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PubMedDate not supplied

The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses.

We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.

Adult↗

PubMed2001

Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium.

The DRS-R-98, a 16-item clinician-rated scale with 13 severity items and 3 diagnostic items, was validated against the Cognitive Test for Delirium (CTD), Clinical Global Impression scale (CGI), and Delirium Rating Scale (DRS) among five diagnostic groups (N=68): delirium, dementia, depression, schizophrenia, and other. Mean and median DRS-R-98 scores significantly (P<0.001) distinguished delirium from each other group. DRS-R-98 total scores correlated highly with DRS, CTD, and CGI scores. Interrater reliability and internal consistency were very high. Cutoff scores for delirium are recommended based on ROC analyses (sensitivity and specificity ranges: total, 91%-100% and 85%-100%; severity, 86%-100% and 77%-93%, respectively, depending on the cutoffs or comparison groups chosen). The DRS-R-98 is a valid measure of delirium severity over a broad range of symptoms and is a useful diagnostic and assessment tool. The DRS-R-98 is ideal for longitudinal studies.

Adolescent↗

PubMed2001

Assessing delirium in cancer patients: the Italian versions of the Delirium Rating Scale and the Memorial Delirium Assessment Scale.

To validate the Italian versions of the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS), 105 cancer patients consecutively referred for neurological or psychiatric consultation for mental status change were evaluated using the Confusion Assessment Method (CAM), the DRS, the MDAS, and the Mini-Mental State Examination (MMSE). According to the CAM criteria and clinical examination, 66 patients were delirious, and 39 received diagnoses other than delirium. The DRS and the MDAS scores significantly distinguished delirious from non-delirious patients. The MDAS and the DRS were mutually correlated. When using the proposed cut-off scores for the two scales, the MDAS had higher specificity (94%) but lower sensitivity (68%) than the DRS (sensitivity = 95%, specificity = 61% for DRS cut-off 10; sensitivity = 80%, specificity = 76%, DRS cut-off 12). The MMSE showed high sensitivity (96%) and very low specificity (38%). Exploratory factor analysis of the DRS and the MDAS suggested a three-factor and two-factor structure, respectively. Both instruments in their Italian version proved to be useful for the assessment of delirium among cancer patients. Further research is needed to examine the use of the DRS and the MDAS in other clinical contexts.

Aged↗

PubMed2000

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment.

BACKGROUND: Delirium is common in hospitalized elderly people. In the frail elderly, delirium may occur in 60% of those hospitalized. In the cognitively impaired, 45% have been shown to develop delirium and these patients have longer lengths of stay and a higher rate of complications which, amongst other things, together contribute to an increase in cost of care. The combination of being elderly and chronically cognitively impaired leads to a high risk of delirium with the associated increased risk of prolonged hospital stay, complications, and poor outcomes. The management of delirium has commonly been multifaceted - the primary emphasis has always been on the diagnosis and therapy of the precipitating factors, but as this may not be immediately resolved, symptomatic and supportive care may become of major importance. OBJECTIVES: The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of patients with delirium superimposed on an underlying chronic cognitive impairment compared with the usual care of older cognitively impaired patients. SEARCH STRATEGY: The Cochrane Controlled Trials Register (Cochrane Library, up to and including Issue 1, 1998) was searched using the terms 'delirium, controlled trial, cognitive'. MEDLINE, EMBASE and Psychlit (Ovid via Winspirs up to Feb 1998) were also searched with the same terms. Other sources including personal communications, ongoing trials, conference proceedings, handsearching and reference lists of published papers and books were all searched for relevant randomized controlled trials. The total yield from searching was 157 from which 8 (eight) were retained for consideration in the review. SELECTION CRITERIA: From the initial search yields, all randomised controlled trials involving the management of elderly patients with delirium were identified. A single reviewer (AMB) discarded irrelevant publications based on the title of the publication and its abstract. In the event that the article could possibly be relevant, it was retrieved for further assessment. All references were compiled in a list with a commentary on type of article, eg review, prospective study etc and this was independently considered by the second reviewer (RR) who agreed to review all randomised controlled studies reported on patients with delirium. Selection for possible inclusion in this review was then made on the basis of the participants reported as having chronic cognitive impairment, who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. The outcomes of interest were length of stay in hospital, morbidity (including complications), patient distress & impact on care environment, mortality, discharge arrangements and follow-up including assessment of cognitive function at 6 months. Studies in which patients with chronic cognitive impairment or dementia, managed for incident delirium, according to ICD 9 criteria (see note) were considered eligible for inclusion in the review. Studies of risk factors and non-randomized studies were excluded. Note: this classification has been widely utilised throughout the English speaking medical literature over the past 20 years: ICD 10 is still being incorporated into clinical coding systems and has not been utilised in studies published in 1996. (ABSTRACT TRUNCATED)

