Biomedical subjects

F J Primeau

Publications and source records attributed to F J Primeau.

7 recordsLinked to original sources

PubMed1998

Detection and diagnosis of delirium in the elderly: psychiatrist diagnosis, confusion assessment method, or consensus diagnosis?

The clinical diagnosis of delirium has traditionally been based on an assessment by one or more physicians. Because of the transient, ubiquitous, and fluctuating nature of the symptoms of delirium, however, this approach may be flawed. Therefore, we decided to compare diagnosis based on one assessment by a psychiatrist, diagnosis by a nurse clinician (using the Confusion Assessment Method [CAM] and multiple observation points), and diagnosis by consensus. The study subjects were 87 patients aged 65 and over who were admitted consecutively from the emergency department to the medical wards, and who scored 3 or more on the Short Portable Mental Status Questionnaire. All subjects were assessed independently by one of three psychiatrists (a chart review and clinical examination) and a nurse clinician (using the CAM and multiple observation points). A consensus conference, attended by the three psychiatrists and the nurse clinician, used all available information to reach a consensus diagnosis. Compared to the consensus diagnosis, the clinical diagnosis by a psychiatrist had a sensitivity of .73 (95% confidence interval [CI]: .61-.85), a specificity of .93 (95% CI: .79-1.0), and an agreement kappa coefficient of .58 (95% CI: .41-.74). The nurse clinician diagnosis had a sensitivity of .89 (95% CI: .81-.97), a specificity of 1.00, and an agreement kappa coefficient of .86 (95% CI: .75-.97). These results suggest that one clinical assessment by a psychiatrist may not be the best method for detecting and diagnosing delirium in the elderly. A consensus diagnosis or diagnosis by a trained rater (using the CAM and multiple observation points) may be more sensitive approaches.

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PubMed1998

Delirium risk factors in elderly hospitalized patients.

OBJECTIVE: Delirium is frequent in elderly hospitalized patients. Many studies have examined its risk factors, but results have been quite variable. Thus, the goal of this study is to identify through systematic literature review the risk factors associated with the development of delirium in hospitalized geriatric patients. MEASUREMENTS AND MAIN RESULTS: First, MEDLINE/CURRENT CONTENTS databases were screened for relevant articles published from 1966 to December 1995, and from bibliographies of identified articles additional reports were selected. Second, the reports were screened by two different investigators and retained only if meeting the five following criteria: (1) original research in French or English; (2) prospective study; (3) patients over age 50; (4) minimum of one risk factor examined; (5) acceptable definition of delirium. Third, the methodology of each study was graded according to specific criteria for risk factor studies. Fourth, risk factors were identified and tabulated, unadjusted odds ratios (ORs) were computed, and where appropriate a combined OR with the Mantel-Haenszel estimator was calculated. Twenty-seven articles were retained meeting all of the above criteria. Among these studies, 11 were done on medical patients, 9 on surgical patients, 2 on medical and surgical patients, and 5 on psychiatric patients. In total 1,365 subjects with delirium were studied. Sixty-one different risk factors were examined, the five most common being dementia, medication, medical illness, age, and male gender. Mantel-Haenszel estimator was calculated for 10 risk factors, the most strongly associated being dementia (OR 5.2; 95% confidence interval [CI] 4.2, 6.3), medical illness (OR 3.8; 95% CI 2.2, 6.4), alcohol abuse (OR 3.3; 95% CI 1.9, 5.5), and depression (OR 1.9; 95% CI 1.3, 2.6). Methodologic weaknesses were present in many studies. CONCLUSIONS: Despite methodologic limitations, certain risk factors for delirium seem to be consistent and could help identify high-risk patients. These risk factors include dementia, advanced age, and medical illness. Other risk factors appear to play a contributory role in the development of delirium in elderly hospitalized patients.

Age Factors↗

PubMed1998

Clinical case discussion: the elderly patient with psychosis.

OBJECTIVE: To present a clinical case of an elderly person with psychosis and to discuss associated diagnostic and treatment issues. METHODS: A case from 1 of the authors' clinical practices was presented in English and French to several groups of Canadian psychiatrists attending a teaching day on psychosis. Three geriatric psychiatrists acted as facilitators, soliciting the clinical experiences of the participants in the discussion. The authors integrated clinical content from these sessions with results of a Medline search on psychosis in elderly persons. RESULTS: The assessment of elderly patients with psychosis is more often than in younger patients by overlying organicity, including delirium due to illness or medication use, dementia, or sensory deficits. Treatment might further worsen cognitive, affective, and functional impairment through adverse effects such as extrapyramidal symptoms (leading to decreased mobility and general functioning), anticholinergic effects (predisposing to delirium), and hypotension (predisposing to falls). Newer antipsychotics with less hazardous side effect profiles have an increasing role, but they must be coupled with psychosocial support to maximize the patient's independent functioning and quality of life after discharge. CONCLUSIONS: Assessment and treatment of the elderly person with psychosis must consider a wide variety of biopsychosocial variables, seeking to minimize further treatment-related deterioration. Controlled studies of antipsychotics in elderly people must be conducted in a variety of diagnostic situations that reflect their actual use in the community, and information must be propagated effectively among general psychiatrists, family physicians, and geriatric psychiatrists. The role of nonpharmacologic interventions in elderly persons with psychosis is even less well understood and deservers further study.

