Delirium: making the diagnosis, improving the prognosis

Delirium is a common development in at-risk older patients hospitalized for acute illness or postoperative care. Although delirium's risk factors are well documented, less is known about its pathophysiology and long-term prognosis or about the relationship between delirium, dementia, and depression. Evaluation and management of delirium is a medical emergency. Diagnostic tools include the Confusion Assessment Method rating scale, patient history from capable informants, and physical/mental examinations. Management consists of prevention, treatment of underlying causes or associated factors, supportive care, and pharmacologic intervention (as indicated). Studies that have looked at the reversibility of delirium suggest that patients often are slow to recover their previous level of function.     

Seasonal variation in the incidence of delirium among the patients of a geriatric hospital

Delirium syndrome is common in the hospitalized elderly population. However, data on its numerous etiological factors are scarce. Clinical observations suggest that delirium incidence could be related to seasonality. In order to evaluate the seasonal influence on the incidence of delirium syndrome among the patients of a geriatric hospital, we performed a retrospective study reviewing the medical records of 5218 patients aged 65 years and older, who were hospitalized in three medical wards between the years 1991 and 1997. The diagnoses of delirium were made according to ICD-9-CM. Of the 4929 subjects enrolled, 3548 (72%) were referred for assessment to the psychiatric or neurologic specialist, because of acute changes in their mental or behavioral status. Of those patients, 312 (6.3%) were diagnosed with delirium at admission, and 234 (4.7%) developed delirium during their hospitalization. Statistical analysis of incidence revealed a seasonal variation, with higher rates in the winter than in the summer months (P<0.001). This study suggests a seasonal influence on delirium syndrome incidence and a possible etiological relation with seasonal factors like the light -dark cycle.     

Prevention of delirium in an acute geriatric care unit

PURPOSE: Delirium is the most common complication of hospitalization in frail elderly. The prognosis is poor with increased mortality and morbidity. Confusion results from one or several precipitating factors in patients at risk. In a randomized study, a preventive multicomponent intervention reduced the incidence of delirium by 40%. The aim of our study was to evaluate the efficacy of such a preventive strategy, in the setting of an acute geriatric care unit. METHODS: The study was conducted in a French 26-bed geriatric acute care ward. The primary outcome was the comparison of the incidence of delirium among patients aged 75 years and older, before and after the implementation of a preventive strategy. The overall adherence of the ward staff to the prevention procedures was also determined. RESULTS: Before intervention, 367 patients were admitted (mean age: 80.6 years). The incidence of delirium was of 8.99%. In the subgroup of 123 demented patients, the incidence of delirium was of 15.4%. After intervention, 372 patients were admitted (mean age 84.9). The incidence of delirium was of 2.4% (relative risk reduction of 73%, P=0.001). In the subgroup of 133 demented patients, the incidence of delirium was 5.3% (relative risk reduction of 66%, P=0.01). The ward staff applied the prevention procedures in 96% of the 10 230 patients-day during the study period. CONCLUSION: This study shows that it is possible to apply the results of clinical research in clinical practice to prevent delirium in frail elderly hospitalized in an acute geriatric care unit. Such an easy preventive strategy could be applied in medical units admitting old patients at risk, in the context of a quality procedure.     

Delirium symptoms in post-acute care: prevalent,persistent, and associated with poor functional recovery

OBJECTIVES: To determine the prevalence of delirium symptoms at the time of admission to post-acute facilities, the persistence of delirium symptoms in this setting, and the association of delirium symptoms with functional recovery. DESIGN: Prospective cohort study. SETTING: Eighty-five post-acute care facilities: 55 rehabilitation hospitals and 30 skilled nursing facilities in 29 states. PARTICIPANTS: Five hundred fifty-one consenting patients aged 65 and older newly admitted to participating facilities from acute care hospitals. MEASUREMENTS: Data were collected as part of a field study effort related to the Minimum Data Set (MDS). Basic demographic data, medical comorbidity, delirium symptoms, and functional status--activities of daily living (ADLs) and instrumental activities of daily living (IADLs)--were obtained from MDS assessments performed within 4 days of admission and again 1 week later by the patient's primary nurse. Six delirium symptoms (easily distracted, periods of altered perception, disorganized speech, periods of restlessness, periods of lethargy, and mental function varies over the course of a day) were assessed after appropriate training. RESULTS: Of the 551 patients (mean age +/- standard deviation 78 +/- 7, 64% women), 126 had delirium symptoms on post-acute admission, for an overall prevalence of 23%. In patients with delirium symptoms on the admission assessment, 1 week later, 14% had completely resolved, 22% had fewer delirium symptoms, 52% had the same number of symptoms, and 12% had more symptoms. Of those with no delirium symptoms on admission, 4% had new symptoms 1 week later. Patients who had the same number of or more delirium symptoms at the second assessment had significantly worse ADL and IADL recovery than those with fewer or resolved delirium symptoms or those with no delirium symptoms at either assessment. Persistent delirium symptoms remained significantly associated with worse ADL and IADL recovery after adjusting for age, comorbidity, dementia, and baseline functional status. CONCLUSIONS: The data from this study provide strong preliminary evidence that, in patients newly admitted to post-acute care facilities from acute care hospitals, delirium symptoms are prevalent, persistent, and associated with poor functional recovery. Educational efforts are warranted to help post-acute facility staff recognize and manage this common and morbid condition.     