Delirium↗

PubMed1976

[Criteria of the efficacy of therapeutic measures in alcoholic delirium. Study on the effectiveness of aprotinin in alcoholic delirium].

30 patients with delirium tremens were given in a double-blind trial--beside the basic treatment with chlormethiazol (Distraneurin)--aprotinin (Trasylol) or placebo. Duration of the delirium and the amount of chlormethiazol used were the criteria for successful treatment. It was shown that the additional application of aprotinin did neither shorten significantly the duration of the delirium not save the amount of chlormethiazol used. Methodologically, special attention was given to the question of duration of the delirium and of registering symptoms. A delirium-rating scale was devised and its analysis showed a good randomization of the items. One main question was as to what extent the individual items were good indicators of a delirium. An item intercorrelation showed that there were two clusters of symptoms: psychological and sympathetic nervous system symptoms. It could be shown that the items 'consciousness, orientation, hallucinations and short-term memory' were good indicators of the delirium, while items of the autonomous nervous system, as tremor of hands and body, facial muscular twitching and exteroceptive reflexes, were less indicative of delirium. The duration of the delirium seems to be the best criterion for the question as to whether a drug is effective or not in delirium tremens. There is a highly significant correlation between the degree of the severity of the delirium and its duration. Other significant predictors for the severity of the delirium were the maximal pulse rate and change in blood pressure. Age, duration of alcoholism and psychological or physical depravation showed no influence on the duration of the delirium.

Adult↗

PubMed2000

Clinical utility, factor analysis, and further validation of the memorial delirium assessment scale in patients with advanced cancer: Assessing delirium in advanced cancer.

BACKGROUND: Delirium is a common neuropsychiatric complication in patients with advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a recently developed 10-item severity rating instrument. The purpose of the current prospective study was to further assess the clinical utility, factor structure, and validity of the MDAS in a relatively homogeneous population of patients with advanced cancer. METHODS: Study entry of 104 patients occurred on their consecutive admission to a tertiary-level, acute palliative care unit in a university-affiliated teaching hospital. Patients underwent regular cognitive screening using the Mini-Mental State Examination, and serial monitoring of delirium using standardized semistructured interviews and MDAS ratings, up to the study endpoints of either patient discharge or death. RESULTS: Seventy-one patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a first episode of delirium. In 15 of 71 (21%) patients with a first episode of delirium, the first MDAS ratings were prorated because of dyspnea, fatigue, or profound delirium. In the remaining 56 patients (79%), the first MDAS ratings were rated fully and therefore evaluable. Correlations among the scale items ranged from moderate to low (correlation coefficient [r] = 0.68-0.02). Analysis of the pattern of factor loadings identified two primary correlated factors: global cognitive (Factor I) and neurobehavioral (Factor II) (r = 0.33). Cronbach alpha coefficients for Factors I and II were 0.8 and 0.66, respectively, indicating a relatively high level of correlation for items within each. The Cronbach alpha coefficient for all 10 items was 0.78, suggesting a general underlying factor. In a larger sample of complete MDAS ratings (n = 330) a cutoff total MDAS score of 7 of 30 yielded the highest sensitivity (98%) and specificity (96%) for delirium diagnosis. The MDAS was correlated moderately with the Mini-Mental State Examination (r = 0.55). CONCLUSIONS: The authors concluded that the MDAS structure is representative of the many features of delirium, broadly grouped as global cognitive and neurobehavioral dimensions. Prorating item scores is necessary in approximately 20% of advanced cancer patients with delirium. This poses potential limitations on the applicability of the MDAS in research. Conversely, the ability to prorate item scores confers a clinical advantage to the instrument when assessing delirium in a patient population with advanced cancer.

