- Email: [email protected]
Delirium
Psychiatric aspects of general medicine
Delirium
What’s new?
Max Henderson
• Improved understanding of the independence of the cognitive, motoric and psychotic aspects of delirium • Increase in the use of atypical antipsychotic medications although little good-quality evidence to support this so far • Increased use of cholinesterase inhibitors although little good-quality evidence to support this so far
Abstract Delirium tremens is a particular form of delirium associated with cessation of drinking in those with alcohol dependence syndrome.5 It is distinct from other forms of delirium (see also pages 422–429).
Delirium is a common life-threatening condition, suggestive of global organic cognitive dysfunction, which is the final common pathway for a number of insults. Inattention is the most common feature but disorientation, hallucinations, affective changes, and alterations in the sleep–wake cycle are also seen. The classical picture of the hyperactive wandering patient is less common than the withdrawn hypoactive presentation. Psychosis is equally likely in both groups and should be investigated. Many different assessment tools are available to assist in the diagnosis of delirium, though the most important step is to consider the diagnosis in the first place. Non-pharmacological interventions are vital; their aim is to minimize the impact of factors which predispose an individual to an episode of delirium. In established delirium, investigation and management of the underlying cause is crucial. Most drug treatment involves the use of antipsychotic medication, although the evidence is limited. Short-acting reversible benzodiazepines specifically target the anxiety experienced in delirium and thus may be useful if not contraindicated.
Epidemiology Delirium is common. Community studies suggest a prevalence of 0.4% in those aged over 18, rising to 13.6% in those over 85 years.6 A higher prevalence is found in hospital studies, typically 10–20%.7 Acute confusion appears especially common in burns units,8 cancer units9 or intensive care units (ICU)10 where up to half of patients may be delirious.
Risk factors Risk factors for delirium are best understood as either predisposing or precipitating (Table 1).11 Predisposing factors affect the
Keywords antipsychotics; delirium; hallucinations; hyperactive; hypoactive; inattention
Risk factors for delirium Definition Predisposing factors Older age Pre-existing cognitive function Sensory impiarment
Delirium describes an organic brain disorder, often of acute onset, in which multiple domains of cognitive function are disturbed along with changes in levels of arousal and alterations in the sleep–wake cycle.1,2 It commonly follows a fluctuating course. The disturbances in brain activity are secondary to another insult although the nature of the presentation is rarely a reliable indicator of the underlying cause. Delirium should be distinguished from dementia, although cognitive impairment is seen in both, and an underlying dementia might be a predisposing factor for delirium.3 Dementia typically has an insidious onset over months or years whilst delirium runs an acute and fluctuating course.4 Attention is often normal in dementia but impaired in delirium. In the early stages of dementia, orientation and working memory are normal and psychosis rarely seen – this is not true for delirium (see also pages 467–470).
Precipitating factors
Post-operative Drug side effect New cerebrovascular event Myocardial infarction Infection • Urinary tract • Respiratory • Meningitis • Osteomyelitis • Endocarditis Hypoxia Metabolic disturbance • ↑↓ sodium/potassium/calcium • ↑↓ glucose Terminal illness Constipation
Max Henderson MSc MRCP MRCPsych is MRC Research Training Fellow in the Department of Psychological Medicine at the Institute of Psychiatry, King’s College London, UK. Competing interests: none declared.
MEDICINE 36:9
Table 1
463
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
delirium threshold, i.e. make one more vulnerable to delirium. Precipitating factors are insults which result in someone becoming confused.
