The Usefulness of Quantitative Electroencephalography in Diagnosis and Severity Evaluation of Delirium: A Retrospective Study

ObjectiveIncontrovertible disease markers are absent in delirium. This study investigated the usefulness of quantitative electroencephalography (qEEG) in diagnosing delirium. MethodsThis retrospective case-control study reviewed medical records and qEEG data of 69 age/sex-matched patients (delirium group, n=30; control group, n=39). The first minute of artifact-free EEG data with eyes closed was selected. Nineteen electrodes’ sensitivity, specificity, and correlation with delirium rating scale-revised-98 were analyzed. ResultsOn comparing the means of absolute power by frontal, central, and posterior regions, the delta and theta powers showed significant differences (p<0.001) in all regions, and the magnitude of the absolute power was higher in the delirium group than in the control group; only the posterior region showed a significant (p<0.001) difference in beta power. The spectral power of theta at the frontal region (area under the curve [AUC]=0.84) and theta at the central and posterior regions (AUC=0.83) showed 90% sensitivity and 79% specificity, respectively, in differentiating delirious patients and controls. The beta power of the central region showed a significant negative correlation with delirium severity (R=-0.457, p=0.011). ConclusionPower spectrum analysis of qEEG showed high accuracy in screening delirium among patients. The study suggests qEEG as a potential aid in diagnosing delirium.     

Delirium in children and adolescents: A systematic review of the literature

Objectives

The purpose of this study was to collate all works relating to delirium and probable delirium in children and adolescents published since 1980.

Methods

A systematic review of the literature in all languages published between 1980 and March 2009 was conducted.

Results

The literature is limited to small case series and case reports including a total of 217 children or adolescents with definite delirium and a further 136 children and adolescents with “probable delirium.” These articles, in addition to unsystematic reviews, overviews, editorials, journal commentaries, and pertinent book chapters, are discussed in relation to prevalence, predisposing and precipitating factors, phenomenology, residual psychopathology, mortality, management, and prevention of delirium in childhood and adolescence.

Conclusions

Delirium is an important but neglected disorder of childhood associated with significant morbidity and high mortality. Current clinical practice for management is based on slim empirical evidence.     

Delirium in patients admitted to a cardiac intensive care unit with cardiac emergencies in a developing country: incidence,prevalence, risk factor and outcome

Aim

To assess the incidence, prevalence, risk factors and outcome of delirium in patients admitted to a cardiac intensive care unit (ICU) of a tertiary care hospital.

Methods

Three hundred nine consecutive patients admitted to a 22-bed coronary care unit were screened for presence of delirium by using Confusion Assessment Method for Intensive Care Unit (CAM-ICU), and those found positive on CAM-ICU were further evaluated by a psychiatrist to confirm the diagnosis of delirium as per DSM-IV-TR criteria. Patients were also evaluated for the risk factors for delirium and outcome of delirium.

Results

Incidence rate of delirium was 9.27%, and prevalence rate was 18.77%. The risk factors identified for delirium in binary logistic regression analysis were hypokalemia, Sequential Organ Failure Assessment score, presence of cognitive deficits, receiving more than three medications, sepsis, hyponatremia, presence of cardiogenic shock, having undergone coronary artery bypass grafting, left ventricular ejection fraction < 30, currently receiving opioids, age more than 65years, presence of diabetes mellitus, presence of uncontrolled diabetes mellitus, history of seizures, presence of congestive cardiac failure, having undergone angioplasty, presence of atrial fibrillation, ongoing depression, currently receiving/taking benzodiazepines, warfarin, ranitidine, steroids, non-steroidal anti-inflammatory drugs, higher total number of medications, presence of raised creatinine, anaemia, hypoglycemia, Acute Physiology and Chronic Health Evaluation II score and Charlson Comorbidity Index score. About one fourth (n= 22; 27%) of the patients who developed delirium died during the hospital stay in contrast to 1% mortality in the non-delirious group. Those with delirium also had longer stay in the ICU.