Delirium: recognition and management in the older patient

The EEG can be an enormous aid in distinguishing between organic and "functional" problems and between acute drug intoxication and other forms of delirium. The characteristic EEG finding in delirium is bilateral diffuse slowing that parallels the severity of the syndrome. The vulnerability of the elderly cannot be overstressed. Their health and nutritional status, borderline cerebral changes, and sensory deprivation due to impaired vision or hearing are all predisposing factors for delirium.     

Delirium among elderly general medical patients in a New Zealand hospital

Background: Overseas studies suggest that delirium is a common and serious health problem of hospitalized elderly. There is very little information in New Zealand. Aims: To study prospectively the frequency and effect of delirium on a cohort of elderly general medical patients. Methods: Over 2 months, 317 patients were admitted to general medical wards; 70% were aged 65 years and above. These patients were screened for delirium. Comparisons were made between the delirious and non‐delirious patients. Results: Fifty‐six of the 216 patients screened had delirium. The prevalence and incidence of delirium were 23.4 and 5.7%, respectively. Thirty‐one per cent of delirious patients had a previous history of dementia; 48% of delirious patients had multiple precipitants, most commonly infections. Delirium was associated with higher complication rates – 94 versus 39% in the non‐delirious patients – and a doubling in the length of hospital stay. Over 50% of delirious patients required increased supports on discharge with a general trend towards higher frequency of institutionalization. The presence of delirium was associated with increased use of neuroleptic medications, special nursing care, cot sides and restraints. A non‐significant trend towards increased mortality was seen in the delirious group. Conclusions: Delirium is a common health problem in elderly patients, associated with multiple adverse outcomes. This study highlighted the prognostic importance of diagnosing delirium. Recommendations included improved health professional education, development of guidelines including rational use of neuroleptic medication and measures to improve follow up for these patients.     

Psychiatric aspects of heart and lung disease in critical care

Psychiatric issues are important in the management of patients with heart and lung disease in acute, intensive, and critical care. Adjustment disorders, anxiety disorders, depression, and delirium, sometimes in association with substance abuse and withdrawal problems, are the most common issues, and may affect risk and prognosis of the associated general medical conditions and management in the acute care setting. In children with lung and heart diseases requiring critical care, appreciation of cognitive and social-psychologic developmental milestones is necessary to provide adequate care.     

Southwestern Internal Medicine Conference. Etiology and management of delirium

Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.     

新型冠状病毒疫情期间RICU患者抑郁和急性脑病综合征发生情况及危险因素分析

目的 了解新型冠状病毒肺炎疫情期间,呼吸与危重症医学科监护室(RICU)患者发生抑郁及急性脑病综合征的情况,分析危险因素,为采取心理干预和减少急性脑病综合征发生提供依据.方法 选择2020年1月25日至2020年3月25日入住RICU的患者,在住院期间采用健康抑郁症状群量表(PHQ-9)对患者进行抑郁评分,并采用ICU...     

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

BACKGROUND: While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium. METHODS: Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics. RESULTS: During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. CONCLUSIONS: The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.     

Enzymes of drug metabolism during delirium

BACKGROUND: Delirium is common in ill medical patients. Several drugs and polypharmacy are recognised risk factors, yet little is known about drug metabolism in people with delirium. OBJECTIVE: The aim of this study was to investigate the activities of plasma esterases (drug metabolising enzymes) in delirium. DESIGN: This was a prospective study of delirium present at time of hospital admission (community acquired) or developing later (hospital acquired) in patients admitted as a medical emergency and aged 75 years or over. METHODS: Following informed consent or assent cognitive screening was completed on all patients on admission and every 48 hours subsequently. Delirium was diagnosed by Confusion Assessment Method and DSM IV criteria. Blood samples were taken on admission and at onset of delirium if this was later. Four plasma esterase assays were performed spectrophotometrically: acetylcholinesterase, aspirin esterase, benzoylcholinesterase, butyrylcholinesterase. RESULTS: 283 patients (71% of eligible) were recruited, with mean age 82.4 years and 59% female. 27% had community acquired delirium, 10% developed hospital acquired delirium, 63% never developed delirium. On admission the mean activities of all four esterase assays were statistically significantly lower in delirious than non delirious patients. There were no significant differences on admission in any plasma esterase activity between patients with hospital and community acquired delirium. In-hospital mortality was associated with low plasma esterase activities on admission. CONCLUSION: Plasma esterase activities are suppressed during delirium. These data reinforce the need for extreme caution with drugs in this vulnerable population.     