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PubMed1998

Delirium: prevention, treatment, and outcome studies.

The purpose of this paper was to contribute to a new conceptual understanding of delirium by reviewing evidence related to its prevention, treatment, and outcome. The review process involved a systematic search of the literature on each topic, assessment of the validity of the studies retrieved, and examination of their results. The literature search identified 10 studies on prevention, 13 studies on treatment, and 15 studies on outcome. Most studies had methodological limitations. Abroad spectrum of interventions appeared to be modestly effective in preventing delirium in young and old surgical patients but not elderly medical patients; systematic detection and intervention programs and special nursing care appeared to add large benefits to traditional medical care in young and old surgical patients and modest benefits in elderly medical patients; haloperidol, chlorpromazine, and mianserin appeared to be useful in controlling the symptoms of delirium in both surgical and medical patients; and good levels of premorbid function seemed to be related to better outcomes. Although the above findings do not contribute to a new conceptual understanding of delirium, they do suggest directions for further research on the treatment of delirium.

Age Factors↗

PubMed1994

Systematic intervention for elderly inpatients with delirium: a randomized trial.

OBJECTIVE: To assess a systematic intervention in cases of delirium in elderly inpatients. DESIGN: Randomized, controlled trial. SETTING: University-affiliated, primary acute care hospital. PATIENTS: Patients aged 75 years or over admitted to the medical department. They were screened within 24 hours after admission, and 88 patients with delirium (according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, third revised edition) were detected and enrolled in the trial. The patients were randomly allocated to the treatment group (42) or the control group (46); all were followed up until the end of the study. INTERVENTION: Patients were assessed on enrolment and 1, 2, 4 and 8 weeks later. Those in the treatment group received a consultation by a geriatric internist or psychiatrist and follow-up by a liaison nurse. Those in the control group received regular medical care. OUTCOME MEASURES: Short Portable Mental Status Questionnaire (SPMSQ), Crichton Geriatric Behavioural Rating Scale (CGBRS), use of restraints, length of hospital stay, discharge to a setting providing more care than was needed before admission and mortality rate. RESULTS: Two weeks after admission, patients in the treatment group showed an improvement in their mean SPMSQ scores, from 8.2 (standard deviation [SD] 1.9) to 7.9 (SD 2.5), whereas the control group showed a deterioration, from 8.4 (SD 1.7) to 9.1 (SD 1.1); this difference had disappeared by the end of the 8-week period (p < 0.05). Mean CGBRS scores were higher in the treatment group (32.0 [SD 8.6]) than the control group (28.5 [SD 9.4]) on enrolment and had improved more markedly by the end of the 8-week period (to 23.9 [SD 7.8] v. 25.0 [SD 7.0], p = 0.06). There was no statistically significant difference between the groups in use of restraints, length of hospital stay, discharge to a setting providing more care than was needed before admission or mortality rate. CONCLUSION: The beneficial effects of systematic detection and intervention in cases of delirium in elderly inpatients were small.

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PubMed1993

Prognosis of delirium in elderly hospital patients.

OBJECTIVE: To determine the prognosis of delirium in elderly patients. DATA SOURCES: MEDLINE was searched for relevant articles published from January 1980 to March 1992. The bibliographies of identified articles were searched for additional references. STUDY SELECTION: Eight reports (involving 573 patients with delirium) met the following inclusion criteria: original research, published in English or French, prospective study design, diagnosis based on acute deterioration in mental state, sample of at least 20 patients, patients aged 60 years or over and follow-up of at least 1 week. The validity of the studies was independently assessed according to the criteria for prognostic studies established by McMaster University, Hamilton, Ont. No study met all the criteria. DATA EXTRACTION: Information about the patient sample, length of follow-up and results was systematically abstracted from each report and tabulated. DATA SYNTHESIS: A meta-analysis of the outcomes indicated that elderly patients with delirium had a mean length of stay of 20.7 days. One month after admission 46.5% were in institutions, and 14.2% had died; only 54.9% had improved mentally. Six months after admission 43.2% were in institutions. Compared with unmatched control subjects they had longer hospital stays, higher mortality rates at 1 month and higher rates of institutional care at 1 and 6 months. The presence of severe physical illness or dementia may have been related to some outcomes. CONCLUSIONS: Delirium in the elderly appears to have a poor prognosis. However, this finding may have been confounded by the presence of concomitant dementia or severe physical illness. Future studies must pay attention to methods and design, particularly the composition of study populations and the control of extraneous prognostic factors.

Age Factors↗

PubMedDate not supplied

Comparative ethics and geriatric psychiatry: looking at motivations.

In the broadest sense, medicine is a biologic-anthropologic model. The latest data on epidemiology and biology confirm earlier apprehensions about life expectancy, number of elderly, and the impact of mental impairment. The author wishes to reflect rather on anthropology by comparing the American and French cultures faced with the ethical dilemmas of aging and end-of-life issues. On this perilous frontier of biomedical ethics, the author suggests that the right to be treated as a person is an effective source of motivation for physicians to respect the dignity of geriatric patients in the context of high-technology medicine.

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