Conclusions

Delirium is highly prevalent in the cardiac ICU setting and is associated with presence of many modifiable risk factors. Development of delirium increases the mortality risk and is associated with longer cardiac ICU stay.     

Depression Predicts Delirium After Coronary Artery Bypass Graft Surgery Independent of Cognitive Impairment and Cerebrovascular Disease: An Analysis of the Neuropsychiatric Outcomes After Heart Surgery Study

Objective

Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression, mild cognitive impairment (MCI), and cerebrovascular disease as post-CABG delirium risk factors.

A DAY HOSPITAL FOR COGNITIVE DISORDERS: EXPERIENCE OF THE FIRST YEAR OF ACTIVITY

The aims of this study were to (i) describe the typology of patients admitted to the day hospital for cognitive disorders of the Alzheimer's Disease Unit, Brescia, Italy, and (ii) describe the diagnostic, therapeutic and rehabilitative interventions carried out. Data are presented on the first 102 consecutive patients admitted to the day hospital. Seventy-five per cent of patients had not previously received an appropriate diagnostic evaluation. The mean length of stay in the day hospital was 5 days for patients receiving diagnostic evaluation only, 2 weeks for those also receiving treatment for medical disorders or behavioural disturbance, and 1 month for cognitive rehabilitation. Though the effectiveness and usefulness of a day hospital service remains largely undemonstrated in terms of user satisfaction and quality of care, the present study suggests a day hospital may have a role in the diagnosis of cognitive disorder.     

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.     

Delirium in the elderly: A review and a suggestion for a research programme

Delirium in the elderly attracts sporadic attention in the literature yet constitutes a major challenge to health services, complicating many illnesses and procedures in elderly patients, associated with high rates of mortality, cutting across disciplinary boundaries and posing theoretical difficulties for the organic/functional distinction that pervades medicine. In this review the importance of delirium in the elderly is emphasized, drawing attention to the suffering caused to the patient and the excess mortality. Problems of nomenclature (why use one word when three will do?) are discussed, the conclusion being that the oldest term is probably the best, provided that the concept of a ‘syndrome’ is preserved. Difficulties in research assessment are identified, and aetiology and the relationship of the delirium syndrome to dementia syndromes are discussed. Deficiencies in past approaches to management are identified and a definition of delirium is suggested. Finally, a proposal for a research programme is outlined.     

Deficits of visuospatial working memory and executive function in single- versus multiple-domain amnestic mild cognitive impairment: A combined ERP and sLORETA study

ObjectiveAccording to recent criteria of classification, amnestic mild cognitive impairment (aMCI) could be divided into two categories: single-domain aMCI (sd-aMCI) and multiple-domain aMCI (md-aMCI). The difference between sd-aMCI and md-aMCI needs further exploration. The present study aimed to compare deficits in visuospatial working memory (VSWM) and executive function between sd-aMCI versus md-aMCI patients by use of event-related potentials (ERP) and standardized low-resolution brain electromagnetic tomography analysis (sLORETA).MethodsThe ERP data were measured and analyzed in 26 sd-aMCI, 13 md-aMCI patients and 46 healthy elderly controls (HEC) during VSWM and Go/Nogo processes.ResultsDuring VSWM task, md-aMCI patients showed decreased P300 amplitude compared to HEC and sd-aMCI patients (All p < 0.05). As compared to sd-aMCI, md-aMCI showed a hypoactivation in the right middle frontal gyrus in 1-back task during the P300 time range. During the Go/Nogo task, sd-aMCI and md-aMCI patients showed reduced N200 amplitude, compared to HEC (All p < 0.05). However, md-aMCI patients had decreased N200 amplitude, with respect to sd-aMCI patients. Further, as compared to sd-aMCI patients, md-aMCI patients showed a hypoactivation in the right superior frontal gyrus during the N200 time range.ConclusionsThese findings with a combined ERP and sLORETA study showed more severe deficits in updating operations of WM, detections of the target stimulus and conflict processes in md-aMCI, compared to sd-aMCI patients.SignificanceThe present study showed that a combined ERP and sLORETA study during the VSWM and Go/Nogo tasks could distinguish md-aMCI from sd-aMCI.     

