Relationship between symptoms and motoric subtype of delirium

For 46 patients with delirium who were consecutive referrals to a consultation-liaison psychiatry service, the authors describe the relationships between symptoms, as rated on the Delirium Rating Scale, and delirium motoric subtypes, as defined by Liptzin and Levkoff's criteria. Most cases were of the mixed subtype (46%), 24% were hypoactive, and 30% were hyperactive. Overall scores differed significantly among motoric subtype groups, being highest in the hyperactive, lowest in the hypoactive, and intermediate in the mixed. On item scores, the hypoactive group scored lower than the hyperactive group for delusions, mood lability, sleep-wake cycle disturbances, and variability of symptoms, but lower than the mixed group only for mood lability. The results suggest that delirium presents as motoric subtypes that differ according to symptom profile and severity of delirium. These subtypes may differ in their underlying pathophysiologies, responsiveness to therapeutic interventions, and outcome.     

Factor analysis supports the evidence of existing hyperactive and hypoactive subtypes of delirium

OBJECTIVE: The aim of this study was to examine whether delirium has specific clinical subtypes. METHOD: One hundred and eighty-three elderly subjects meeting DSM-IIIR criteria for delirium were evaluated using a 19-item symptom check-list assessing different dimensions of delirium symptomatology. Exploratory factor analysis was conducted in order to examine which symptoms clustered. RESULTS: Factor analysis confirmed the existence of two different clusters of symptoms: first, symptoms of hyperalert/hyperactive features (agitation, hyper-reactivity, aggressiveness, hallucinations, delusions); and second, symptoms of hypoalert/hypoactive features (decreased reactivity, motor and speech retardation, facial inexpressiveness). CONCLUSION: This preliminary study seems to support the evidence of hypoactive and hyperactive subtypes of delirium, even though their aetiology and prognostic values need to be further examined.     

Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium

The existence of hyperactive, hypoactive, or mixed clinical subtypes of delirium is widely accepted. But relationships between these motor profiles and etiology or outcome remain unclear. The aim of this study was to compare etiologic and outcome profiles in a case series of 183 elderly patients (mean age = 84.1 years, SD = 5.9) consecutively admitted into the geriatric wards of two French university hospitals or referred to a geriatric psychiatry consultation-liaison unit within a Swiss university hospital. All patients met DSM-III-R criteria for delirium and were classified into clinical subtypes according to the results of a previous factor analysis of scores on a 19-item checklist rating a wide range of delirium symptoms. The hyperactive subtype was more frequent (n = 85, 46.5%) than the unspecified (n = 50, 27.3%) and hypoactive subtypes (n = 48, 26.2%). There was no significant difference in terms of etiologic or outcome profile between clinical subtype groups. The presence of acute metabolic disorders, cardiovascular disease, and hyperthermia as etiologic factors was significantly associated with full recovery of the episode at 3 weeks follow-up, whereas probable preexisting dementia was significantly associated with partial recovery or failure to recover.     

A longitudinal study of motor subtypes in delirium: frequency and stability during episodes

ObjectiveMotor-defined subtypes are a promising means of identifying clinically relevant patient subgroups but little is known about their course and stability during a delirium episode.MethodsWe assessed 100 consecutive adult palliative care patients with DSM-IV delirium twice weekly during their episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Rating Scale-Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). DMSS subtypes were assigned for each assessment and analysed for stability within patients during episodes.ResultsAcross all assessments (n = 303; mean 3 per patient, range 2–9), subtype occurrence was hypoactive (35%), mixed (26%), hyperactive (15%) and no subtype (24%). “No subtype” was associated with significantly lower DRS-R98 severity scores, of which 80% were subsyndromal, whereas mixed subtype assessments were the most impaired on the DRS-R98 and CTD. Subtypes were stable within delirium episodes in 62% of patients: 29% hypoactive, 18% mixed, 10% hyperactive and 6% no-subtype. The DRS-R98 noncognitive subscale scores differed across groups whereas cognitive subscale scores did not (p < 0.001).ConclusionsWe conclude that motor subtypes occur in nearly all patients with full syndromal delirium and are often stable during an episode. Subtypes exhibited comparable levels of cognitive impairment but differed in non-cognitive symptoms, supporting the importance of cognitive testing to detect delirium in less overt cases.     

Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures

OBJECTIVE: To describe the incidence, risk factors and clinical features (subtypes) of delirium during the postoperative period after hip fracture surgery in elderly patients. DESIGN: Prospective study. METHODS: Thirty-four consecutive patients (9 men and 25 women) were included in this study between June 16 to July 14, 2003. All patients underwent surgery for a fractured neck of femur and were pre- and postoperatively cared for at a combined geriatric/orthopedic ward. ASSESSMENT: The diagnosis of delirium was based on the criteria of the DSM-IV and the Confusion Assessment Method Scale. Subtypes of delirium were classified according to the criteria proposed by Lipowski: hyperactive-hyperalert (or agitated), hypoactive-hypoalert (somnolent) and mixed delirium. Results: Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The development of delirium was associated with the medication midazolam taken perioperatively. Nine (47%) of the delirious patients had a hyperactive type of delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed type. We did not find any association among subtypes of delirium and clinical features. CONCLUSIONS: Delirium is a common complication in the postoperative period of elderly patients treated for hip fractures. The use of midazolam in the perioperative period increased the risk of developing postoperative delirium. The hyperactive type of delirium was the most common subtype of delirium.     

A Retrospective Study on Delirium Type

Abstract: The clinical features of delirium type were retrospectively studied to characterize a delirium type in consecutive 106 patients. The subjects suffered from 15 medical diseases and were grouped into hyperactive, hypoactive and mixed types according to their cardinal features. The incidence of delirium was the highest in 70-year-old subjects and there was a gender effect in all the subjects. A decade effect was present in the outcome, delirium type and delirium duration. The delirium type was associated with age at the delirium onset, outcome and underlying disease. The incidence of hypoactive type correlated with that of mixed and hyperactive types, and a high rate of full recovery in the hyperactive type and a high rate of death in the mixed type were noted. The increase in incidence of the mixed type and the decrease in incidence of the hyperactive type contributed to a poor outcome. Malignancy, hepatic, cerebrovascular and bone and joint diseases highly correlated with the occurrence of delirium.     

A longitudinal study of motor subtypes in delirium: Relationship with other phenomenology,etiology, medication exposure and prognosis

ObjectiveMotor subtypes have promise as a means of identifying clinically relevant delirium subgroups. Little is known about their relationship to etiologies, medication exposure, and outcomes.MethodsConsecutive cases of DSM-IV delirium in palliative care patients were assessed twice-weekly throughout their delirium episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Etiology Checklist (DEC) and Delirium Rating Scale Revised-98 (DRS-R98).Results100 patients [mean age 70.2±10.5] were assessed on 303 visits [range 2–9]. Over the entire episode, mean DRS-R98 Severity scores were 16.2±5.7. The mean number of etiologies per case was 3.4±1.2. Motor subtypes were no subtype throughout (6%), hypoactive subtype throughout (28%), mixed subtype throughout (18%), hyperactive subtype throughout (10%) and variable subtype (38%). DRS-R98 Total and Severity scales differed significantly across categories (highest in mixed) but only motor, sleep–wake cycle, perceptual and language disturbance items differed. The Generalized Estimating Equations (GEE) approach was used to explore the relationship between subtype profile and symptoms, medication exposure and etiology. This showed that apart from motor items, only delusions, affective lability, metabolic disturbance and CVA related to any subtype. Cross-sectional assessments indicated greater use of benzodiazepine and antipsychotics in hyperactive patients but GEE analyses did not identify major associations between motor subtype and medication exposure. Patients with sustained hypoactive subtype were significantly more likely to die within one month of study entry.ConclusionsMotor profile in delirium is relatively consistent over episode course and relates more closely to delirium phenomenology than to etiology or medication exposure. Motor subtypes have comparable disturbance of key diagnostic features such as cognitive and thought process abnormalities. Although mixed subtype is the most phenomenologically intense, hypoactives have the poorest prognosis.     

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

Objective

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

Methods

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

Results

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

Conclusion

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

Motion analysis in delirium: a novel method of clarifying motoric subtypes

The usefulness of motor subtypes of delirium is unclear due to inconsistency in subtyping methods and a lack of validation with objective measures of motor activity levels. We studied patients with hyperactive, hypoactive, and mixed presentations of delirium were studied with 24-h accelerometer-based monitoring. The procedures were well tolerated and motor presentations were readily distinguished using the accelerometer-based measurements. The system was capable of identifying static versus dynamic activity and the frequency of changes in posture. Electronic motion analysis concurs with observed gross movement and can distinguish motorically defined subtypes according to quantitative and qualitative aspects of movement.     

Motion Analysis in Delirium: A Novel Method of Clarifying Motoric Subtypes

The usefulness of motor subtypes of delirium is unclear due to inconsistency in subtyping methods and a lack of validation with objective measures of motor activity levels. We studied patients with hyperactive, hypoactive, and mixed presentations of delirium were studied with 24-h accelerometer-based monitoring. The procedures were well tolerated and motor presentations were readily distinguished using the accelerometer-based measurements. The system was capable of identifying static versus dynamic activity and the frequency of changes in posture. Electronic motion analysis concurs with observed gross movement and can distinguish motorically defined subtypes according to quantitative and qualitative aspects of movement.     

A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis

Objective

Motor subtypes have promise as a means of identifying clinically relevant delirium subgroups. Little is known about their relationship to etiologies, medication exposure, and outcomes.