Tests of attention Reverse digit span Give the patient a series of numbers, spoken in a consistent rhythm, and ask the patient to repeat them to you in reverse order 1-4-6 6-4-1 2-7-4-8 8-4-7-2 3-1-9-2-5 5-2-9-1-3 Serial subtraction Ask the patient to start at 100 (or 20) and ask the patient to subtract 7 (or 3), then subtract a further 7 from the result and so on. Record what they actually say
Clinical features Delirium is a syndrome with a range of abnormalities including cognitive, perceptual, motor, affective, and sleep disturbances (Table 2).12 The most common feature is inattention, which is a failure to focus or concentrate, present in 97% of cases. The level of inattention correlates with other aspects of cognitive impairment, but not other abnormalities, such as motoric state or the presence of psychosis. Disorientation is one of the least common problems, so therefore the Mini Mental State Examination (MMSE)13 is a poor screening tool for delirium (see also pages 393–398). Hallucinations occur in half of cases but are prominent in only 20%.12 They are most commonly visual or auditory. Paranoid delusions and disordered thinking also occur. Affective disturbances range from manic presentations with high levels of arousal, elation and irritability to an apparently depressive picture with isolative behaviour, poor eye contact and paucity of spontaneous movement. One symptom commonly overlooked is anxiety. The bewildering experiences of the delirious patient can be terrifying. Disturbances, especially reversal, of the sleep–wake cycle are often seen. Motor disturbance is a prominent feature of delirium. Hyperactive delirium is the most easily recognized subtype, characterized by high levels of arousal, restlessness, distractibility and wandering. In contrast, the hypoactive subtype includes the ‘faceto- the-wall’ patients with reduced or slowed movement, reduced or absent speech, apparently reduced awareness and apathy.14,15 About 50% of cases are of the hypoactive subtype, and a further 30% present with a mix of both. The hyperactive presentation is the least common. Furthermore there is no association between the motoric subtype and psychosis – the hypoactive patient is just as likely to be hallucinating.12
Table 3
via its impact on memory is also possible – examples include remembering the examiner’s name after 2 minutes or recalling specific objects identified by the examiner. Standardized instruments can be useful. However, it is vital to be clear whether they have been designed for screening (e.g. Clock Drawing Test17; Table 4), diagnosis (e.g. Confusion Assessment Method18) or to assess severity (e.g. Memorial Delirium Assessment Scale19). One simple screening tool is the Clock Drawing Test which has been validated in several settings.20 It is quick, easy and non-threatening, although the physical requirements limit its use in those with a stroke or motor neurone disease. The Abbreviated Mental Test Score is also widely used.21 The Confusion Assessment Method18 is one of the best validated and most widely used. It is relatively brief, non-threatening and is designed to be used by non-psychiatrists.
Management Prevention Two quite different approaches to primary prevention have been reported. The Yale Delirium Prevention Trial was based on the predisposing/precipitating model of causation already described.22 Strategies to optimize the patient’s condition with special attention paid to orientation, hydration, correcting visual and hearing impairment, and minimizing sleep–wake cycle disturbance by reducing night-time noise from movement, telephones and bleeps reduced the incidence of delirium on the intervention ward by a third. Kalisvaart attempted a different approach on a high-risk group of patients.23 The severity of delirium was reduced in patients randomized to 1.5 mg haloperidol starting pre-operatively and continuing up to day 3 post-operatively. Furthermore, the length
Assessment Many episodes of delirium are missed, often because the hypoactive presentation does not prompt a consideration of delirium as a differential diagnosis. Hence, the first step is a low threshold for considering the diagnosis. Gentle exploration for the key features can follow. Impaired attention has been identified as a core feature. This can be assessed using the reverse digit span,16 serial 7s (from 100) or serial 3s (from 20) (Table 3). Assessing attention
Diagnostic criteria for delirium
Clock drawing test
ICD-10 criteria4 Impairment in consciousness or attention Global cognitive impairment Psychomotor disturbance Sleep–wake cycle disturbance Emotional disturbance
• Give the patient a sheet of paper with a large circle drawn on it • Ask the patient to add in the numbers to create a clock-face • Ask the patient to add the hands so show a time you tell them • Several scoring systems have been described
Table 2
MEDICINE 36:9
Table 4
464
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
features of delirium, which is anxiety.27 Others are concerned about the possibility of over-sedation and the paradoxical reaction where patients can become more rather than less agitated. There are several case reports of cholinesterase inhibitors such as donepezil and rivastigmine which appear well tolerated. There is insufficient evidence however to recommend them more widely.28
of each episode was on average halved and there was a reduction in the length of hospital stay. Treatment There are two clear and distinct goals for the treatment of delirium: • The identification and correction of the underlying insult. • The amelioration of the worst symptoms of the delirium, so as to make the patient more comfortable until the underlying problem has been resolved. Investigation of the underlying insult should be guided by information about the individual patient (including current and recent medications), the results of a thorough clinical examination and evidence from previous investigations. The general rule of starting with the least invasive investigations still applies (Table 5). When considering symptomatic treatment it should be remembered that the patient’s most distressing symptoms may not be the most obvious or the easiest to treat. Drug treatment is not always needed – there is no drug treatment for a wandering patient.