Cognitive Assessment and Reference Diagnosis System: development of a neuropsychological and clinical examination for clinic and population use

Background: Recent therapeutic advances to delay the progression of dementia have renewed calls to improve the early detection and management of individuals with dementia. A new computerized neuropsychological interview and clinical examination, the Cognitive Assessment and Reference Diagnosis System (CARDS) was developed to incorporate in a single instrument all the information required to make an accurate clinical diagnosis of dementia (its subtype, depression and delirium), to present reference diagnoses following the completion of tests and to detect early dementia. This study aims to verify the validity and reliability of CARDS. Methods: The CARDS was administered to 70 dementia patients (51 Alzheimer's disease, 19 vascular dementia) and 34 healthy (control) subjects. Three aspects of reliability (internal consistency reliability, inter‐rater and test–retest reliability) were tested. Correlations with the Alzheimer's Disease Assessment Scale, Korean version (ADAS‐K), the Cambridge Cognitive Examination, Korean version (CAMCOG‐K) and the Mini‐Mental State Examination, Korean version (MMSE‐K) were used to estimate the concurrent validity of CARDS. To evaluate the sensitivity of CARDS, mean scores from CARDS, ADAS‐K, CAMCOG‐K and MMSE‐K were compared between dementia patients and control subjects. Results: The CARDS demonstrated high levels of reliability. Mean CARDS scores for dementia patients were significantly different from the control group (P < 0.001). Furthermore, CARDS was significantly correlated with other tests and scales (P < 0.01). Conclusion: We demonstrated that CARDS is a reliable and valid instrument not only for dementia diagnosis, but also for the evaluation of impaired cognitive domains. A regression equation, derived from nationwide population surveys for norm data from CARDS, will be applied for individualized cutoff scores of five domains of dementia to eliminate the influence of age, sex and educational attainment on test scores.     

The Role of Inflammation in the Pathogenesis of Delirium and Dementia in Older Adults: A Review

Aims: To review recent evidence that suggests inflammation plays a similar role in the pathogenesis of delirium and dementia. Methods: We performed a literature search of original research and review articles in PubMed using the keywords: delirium, dementia, and inflammation. We summarized the evidence linking inflammation to the pathogenesis of delirium and dementia. Discussion: Delirium and dementia share similarities in clinical and pathogenic features, leading to the speculation that instead of being distinct clinical entities, the two age‐related conditions may be linked by a common pathogenic mechanism. Inflammatory markers have been shown to be elevated in both delirium and dementia, thereby implicating inflammation as a possible mediating factor in their genesis. There is evidence in both basic science and clinical research literature that elevated cytokines play a crucial role in the development of cognitive dysfunction observed in both dementia and delirium. Conclusion: Mounting evidence supports the role of inflammation in the development of both dementia and delirium. Further studies are needed to elucidate the mechanisms underlying these relationships.     

Topographical Disorientation in Mild Cognitive Impairment: A Voxel-Based Morphometry Study

Background and Purpose

To assess the neural substrates underlying topographical disorientation (TD) in patients affected by mild cognitive impairment (MCI), forty-one patients diagnosed with MCI and 24 healthy control individuals were recruited.

Methods

TD was assessed clinically in all participants. Neurological and neuropsychological evaluations and a volumetric-head magnetic resonance imaging scan were performed in each participant. Voxel-based morphometry was used to compare patterns of gray-matter atrophy between patients with and without TD, and a group of normal controls.

Results

We found TD in 17 out of the 41 MCI patients (41.4%). The functional abilities were significantly impaired in MCI patients with TD compared to in MCI patients without TD. Voxel-based morphometry analyses showed that the presence of TD in MCI patients is associated with loss of gray matter in the medial temporal regions, including the hippocampus and parahippocampal cortex, the fusiform gyrus, the inferior occipital gyrus, the amygdala, and the cerebellum.

