug of choice in this group of patients, as it does not cross the blood brain barrier. Patients should continue to take their usual medications in hospital and do not let the change in routine alter the times at which treatments are administered. This is particularly relevant to the timing of levodopa in Parkinson's disease, as missed treatment can be detrimental. Regional anaesthesia may, however, have significant advantages in patients with Parkinson's disease, who can continue to take oral levodopa preoperatively, during surgery, if required, and early in the postoperative period. Anti-emetic drugs such as phenothiazines, butyrophenones and metoclopramide should be used carefully in the postoperative period in these patients as their antidopaminergic effects may induce or exacerbate parkinsonian effects.

Predicting post-surgical cognitive disturbance in older Taiwanese patients

The purpose of this study was to test a theoretical model to understand the influences of six predicting variables in post-surgical cognitive disturbance in older Taiwanese patients after elective surgery. The data were collected in a medical center in Taipei, Taiwan. Ninety-three patients were included in the final analysis. The findings showed that cognitive function at admission (beta=0.50, p<0.001), physical function at admission (beta=-0.34, p<0.001), and physiological stability (beta=-0.21, p<0.01) had direct effects on post-surgical cognitive disturbance. Physical function and cognitive function at admission also affected post-surgical cognitive disturbance indirectly through physiological stability. These variables accounted for 67% of the total variance of post-surgical cognitive disturbance. The findings from this study suggest that a careful and systematic assessment of the patient's condition at the time of admission is important. It is necessary to monitor and correct these variables at admission or before surgery to prevent or reduce the impact of post-operative delirium. It is also necessary to monitor these variables during the hospital stay to help nurses to distinguish the etiology of delirium. In each case, knowing when confusion is more likely to occur can assist in focusing more appropriate and effective efforts at detection, thereby reducing the consequences associated with confusion.

Recovery of elderly patients from two or more hours of desflurane or sevoflurane anaesthesia †

BACKGROUND

The solubility of desflurane compared with sevoflurane suggests more rapid recovery from desflurane anaesthesia. This could be important after prolonged anaesthesia and fast recovery may be advantageous in the elderly where slow recovery of mental function is a concern. We compared emergence from desflurane vs sevoflurane in elderly patients undergoing two or more hours of anaesthesia.

METHODS

Fifty ASA physical status I, II, or III patients, 65 yr of age or older, undergoing anaesthesia expected to last two or more hours were randomly assigned to receive desflurane/nitrous oxide or sevoflurane/nitrous oxide anaesthesia. Patients were given 1-2 microg x kg(-1) fentanyl i.v. and anaesthesia was induced with propofol 1.5-2.5 mg x kg(-1) i.v. and maintained with either desflurane 2-6% or sevoflurane 0.6-1.75% with nitrous oxide 65% in oxygen. Inspired anaesthetic concentrations were adjusted to obtain adequate surgical anaesthesia and to maintain mean arterial pressure within 20% of baseline values. Early and intermediate recovery times were recorded. Digit-Symbol Substitution Test (DSST) scores and Visual Analog Scale (VAS) scores for pain and nausea were recorded before pre-medication and every 15 min in the Post Anaesthesia Care Unit (PACU) until patients were discharged.

RESULTS

Early recovery times are given as median, quartiles. The times to extubation (5 (4-9); 9 (5-13) min), eye opening (5 (3-5); 11 (8-16) min), squeezing fingers on command (7 (4-9); 12 (8-17) min); and orientation (7 (5-9); 16 (10-21) min) were significantly less (P<0.05) for desflurane than for sevoflurane. Intermediate recovery, as measured by the DSST and time to ready for discharge from the PACU (56 (35-81); 71 (61-81) min) was similar in the two groups.

CONCLUSIONS

Early but not intermediate recovery times of elderly patients undergoing a wide range of surgical procedures requiring two or more hours of anaesthesia is significantly (P<or=0.05) faster after desflurane.