Aged↗

PubMed2004

Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery.

BACKGROUND: Despite improved outcomes after cardiac operations, postoperative delirium remains a common complication that is associated with increased morbidity and prolonged hospital stay. METHODS: Univariate and multivariate predictors of postoperative delirium were determined from prospectively gathered data on 16,184 patients undergoing cardiac operations with cardiopulmonary bypass (conventional, n = 14,342) and without cardiopulmonary bypass (beating-heart surgery, n = 1847) between April 1996 and August 2001. Delirium was defined as a transient mental syndrome of acute onset characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity, and a disordered sleep-wake cycle. RESULTS: The overall prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related risk factors and treatment variables, 35 were highly associated with postoperative delirium by univariate analysis. Stepwise logistic regression revealed the following variables as independent predictors of delirium: history of cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours or more, and a high perioperative transfusion requirement. Two variables were identified as having a significant protective effect against postoperative delirium: beating-heart surgery and younger patient age. CONCLUSIONS: Postoperative delirium is a common complication in cardiac operations. The increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower prevalence of this complication and thus improve patient outcomes.

Age Distribution↗

PubMedDate not supplied

Delirium in clinical practice: experiences from a specialized delirium ward.

Geriatric patients with known dementia and suffering from an acute somatic disease are highly vulnerable to develop delirium. It is therefore essential to suspect and recognize delirium in these patients, especially in emergency wards. In the present study we evaluated activities on a dedicated delirium ward at a Swedish University Hospital. Over one and a half years 637 patients were treated for suspected delirium, the majority of patients being referred from the emergency ward at the same hospital. Infectious diseases were the main cause of delirium in 67% of cases. Other common causes were heart disease and stroke. Drug use as the only cause of delirium was found in less than 1% of cases. Approximately 70% of patients had cognitive disturbances, either dementia or mild cognitive impairment. The existence of multiple diseases as causative factors was frequent. Knowledge about delirium and how it is both diagnosed and treated is of great importance in all kinds of settings where acute somatic treatments are common.

Aged↗

PubMed1990

Senile delirium with special reference to situational factors and recurrent delirium.

Factors initiating senile delirium were examined in 129 elderly inpatients (65 years or older). Sixty-eight patients were males and 61 females, with a mean age of 76.3 years. Delirium developed in most cases on the first two days of admission in the hospital, and the admission appeared to be a key factor precipitating delirium in about 30% of the patients. Delirium resolved or improved in 80% of the patients, but usually persisted in patients with dementia. Senile delirium tended to reappear repeatedly in patients whose episode of delirium lasted for more than 2 weeks, was associated with dementia, or had a prior history of delirium.

Aged↗

PubMed1988

Operative predictors of delirium after pulmonary thromboendarterectomy. A model for postcardiotomy delirium?

Pulmonary thromboendarterectomy is an innovative surgical technique for treating pulmonary hypertension caused by chronic thromboembolism. The procedure uses cardiopulmonary bypass but necessitates dramatically longer bypass times than coronary artery bypass grafting or valve operations. We prospectively evaluated 22 patients undergoing pulmonary thromboendarterectomy to determine the incidence of delirium and its relationship to certain preoperative and postoperative medical variables as well as to duration of cardiopulmonary bypass, deep hypothermia, and circulatory arrest. Delirium occurred in 77% of patients with a peak incidence around 72 hours postoperatively. No preoperative or postoperative medical variable distinguished delirious from nondelirious patients. Total bypass time was not associated with delirium, but deep hypothermia time and total circulatory arrest time were both strongly associated. Overall prediction of delirium was 81% when total circulatory arrest time was considered. Further analysis suggested that a total circulatory arrest time greater than 55 minutes was both sensitive to (82%) and specific for (80%) delirium. Implications for the mechanism of postcardiotomy delirium and future research directions are discussed.

Cardiopulmonary Bypass↗

PubMed1994

The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients.