The prognostic significance of subsyndromal delirium in elderly medical inpatients

OBJECTIVES: To determine the prognostic significance of subsyndromal delirium (SSD) presentations. DESIGN: Cohort study. SETTING: University-affiliated primary acute care hospital. PARTICIPANTS: One hundred sixty-four elderly medical inpatients who did not meet Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for delirium during the first week after admission were classified into three mutually exclusive groups. The first group, prevalent SSD, included those who had two or more of four core symptoms of delirium (clouding of consciousness, inattention, disorientation, perceptual disturbances) at admission. The second group, incident SSD, included those who did not meet criteria for prevalent SSD but displayed one or more new core symptoms during the week after admission. The third group had no prevalent or incident SSD. The three groups were followed up at 2, 6, and 12 months. MEASUREMENTS: Outcomes (length of stay, symptoms of delirium (Delirium index), cognitive (Mini-Mental State Examination) and functional status (instrumental activities of daily living), and mortality) were compared using univariate techniques and multivariate regression models that adjusted for age, sex, marital status, living arrangements before admission, comorbidity, clinical and physiological severity of illness, and dementia status and severity. RESULTS: Patients with prevalent SSD had longer acute care hospital stay, increased postdischarge mortality, more symptoms of delirium, and a lower cognitive and functional level at follow-up than patients with no SSD. Most of the findings for incident SSD were similar but not statistically significant. Patients with prevalent or incident SSD had risk factors for DSM-defined delirium. CONCLUSION: SSD in elderly medical inpatients appears to be a clinically important syndrome that falls on a continuum between no symptoms and DSM-defined delirium.     

Gamma-hydroxybutyrate withdrawal syndrome

STUDY OBJECTIVE: Gamma-hydroxybutyrate (GHB) withdrawal syndrome is increasingly encountered in emergency departments among patients presenting for health care after discontinuing frequent GHB use. This report describes the characteristics, course, and symptoms of this syndrome. METHODS: A retrospective review of poison center records identified 7 consecutive cases in which patients reporting excessive GHB use were admitted for symptoms consistent with a sedative withdrawal syndrome. One additional case identified by a medical examiner was brought to our attention. These medical records were reviewed extracting demographic information, reason for presentation and use, concurrent drug use, toxicology screenings, and the onset and duration of clinical signs and symptoms. RESULTS: Eight patients had a prolonged withdrawal course after discontinuing chronic use of GHB. All patients in this series were psychotic and severely agitated, requiring physical restraint and sedation. Cardiovascular effects included mild tachycardia and hypertension. Neurologic effects of prolonged delirium with auditory and visual hallucinations became episodic as the syndrome waned. Diaphoresis, nausea, and vomiting occurred less frequently. The onset of withdrawal symptoms in these patients was rapid (1 to 6 hours after the last dose) and symptoms were prolonged (5 to 15 days). One death occurred on hospital day 13 as withdrawal symptoms were resolving. CONCLUSION: In our patients, severe GHB dependence followed frequent ingestion every 1 to 3 hours around-the-clock. The withdrawal syndrome was accompanied initially by symptoms of anxiety, insomnia, and tremor that developed soon after GHB discontinuation. These initial symptoms may progress to severe delirium with autonomic instability.     

An organ systems-based review of outcomes associated with sleep apnea in hospitalized patients

The current global health crisis due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has prompted the medical community to investigate the effects of underlying medical conditions, including sleep-disordered breathing, on inpatient care. Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing that may complicate numerous acquired conditions, particularly in inpatient and critical care settings. Viral pneumonia is a major contributor to intensive care unit (ICU) admissions and often presents more severely in patients with underlying pulmonary disease, especially those with obesity and OSA. This review summarizes the most recent data regarding complications of both OSA and obesity and highlights their impact on clinical outcomes in hospitalized patients. Additionally, it will highlight pertinent evidence for the complications of OSA in an organ-systems approach. Finally, this review will also discuss impatient treatment approaches for OSA, particularly in relation to the SARS-CoV-2 pandemic.     