Conclusions Delirium is a common and distressing condition. A classical presentation is rare and many episodes go undiagnosed and untreated. Improved care must start with the diagnosis being considered more readily. Good evidence exists for the prevention of delirium both by pharmacological and non-pharmacological methods and these should be employed more widely. Treatment should focus on the individual needs of the patient rather than the most prominent symptoms and both antipsychotic and anxiolytic medications are widely used. ◆
Antipsychotic medications are the most commonly used although there is little evidence to support this. The most recent Cochrane systematic review found only three small studies of sufficient quality.24 One study compared haloperidol, chlorpromazine and lorazepam in patients with HIV and showed a clear advantage for haloperidol.25 However, this is only one study in a very select group and so we need to be aware of risk of over-generalization. Haloperidol is well tolerated with few extrapyramidal side effects at low doses. It is relatively non-sedative, but hypotension can be a problem. More recent studies have used newer atypical antipsychotics such as risperidone and quetiapine. There is no evidence at present that they are more effective.26
References 1 Young J, Inouye SK. Delirium in older people. BMJ 2007; 334: 842–46. 2 Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004; 75: 362–67. 3 Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev 2004; 14: 87–98. 4 World Health Organization. International classification of diseases 10th revison. Geneva: World Health Organization, 1993. 5 Dunn N, Cook CC. Psychiatric aspects of alcohol misuse. Hosp Med 1999; 60: 169–72. 6 Folstein MF, Bassett SS, Romanoski AJ, Nestadt G. The epidemiology of delirium in the community: the Eastern Baltimore Mental Health Survey. Int Psychogeriatr 1991; 3: 169–76. 7 Lindesay J, Rockwood K, Rolfson D. The epidemiology of delirium. In: Lindesay J, Rockwood K, McDonald A, eds. Delirium. Oxford: Oxford University Press, 2002. 8 Ilechukwu ST. Psychiatry of the medically ill in the burn unit. Psychiatr Clin North Am 2002; 25: 129–47. 9 Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 2000; 160: 786–94. 10 Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for intensive care delirium: a systematic review. Intensive Crit Care Nurs 2008; 24: 98–107. 11 Inouye SK. Predisposing and precipitating factors for delirium in hospitalized older patients. Dement Geriatr Cogn Disord 1999; 10: 393–400. 12 Meagher DJ, Moran M, Raju B, et al. Phenomenology of delirium. Assessment of 100 adult cases using standardised measures. Br J Psychiatry 2007; 190: 135–41. 13 Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Arch Gen Psychiatry 1983; 40: 812. 14 Lipowski Z. Delirium: acute confusional states. New York: Oxford University Press, 1990.