Drug interactions with cholinesterase inhibitors

Cholinesterase inhibitors are used for the symptomatic treatment of patients with Alzheimer's disease. This population often has numerous comorbidities and receives treatment with multiple medications. The astute clinician should remain mindful of possible drug interactions, both pharmacokinetic and pharmacodynamic, that may occur with concomitant treatment. Although pharmacokinetic interactions have been reported, pharmacodynamic interactions play a far greater role in the significance of drug interactions, with anticholinergic medications being most concerning. Commonly prescribed medications, such as antihistamines and tricyclic antidepressants, often have anticholinergic properties that alone or in combination with one another can antagonise the effects of cholinesterase inhibitors. Other medication classes such as antipsychotics and cholinergic agents may also result in pharmacodynamic interactions. However, for the most part, cholinesterase inhibitors can be used safely in combination with other medications.

Cognitive function after anaesthesia in the elderly

Despite advances in peri operative care, a significant percentage of elderly patients experience transient post operative delirium and/or long-term post-operative cognitive dysfunction (POCD). This chapter reviews the aetiology, clinical features, preventive strategies and treatment of these syndromes. Pre-operative, intra-operative, and post-operative risk factors for delirium and POCD following cardiac and non-cardiac surgery are discussed. It is most likely that the aetiology of delirium and POCD is multifactorial and may include factors such as age, decreased pre-operative cognitive function, general health status and, possibly, intra-operative events. Currently there is no single therapy that can be recommended for treating post-operative cognitive deterioration. Primary prevention of delirium and POCD is probably the most effective treatment strategy. Several large clinical trials show the effectiveness of multicomponent intervention protocols that are designed to target well-documented risk factors in order to reduce the incidence of post-operative delirium and, possibly, POCD in the elderly.

Anesthesia with ketamine, propofol, and fentanyl decreases the frequency of postoperative psychosis emergence and confusion in schizophrenic patients

STUDY OBJECTIVE

To investigate whether total IV anesthesia with ketamine, propofol, and fentanyl affects the frequency of postoperative psychosis emergence or confusion in schizophrenic patients.

DESIGN

Prospective, controlled study.

SETTING

Hirosaki National Hospital and Hakodate Watanabe Hospital.

PATIENTS

76 ASA physical status I and II schizophrenic patients taking chronic antipsychotic drugs and schedule for orthopedic surgery of extremities.

INTERVENTIONS

In Group A (n = 38) patients, anesthesia was maintained with sevoflurane, nitrous oxide, and fentanyl. In Group B (n = 38) patients, anesthesia was maintained with ketamine, propofol, and fentanyl.

MEASUREMENTS AND MAIN RESULTS

The frequency of psychosis emergence or confusion (54%) in Group A during the first 48 hours after surgery was significantly higher than the 30% figure in Group B.

CONCLUSION

Ketamine, when combined with propofol and fentanyl, is an appropriate anesthetic drug for schizophrenic patients.

The recovery of cognitive function after general anesthesia in elderly patients: a comparison of desflurane and sevoflurane

We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I-III consenting elderly patients (> or =65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%-4% or sevoflurane 1%-1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 +/- 0.6 MAC. h) and sevoflurane (2.7 +/- 0.5 MAC. h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 +/- 2.4 min versus 8.0 +/- 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 +/- 66 min versus 241 +/- 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 +/- 1.7 versus 29.5 +/- 0.5 in the Desflurane group, and 27.4 +/- 1.7 versus 29.2 +/- 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia.

IMPLICATIONS

Desflurane was associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar with both volatile anesthetics.

Psychiatric dimensions of palliative care

A critically important aspect of palliative care is the prompt recognition and effective treatment of psychiatric complications. Psychiatric syndromes such as depression, anxiety, confusion, suicidal ideation, and wish for hastened death or assisted-suicide occur in a significant percentage of patients with advanced illness. This article reviews their frequency, diagnosis, associated factors, and management to help expand the focus of palliative care beyond pain and physical symptom control.