Conclusions

The findings found in this study represent the first evidence that the presence of TD in patients with MCI is associated with loss of gray matter in those brain regions that have been documented to be responsible for orientation in both neuropsychological and neuroimaging studies.     

Amnestic mild cognitive impairment in Parkinson's disease: A brain perfusion SPECT study

The purpose of this study was to investigate cortical dysfunction in Parkinson's disease (PD) patients with amnestic deficit (PD‐MCI). Perfusion single photon emission computed tomography was performed in 15 PD‐MCI patients and compared (statistical parametric mapping [SPM2]) with three groups, i.e., healthy subjects (CTR), cognitively intact PD patients (PD), and common amnestic MCI patients (aMCI). Age, depression, and UPDRS‐III scores were considered as confounding variables. PD‐MCI group (P < 0.05, false discovery rate–corrected for multiple comparisons) showed relative hypoperfusion in bilateral posterior parietal lobe and in right occipital lobe in comparison to CTR. As compared to aMCI, MCI‐PD demonstrated hypoperfusion in bilateral posterior parietal and occipital areas, mainly right cuneus and angular gyrus, and left precuneus and middle occipital gyrus. With a less conservative threshold (uncorrected P < 0.01), MCI‐PD showed hypoperfusion in a left parietal region, mainly including precuneus and inferior parietal lobule, and in a right temporal‐parietal‐occipital region, including middle occipital and superior temporal gyri, and cuneus‐precuneus, as compared to PD. aMCI versus PD‐MCI showed hypoperfusion in bilateral medial temporal lobe, anterior cingulate, and left orbitofrontal cortex. PD‐MCI patients with amnestic deficit showed cortical dysfunction in bilateral posterior parietal and occipital lobes, a pattern that can be especially recognized versus both controls and common aMCI patients, and to a lesser extent versus cognitively intact PD. The relevance of this pattern in predicting dementia should be evaluated in longitudinal studies. © 2008 Movement Disorder Society     

A new US-UK diagnostic project: mood elevation and depression in first-year undergraduates at Oxford and Stanford universities

Objective: To investigate differences in prevalence of mood elevation, distress and depression among first‐year undergraduates at Oxford and Stanford universities. Method: An online survey was sent to Oxford and Stanford first‐year undergraduate students for two consecutive years in the winter of 2005 and 2006. Students completed a survey that assessed mood symptoms and medication use. Results: Both universities had similar rates of distress by General Health Questionnaire (Oxford – 42.4%; Stanford – 38.3%), depression by Primary Care Evaluation of Mental Disorders (Oxford – 6.2%; Stanford – 6.6%), and psychotropic and non‐psychotropic medication usage (psychotropic: Oxford – 1.5%; Stanford 3.5%; non‐psychotropic: Oxford – 13.3%; Stanford – 18%). Oxford had higher rates of mood elevation by Mood Disorder Questionnaire (MDQ) (Oxford – 4%; Stanford – 1.7%). Conclusion: Oxford and Stanford students have similar rates of mood distress, depression and general medication usage. Students at Oxford have a higher prevalence of MDQ scores that possibly indicate a bipolar disorder, while Stanford students are prescribed more psychotropics.     

Mild cognitive impairment in adult: A neuropsychological review

Mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. This is clinically relevant overt dementia can be prevented if treatment strategies are devised for MCI. Neuropsychological deficits in this condition are very common and are important clinically for treatment and outcomes. We aimed to review various neuropsychological deficits in MCI. Further, we have presented the current evidence for nosological status, neuroanatomical basis, and clinical outcome of this heterogeneous construct. All published papers on the topic of neuropsychological deficits in MCI on Medline and other databases were reviewed. A wide range of memory and executive function deficits are common in MCI patients. However, several studies are limited by either improper designs or inadequate sample sizes. Several neuropsychological impairments like memory function and executive functions can be diagnosed in MCI. The evidence base for the exact neuroanatomical basis of MCI is not robust yet. However, given the wide range of outcomes, controversies and debates exist regarding the nosological significance of the deficits. Hence, more studies are needed to specifically locate the impairments and further delineate the construct of MCI.