Methods

Consecutive cases of DSM-IV delirium in palliative care patients were assessed twice-weekly throughout their delirium episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Etiology Checklist (DEC) and Delirium Rating Scale Revised-98 (DRS-R98).

Results

100 patients [mean age 70.2±10.5] were assessed on 303 visits [range 2–9]. Over the entire episode, mean DRS-R98 Severity scores were 16.2±5.7. The mean number of etiologies per case was 3.4±1.2. Motor subtypes were no subtype throughout (6%), hypoactive subtype throughout (28%), mixed subtype throughout (18%), hyperactive subtype throughout (10%) and variable subtype (38%). DRS-R98 Total and Severity scales differed significantly across categories (highest in mixed) but only motor, sleep–wake cycle, perceptual and language disturbance items differed. The Generalized Estimating Equations (GEE) approach was used to explore the relationship between subtype profile and symptoms, medication exposure and etiology. This showed that apart from motor items, only delusions, affective lability, metabolic disturbance and CVA related to any subtype. Cross-sectional assessments indicated greater use of benzodiazepine and antipsychotics in hyperactive patients but GEE analyses did not identify major associations between motor subtype and medication exposure. Patients with sustained hypoactive subtype were significantly more likely to die within one month of study entry.

Conclusions

Motor profile in delirium is relatively consistent over episode course and relates more closely to delirium phenomenology than to etiology or medication exposure. Motor subtypes have comparable disturbance of key diagnostic features such as cognitive and thought process abnormalities. Although mixed subtype is the most phenomenologically intense, hypoactives have the poorest prognosis.     

Severity and course of delirium in medically hospitalized nursing facility residents.

Delirium is a common and serious complication of medical illness in frail elderly patients. The authors report on a series of nursing facility delirium patients followed for 3 months during and after acute medical hospitalization. Delirium was persistent to time of death or hospital discharge in 72%. At 1 and 3 months, 55% and 25%, respectively, showed delirium. Mortality rate was high, with in-hospital and 3-month mortality rates of 18% and 47%, respectively. More severe delirium and failure to improve delirium while in the hospital were both associated with increased mortality. A purely hypoactive delirium vs. a hyperactive or mixed was associated with delirium persistence. Delirium is associated with high mortality and frequent persistence. Additional research is needed to clarify who is at risk for delirium with associated persistence and/or mortality.     

A new data-based motor subtype schema for delirium

The authors sought to validate a new approach to motor subtyping in delirium based on data from a controlled comparison of items from three existing psychomotor schema combined into the Delirium Motoric Checklist. Principal components analysis of the Delirium Motoric Checklist identified two factors that correlated significantly with independently assessed motor agitation and retardation. Symptoms loading at >0.65 were extracted to form subtype criteria composed of four hyperactive items and seven hypoactive items which, when applied to the delirious population, suggested a cutoff of two items for subtypes. This new scale is derived from existing approaches but is more concise, focused on motor disturbances, and validated against nondelirious comparison subjects and independently rated motor disturbance.     

Modulation of estrous cycle and LH, FSH and melatonin levels by pinealectomy and sham-pinealectomy in female rats

1. The pineal has been shown to have a role in controlling reproduction of polyestrus mammals (like humans and laboratory rodents). It influences the age of sexual maturation; the timing of the ovulatory cycle; and gonadal steroidogenesis. 2. Here the authors report the early and late effects of pinealectomy (Px) and sham-pinealectomy (SPx) on the estrous cycle periodicity, plasma LH, FSH and urinary 6-sulphatoxymelatonin (6-SMT) excretion in female rats. 3. Female Wistar rats (3-4 months of age) were maintained on 12/12 L/D cycle. Orbital venous plexus blood and urine samples were collected from the same rat during the estrus phase before surgery, 4-7 and 55-60 days post surgery. 4. Daily vaginal smears were taken to monitor the estrous cycle and they showed a time dependent increase in the estrus stage duration in Px rats (estrus stage: 1 day in control; 3-4 days after 45 days Px). 5. The decrease of gonadotropins at early post Px was due to surgical stress. 6. 6-SMT levels were significantly lower at 4-7 days post SPx, but at 55-60 d post surgery these levels returned to control values, which indicate pineal gland integrity. The reduction in urinary 6-SMT may be attributed to a possible high level of plasma corticosterone occurring after surgical manipulations. 7. 6-SMT levels in Px rats were extremely lower at 4-7 and 55-60 days post surgery, but not null, confirming the surgical removal of the pineal gland and indicating the synthesis of melatonin in sites other than the pineal gland.     