Delirium, with occurrence rates from 14% to 56%, associated mortality rates from 10% to 65%, and excess annual health care expenditures from $1 to $2 billion, poses a common and serious problem for hospitalized elderly patients. Delirium is often unrecognized or misdiagnosed by physicians caring for elderly patients. Cognitive testing is rarely done as part of the admission evaluation of elderly hospitalized patients. Specific diagnosis has been difficult, since diagnostic criteria and instruments are still being developed. The etiology of delirium is complex and multifactorial, and both predisposing (host vulnerability) and precipitating factors must be considered. The recommended approach to the evaluation of delirium is empiric, in the absence of objective efficacy data. The cornerstone of evaluation includes a careful history, physical examination, and review of the medication list--since medications are the most common reversible cause of delirium. Research is needed to establish a cost-effective approach and to clarify the role of further testing, such as cerebrospinal fluid examination, brain imaging, and electroencephalography. This article is intended to heighten the awareness of clinicians as well as to stimulate research to address this important, neglected problem for elderly hospitalized patients.

Aged↗

PubMed1986

The treatment of delirium tremens and of incomplete alcoholic delirium--a brief history.

Following the introduction of chlormethiazole for the treatment of delirium tremens a striking reduction in the death rate occurred. The mortality range in most statistics is 1-4%. The patient's age and complications concerning various internal organs affect the clinical outcome and so does the time at which chlormethiazole treatment is initiated. However, this has given rise to the habit of prescribing chlormethiazole at the slightest suspicion of the early stages of delirium tremens. In some cases the use of the drug was no doubt unnecessary, but equally certainly this measure has often prevented the development of complete delirium tremens which is now seen far more rarely than it was 20 years ago. The availability of this well-tolerated and easily controllable drug has made the treatment of most cases of delirium tremens a manageable task for any reasonably experienced physician. However, it should never be forgotten that delirium tremens is a life-threatening condition with many potential complications. Therefore, the initiation of any chlormethiazole therapy calls for careful monitoring by the physician.

Administration, Oral↗

PubMed1998

Is delirium different when it occurs in dementia? A study using the delirium rating scale.

The authors studied 61 geropsychiatric patients with delirium from a cohort of 843 consecutive admissions to a geriatric clinical research unit. A central study goal was to assess how the presence of dementia affected the presentation of delirium. Eighteen delirious (D) and 43 delirious-demented (D-D) patients were compared on the Delirium Rating Scale (DRS), Mini-Mental State Examination (MMSE), Brief Psychiatric Rating Scale (BPRS), and EEG. D-D patients had lower MMSE scores, but no differences were found in total DRS or BPRS scores or in EEG grade. DRS items were similar in the two groups except that D-D had more cognitive impairment than D. An exploratory principal components analysis of DRS items identified two core factors. The authors conclude that the presentation of delirium in the setting of concurrent dementia is very similar to delirium without dementia, with subtle differences probably attributable to dementia.

Aged↗

PubMedDate not supplied

The delirium symptom interview: an interview for the detection of delirium symptoms in hospitalized patients.

To study delirium in hospitalized elderly, a delirium symptom interview (DSI) was developed by an interdisciplinary group of investigators. This interview was administered in an acute care hospital to 50 patients who were over the age of 65 years. Results from the interview were compared to assessments of major symptoms of delirium made independently by a neurologist and a psychiatrist. This interview had good validity and reliability. The sensitivity of the DSI was .90 and the specificity was .80, when compared with the clinical judgment of a psychiatrist and neurologist. Interrater reliability, using lay interviewers, was .90 for the detection of major symptoms of delirium. These results indicate that the DSI could be used by lay interviewers to assess reliably the symptoms of delirium.

Aged↗

PubMed2003

The Delirium Observation Screening Scale: a screening instrument for delirium.