Postoperative delirium and melatonin levels in elderly patients

BACKGROUND

Melatonin, a hormone produced in the pineal gland, is involved in circadian rhythms and the sleep-wake cycle. Postoperative delirium is encountered frequently in elderly patients after major surgery; whether changes in the pattern of melatonin secretion are associated is unclear.

METHODS

Plasma samples were obtained every 2 hours from 19 patients without delirium and 10 with delirium after major abdominal surgery. Postoperative delirium was determined using the Confusion Assessment Method in the Practice Guideline of the American Psychiatric Association.

RESULTS

All patients without delirium showed nearly identical preoperative and postoperative melatonin secretion for 24 hours, although peak values were significantly lower in patients more than 80 years old (7.2 +/- 2.3 pg/mL) than in patients younger than 80 years (24.4 +/- 4.1 pg/mL, P = 0.022). Patients with delirium showed two different abnormal postoperative patterns: in 5 patients without complications, melatonin levels were lower than preoperative values (11.0 +/- 5.8 versus 6.5 +/- 4.2 pg/mL, P = 0.079); and in 5 patients with complications, melatonin levels were markedly increased (21.1 +/- 4.5 versus 58.8 +/- 12.4 pg/mL, P = 0.043).

CONCLUSIONS

Abnormal melatonin secretion may be involved in postoperative sleep disturbances, which triggered delirium in elderly patients.

Delirium in the terminally ill

Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.

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

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

A comparison of subcutaneous morphine and fentanyl in hospice cancer patients

This study compares subcutaneous (s.c.) morphine and fentanyl with respect to pain control and side effects using a 6-day randomized, double-blind, cross-over design. Results were obtained from 23 patients (12 males and 11 females: mean age of 70.5 years) who could tolerate morphine. Thirteen patients were randomized to receive morphine for the first 3 days followed by fentanyl; 10 received fentanyl first followed by morphine. There were no significant differences in the scores for pain between the two drugs, suggesting that fentanyl is equally efficacious and the conversion ratio of morphine 10 mg: fentanyl 150 micrograms is appropriate. Patients had more frequent bowel movements during days 4-6 while on the fentanyl arm [t-test, df (22), P = 0.015]. Other measures for nausea, delirium, and cognitive function showed no differences between the two drugs. This study highlights the need to further assess the role of various opioids in hospice patients, and emphasizes the requirement for sensitive and simple cognitive tests in this population.

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

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

Pathophysiology of delirium

Hypotheses about the pathophysiology of delirium are speculative and largely based on animal research. According to the neurotransmitter hypothesis, decreased oxidative metabolism in the brain causes cerebral dysfunction due to abnormalities of various neurotransmitter systems. Reduced cholinergic function, excess release of dopamine, norepinephrine, and glutamate, and both decreased and increased serotonergic and gamma-aminobutyric acid activity may underlie the different symptoms and clinical presentations of delirium. According to the inflammatory hypothesis, increased cerebral secretion of cytokines due to a wide range of physically stressful events plays an important role in the occurrence of delirium. Since cytokines can influence the activity of various neurotransmitter systems, these mechanisms may interact. Also, more fundamental processes like intraneuronal signal transduction, second messenger systems that at the same time use neurotransmitters as first messengers and play an important role in their synthesis and release, may be disturbed. Furthermore, severe illness and physiologic stress may give rise to modification of blood-brain barrier permeability, the sick euthyroid syndrome with abnormalities of thyroid hormone concentrations, and increased activity of the hypothalamic-pituitary-adrenal axis. These circumstances possibly also contribute to changes in neurotransmitter synthesis and release of cytokines in the brain, and consequently to the occurrence of delirium. Elderly patients are more at risk for developing delirium,very likely due to age-related cerebral changes in stress-regulating neurotransmitter and intracellular signal transduction systems. This paper will expand upon these current theories and discuss their applicability to research and clinical work with elderly patients suffering from delirium.

The Memorial Delirium Assessment Scale

We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinician's ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinician's global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.