Richmond躁动镇静评分量表评估电休克治疗后谵妄的信度及效度

目的:探讨中文版Richmond躁动镇静评分量表(RASS)评估电休克治疗(ECT)后谵妄状态(PECTD)的信度和效度。方法:对335例MECT呼吸恢复后的患者分别进行美国《精神障碍诊断及统计手册》第4版修订版(DSM-IV-TR)谵妄诊断、RASS及格拉斯哥昏迷量表(GCS)评估;以DSM-IV-TR诊断为金标准,分析RASS评估PECTD灵敏度及特异度;采用受试者工作特征曲线(ROC曲线)下面积确定RASS诊断不同亚型PECTD的最佳划界值。结果:RASS评分者的一致性(Kappa值)为0.733;RASS为+1分时诊断活动增多型PECTD灵敏度、特异度分别为94.9%、91.8%,RASS为-1分时诊断活动减少型PECTD灵敏度、特异度分别为93.2%、95.6%。RASS与GCS评分呈正相关(r=0.891,P0.001)。结论:RASS评估PECTD有良好的信度和效度;其诊断活动增多型及活动减少型PECTD的最佳划界值为分别为+1及-1分。     

Phenomenology of delirium among patients admitted to a coronary care unit

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

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

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

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

The effects of coffee consumption on sleep and melatonin secretion

BACKGROUND: In this study we examined the effects of caffeine on sleep quality and melatonin secretion. Melatonin is the principal hormone responsible for synchronization of sleep. Melatonin secretion is controlled by neurotransmitters that can be affected by caffeine. METHODS: In the first part of the study, six volunteers drank either decaffeinated or regular coffee in a double-blind fashion on one day, and the alternate beverage 7 days later. Sleep parameters were assessed by actigraphy. In the second part of the study, the subjects again drank either decaffeinated or regular coffee, and they then collected urine every 3h for quantitation of 6-sulphoxymelatonin (6-SMT), the main metabolite of melatonin in the urine. RESULTS: We found that drinking regular caffeinated coffee, compared to decaffeinated coffee, caused a decrease in the total amount of sleep and quality of sleep, and an increase in the length of time of sleep induction. Caffeinated coffee caused a decrease in 6-SMT excretion throughout the following night. CONCLUSIONS: The results of our study confirm the widely held belief that coffee consumption interferes with sleep quantity and quality. In addition, we found that the consumption of caffeine decreases 6-SMT excretion. Individuals who suffer from sleep abnormalities should avoid caffeinated coffee during the evening hours.     

Documentation and diagnosis of delirium in Parkinson's disease

Objective

To assess the accuracy of documentation of the symptoms and diagnosis of delirium in medical notes of inpatients with Parkinson's disease (PD).

Methods

The DETERMINE-PD pilot study assessed PD inpatients over 4-months. Delirium prevalence was classified prospectively using a standardized assessment at a single visit on the basis of Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) criteria. Incident delirium was diagnosed retrospectively using detailed clinical vignettes and validated consensus method. Inpatient medical notes and discharge summaries of those with delirium were reviewed for documentation of symptoms, diagnosis and follow-up.

Results

Forty-four PD patients consented to take part in the study, accounting for 53 admissions. We identified 30 cases (56.6%) of delirium during the participants' stay in hospital. Of those with delirium identified by the research team, delirium symptoms were documented in the clinical notes of 72.3%; 37.9% had a delirium diagnosis documented. Older patients were more likely to have delirium (p = 0.027) and have this diagnosis documented (p = 0.034). Time from documentation of symptoms to diagnosis ranged from <24 h to 7 days (mean 1.6 ± 4.4 days). Hypoactive delirium was significantly less likely to have been identified and formally diagnosed (63% of not documented were hypoactive vs. 37% hyperactive, mixed or unclear, p = 0.016). Only 11.5% of discharge summaries included diagnosis of delirium.

Conclusion

Delirium in PD is common. Documentation of symptoms of delirium was common; however, fails to lead to a documentation of diagnosis in over half of admissions with delirium and was even less commonly communicated in the Primary Care discharge summaries. This highlights the need for increased education about delirium symptomatology and diagnosis in PD.     

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.     

Delirium in elderly patients.

Delirium is a mental disorder characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior, of acute onset and fluctuating course. It occurs in hyperactive, hypoactive, or mixed forms, in up to 50% of elderly hospital inpatients, many with pre-existing dementia, and appears to be independently associated with significant increases in functional disability, length of hospital stay, rates of admission to long-term care institutions, rates of death, and healthcare costs. Despite its clinical importance, delirium is often not detected or it is misdiagnosed as dementia or other psychiatric illness even though there are potential strategies (e.g., screening by nurses, risk-factor assessment) and instruments that can improve detection and diagnosis. Although there has been limited progress in understanding the etiology, pathogenesis, assessment, and specific treatment of delirium, systematic detection and treatment programs appear to be beneficial for elderly surgical patients, as are preventive programs for elderly medical and surgical patients. Even now, there is probably enough evidence to recommend implementation of these two types of programs in acute-care hospitals.