The Delirium Observation Screening (DOS) scale, a 25-item scale, was developed to facilitate early recognition of delirium, according to the Diagnostic and Statistical Manual-IV criteria, based on nurses' observations during regular care. The scale was tested for content validity by a group of seven experts in the field of delirium. Internal consistency, predictive validity, and concurrent and construct validity were tested in two prospective studies with high risk groups of patients: geriatric medicine patients and elderly hip fracture patients. Among the patients admitted to a geriatric department (N = 82), 4 became delirious; among the elderly hip fracture patients (N = 92), 18 became delirious. The DOS scale was determined to be content valid and showed high internal consistency, alpha = 0.93 and alpha = 0.96. Predictive validity against the Diagnostic and Statistical Manual-IV diagnosis of delirium made by a geriatrician was good in both studies. Correlations of the DOS scale with the Mini Mental State Examination (MMSE) were Rs -0.79 (p < or = 0.001) in the hip fracture patients and Rs -0.66 (p < or = 0.001) in the geriatric medicine patients. Concurrent validity, as tested by comparison of the research nurse's ratings of the DOS scale and the Confusion Assessment Method (CAM), for the group of hip fracture patients was 0.63 (p < or = 0.001). Construct validity of the DOS was tested against the Informant Questionnaire of Cognitive Decline in Elderly (IQCODE), a preexisting psychiatric diagnosis and the Barthel Index. Correlation with the IQCODE was 0.74 (p < or = 0.001) in the study with the hip fracture patients and 0.33 (p < or = 0.05) in the study with the geriatric medicine patients. Correlation with the Barthel Index was -0.26 (p < or = 0.05) in the geriatric medicine patients and -0.55 (p < or = 0.001) in the hip fracture patients. The overall conclusion of these studies is that the DOS scale shows satisfactory validity and reliability, to guide early recognition of delirium by nurses' observation.

Activities of Daily Living↗

PubMed1995

A nursing protocol to assess causes of delirium. Identifying delirium in nursing home residents.

Because delirium is often a harbinger of underlying physical illness in frail elders--which can cause further morbidity and functional decline--it is essential to accurately assess the causes of delirium. Nurses working in nursing homes are in the best position to make these assessments and advocate for the appropriate management of delirium. The implementation of the proposed nursing protocol may empower nurses and, thus, improve outcomes of nursing home residents suffering from delirium.

Aged↗

PubMed1997

Outcome of delirium: Part 1. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the Reversible Cognitive Dysfunction Scale among acute geriatric inpatients.

OBJECTIVE: To study performance of DSM-III-R, ICD-10 and CAMDEX diagnoses of delirium as predictors of improvement in mental state in survivors, and to develop a brief rating scale which will predict reversibility of cognitive dysfunction. DESIGN: Prospective cohort study. SETTING: Acute geriatric inpatient units. PATIENTS: A random sample of consecutive acute admissions of patients over the age of 65 (N = 80). MAIN MEASUREMENTS: Serial assessments of mental state and cognitive function and observational data. Establishment of DSM-III-R, ICD-10, CAMDEX diagnoses. OUTCOME MEASURE: Patients with more than five points of 20% improvement in Mini Mental State Examination following the most severely impaired assessment operationally designated 'reversible cognitive dysfunction'. MAIN RESULTS: Diagnoses of delirium by DSM-III-R and ICD-10 do not predict improvement in cognitive function well; CAMDEX does rather better. Discriminant function analysis yielded the Reversible Cognitive Dysfunction Scale (RCDS), a simple clinical scale which accurately predicted improvement. This comprised reduced conscious level, poor attention, poor contact with the patient, incoherent speech, reduced psychomotor activity, lack of awareness of surroundings and poor orientation and memory. CONCLUSIONS: The concept of and diagnostic criteria for delirium should be reconsidered. The RCDS merits further evaluation.

Acute Disease↗

PubMed1989

[L-tryptophan in pre-delirium and delirium conditions].

The effect of the serotonin precursor l-tryptophan on delirium and pre-delirium states was studied in a prospective study on 32 patients. Patients were given 3 infusions each containing 2.5 g l-tryptophan, a day for at least 7 days. The status of the patients was examined with the Mini Mental State Examination, the SCAG (Sandoz Clinical Assessment Geriatric Scale) and a sleep/awake observation sheet. These showed that the patients experienced significant trends toward improvement. Relevant side effects and interactions were not observed. The application of supplemental tranquilizers could be reduced and in 5 cases it was not necessary at all. It was only necessary to apply l-tryptophan for longer than 7 days in 4 of 32 patients. Furthermore, under this medication no patient in a state of predelirium at delivery into the hospital developed full delirium tremens.

Alcohol Withdrawal Delirium↗