Delirium and cognitive disorders after cardiac operations: relationship to pre- and intraoperative quantitative electroencephalogram

We examined the incidence of delirium and cognitive disorders after cardiac operations and the related risk factors. The value of pre- and intraoperative QEEG was determined. Using the Mini-Mental State Examination and the Saskatoon Delirium Checklist, 321 patients were tested during the immediate postoperative period. Forty-four patients (14%) showed delirium, 68 (23%) cognitive disorders and 26 (9%) both. Significant risk factors for the development of cognitive disorders were age > or = 70 yr, female gender, duration of cardiopulmonary bypass > or = 2.5 h and aorta-cross-clamping > 70 min. Risk factors for delirium were age > or = 70 yr, female gender and Hb < 5 mmol 1(-1) intraoperatively. The preoperative QEEG showed significant differences between the groups with and without a cognitive disorder, while the intraoperative QEEG showed significant differences between the groups with and without delirium. Different risk factors for delirium and cognitive disorders are a possible explanation for the controversies in the literature, where neuropsychologic complications were grouped together. A low intraoperative Hb is an important risk factor for the development of delirium and can be treated. The preoperative QEEG may have prognostic significance in the occurrence of cognitive disorders, while the intraoperative QEEG may have prognostic significance in the occurrence of delirium.

Delirium. Advances in diagnosis, pathophysiology, and treatment

This article discusses research in the areas of morbidity and mortality, epidemiologic risk factors, phenomenology, pathophysiology, and treatment of delirium. Delirium assessment instruments are reviewed. The neuropathophysiologic understanding of delirium is discussed in the context of important CNS neural circuitry. Pharmacologic treatments of delirium in adults and children are outlined, with particular emphasis on intravenous use of butyrophenone neuroleptics.

Problems associated with underrecognition of delirium in critical care: a case study

Delirium, a syndrome that results in high morbidity and mortality rates in the elderly, continues to be underrecognized by physicians and nurses. Factors influencing the underrecognition of delirium are specific to individual institutions and their health care providers. The factors leading to the underrecognition of delirium must be identified so that changes can be made to increase early recognition. A case study conducted in a critical care unit in a midwestern hospital from interviews of nurses, chart audit, and patient observation, identified two major problems associated with the lack of recognition of delirium in that institution: (1) lack of knowledge on the part of nurses about the criteria and methods of detecting delirium, and (2) ineffective communication between all staff members in relaying symptoms of onset of the disorder. As a result of this study, staff education, assessment protocols, and improved communication and documentation techniques are indicated as targeted methods for improving recognition and treatment of delirium in this setting. Similar case studies can be performed to evaluate institutional practice, and thereby identify barriers to early recognition of delirium.

The use of medicines with anticholinergic effects in older people: a population study in an urban area of Sweden

OBJECTIVE

To investigate the use of medicines with anticholinergic properties among older people in an urban population in Sweden.

DESIGN

A cross-sectional survey.

SETTING

Ordinary homes, sheltered accommodations, nursing homes, and geriatric departments.

PARTICIPANTS

All residents aged 75 and older in a district of Stockholm, Sweden.

MEASUREMENTS

Structured interviews with older persons, their relatives and/or health care personnel; prescription forms; medical records.

RESULTS

The overall use of medicines with anticholinergic effects was comparatively low. Doses of these medicines were also generally low. Concurrent use of several such medicines was uncommon. The most prevalent therapeutic/pharmacological group was neuroleptics. In contrast, antidepressants were used by few older people. The prevalence of medicines with anticholinergic effects was highest at institutions, where neuroleptics were frequent and use of low-potency neuroleptics was not uncommon.

CONCLUSION

Our results indicate that the risk of anticholinergic side effects may be quite low in the present population as a whole. However, there may be grounds for revising the therapy in institutions, where the use of neuroleptics was shown to be high and low-potency neuroleptics, known to have a higher incidence of anticholinergic side effects, were not avoided.