Psychiatric Findings in the Population of a Geriatric Evaluation Unit: Implications†

Psychiatric evaluation was performed routinely in 262 patients newly admitted to a Medical Geriatric Evaluation Unit (GEU). The study was conducted in a medical facility that provides excellent medical and surgical care for acute illnesses. The psychiatric disorders found far exceeded those one might expect in a comparable general population, and most were not recognized prior to the patient's transfer. For example, in the GEU, the incidence of organic brain syndrome was 65.3 percent, and of dysphoria-depression 31.3 percent. The data indicate a need to recognize psychiatric problems in order to ensure appropriate care, and suggest that medical care of the elderly with acute illness will be inadequate if it is based upon the approach used for younger populations. This situation apparently exists in most hospitals, including leading medical centers. The needs of the elderly with acute illnesses are quite different from those of younger patients. Recognition of factors that potentially influence outcomes and overall future health will meet public health's primary and secondary prevention goals.     

Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction

The intensivist should think of delirium, or acute central nervous system dysfunction, as the brain's form of "organ dysfunction.' Delirium is extremely common in intensive care unit (ICU) patients due to factors such as comorbidity, critical illness, and iatrogenesis. This complication of hospital stay is extremely hazardous in older persons and is associated with prolonged hospital stays, institutionalization, and death. Neurologic dysfunction compromises patients' ability to be removed from mechanical ventilation or achieve full recovery and independence. Yet ICU nurses and physicians are usually unaware of the presence of hypoactive delirium and only recognize this disturbance in agitated patients (hyperactive delirium). More importantly, there are few studies that have included ICU patients in the assessment or prevention of delirium. This article reviews the definition and salient features of delirium, its primary risk factors, a newly validated instrument for delirium assessment that is being developed for ICU nurses and physicians, and pharmacological agents associated with the development of delirium and used in its management.     

A model for management of delirious postacute care patients

Although delirium has been shown to be a common, morbid, and costly problem for hospitalized older people, evidence has mounted that it may persist for weeks or months. Therefore, concern about delirium can no longer be confined to acute care. After an acute hospitalization, many older people are discharged to postacute care (PAC) facilities--rehabilitation hospitals and skilled nursing facilities. Although several models designed to prevent delirium in the hospital setting have been described, there have been few such efforts in the PAC setting. This article describes the development of a multifactorial delirium abatement program (DAP), a new model of care for older patients admitted to the postacute skilled nursing facility with delirium. The DAP is a nurse-led, unit-based intervention. The program consists of four modules based on best practices as defined by the peer-reviewed literature: standardized screening for symptoms and signs of delirium upon admission to the PAC unit, assessment and treatment of possible causes of and contributors to delirium, prevention and management of common delirium complications, and restoration of patient cognitive and self-care function. This article also presents the process of facility introduction, staff education on DAP content, and multidisciplinary outreach. Key strategies for DAP implementation are reviewed. Program adoption challenges and corresponding model refinements to enhance adherence and overall care quality are highlighted. Last, clinical adaptation of this research-derived program is discussed.     

Delirium: a test of the Diagnostic and Statistical Manual III criteria on medical inpatients

Although 10% to 15% of patients admitted to acute care hospitals are in a state of delirium, few patients are given this diagnosis by their clinician. We field-tested the Diagnostic and Statistical Manual III (DSM-III) criteria for diagnosing delirium on 133 consecutively admitted patients to an acute medical ward. Twenty patients were delirious using DSM-III criteria, 19 more patients than were reported by the primary clinician. Seven delirious patients were less than 65 years of age (range, 32 to 64 years). Sixty-five percent of patients with delirium died, whereas significantly fewer (3.3%) of patients without delirium died (P less than .0001). We found that delirium could be readily and reliably detected (kappa coefficient of agreement = 0.62 for interrater reliability) using the DSM-III criteria. Clinicians should routinely screen hospitalized patients of all ages using DSM-III criteria to identify delirious patients for an immediate evaluation and treatment.     

Delirium and its motoric subtypes: a study of 614 critically ill patients

OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. DESIGN: Prospective cohort study. SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center. PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.     

Capturing side-effect of medication to identify persons at risk of delirium

Delirium, an acute confusional state characterized by decline in attention and cognition, is a common, life-threatening, but potentially preventable clinical syndrome among older persons. Deficits in cholinergic function have been postulated to cause delirium and cognitive decline. In particular, an imbalance between levels of acetylcholine and monoamine (such as dopamine) may cause delirium. We describe two cases of delirium in hospitalized older patients, supporting the "cholinergic deficiency hypothesis". In the first patient, hypo-reactive delirium developed a few hours after a dose of the long-acting opiate tramadol (a drug with anticholinergic effect) as analgesic for pain related to advanced peripheral artery disease. In the second patient, with vascular parkinsonism plus pre-frontal cortex vascular lesions, hyper-reactive delirium developed a few hours after a prescribed administration of L-dopa. These symptoms disappeared completely on the following day. These two "natural" experiments support the hypothesis that both hypo-reactive and hyper-active delirium may be caused by a reduction in cholinergic signaling.