Other drug treatments: a number of alternatives to antipsychotics may be used. Several authors advocate the use of benzodiazepines on the grounds that that they are short-acting, reversible, well tolerated and specifically treat one of the most unpleasant
Possible investigations in delirium • Urinalysis ○ Microscopy ○ Culture • Sputum culture • Full blood count • Urea & electrolytes • Serum calcium • Serum glucose • Liver function tests • Chest X-Ray • ECG • MRI brain • Cardiac ultrasound • Electroencephalogram (EEG) • Lumbar puncture Table 5
MEDICINE 36:9
465
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153: 231–37. 26 Boettger S, Breitbart W. Atypical antipsychotics in the management of delirium: a review of the empirical literature. Palliat Support Care 2005; 3: 227–37. 27 Meagher DJ. Delirium: optimising management. BMJ 2001; 322: 144–49. 28 Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev 2008(1): CD005317.
15 Stagno D, Gibson C, Breitbart W. The delirium subtypes: a review of prevalence, phenomenology, pathophysiology, and treatment response. Palliat Support Care 2004; 2: 171–79. 16 Hodges J. Cognitive assessment for clinicians. Oxford: Oxford University Press, 1994. 17 Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000; 15: 548–61. 18 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: 941–48. 19 Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997; 13: 128–37. 20 Henderson M, Hotopf M. Use of the clock-drawing test in a hospice population. Palliat med 2007; 21: 559–65. 21 Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age ageing 1972; 1: 233–38. 22 Inouye SK, Bogardus Jr ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76. 23 Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658–66. 24 Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev 2007(2): CD005594. 25 Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of
MEDICINE 36:9
Practice points • Disorientation is one of the least common problems • The mini mental state examination (MMSE) is a poor screening tool for delirium • Hypoactive state is more common than hyperactive • Motoric state is not a guide to the presence of psychosis • The underlying cause should be sought and treated appropriately • Fear and anxiety are common and are often overlooked yet easily managed • Drug treatment for the delirium is not always needed – there is no drug treatment for a wandering patient
466
© 2008 Elsevier Ltd. All rights reserved.
Delirium
What’s new?
Max Henderson
• Improved understanding of the independence of the cognitive, motoric and psychotic aspects of delirium • Increase in the use of atypical antipsychotic medications although little good-quality evidence to support this so far • Increased use of cholinesterase inhibitors although little good-quality evidence to support this so far
Abstract Delirium tremens is a particular form of delirium associated with cessation of drinking in those with alcohol dependence syndrome.5 It is distinct from other forms of delirium (see also pages 422–429).
Delirium is a common life-threatening condition, suggestive of global organic cognitive dysfunction, which is the final common pathway for a number of insults. Inattention is the most common feature but disorientation, hallucinations, affective changes, and alterations in the sleep–wake cycle are also seen. The classical picture of the hyperactive wandering patient is less common than the withdrawn hypoactive presentation. Psychosis is equally likely in both groups and should be investigated. Many different assessment tools are available to assist in the diagnosis of delirium, though the most important step is to consider the diagnosis in the first place. Non-pharmacological interventions are vital; their aim is to minimize the impact of factors which predispose an individual to an episode of delirium. In established delirium, investigation and management of the underlying cause is crucial. Most drug treatment involves the use of antipsychotic medication, although the evidence is limited. Short-acting reversible benzodiazepines specifically target the anxiety experienced in delirium and thus may be useful if not contraindicated.
Epidemiology Delirium is common. Community studies suggest a prevalence of 0.4% in those aged over 18, rising to 13.6% in those over 85 years.6 A higher prevalence is found in hospital studies, typically 10–20%.7 Acute confusion appears especially common in burns units,8 cancer units9 or intensive care units (ICU)10 where up to half of patients may be delirious.
Risk factors Risk factors for delirium are best understood as either predisposing or precipitating (Table 1).11 Predisposing factors affect the
Keywords antipsychotics; delirium; hallucinations; hyperactive; hypoactive; inattention
Risk factors for delirium Definition Predisposing factors Older age Pre-existing cognitive function Sensory impiarment
Delirium describes an organic brain disorder, often of acute onset, in which multiple domains of cognitive function are disturbed along with changes in levels of arousal and alterations in the sleep–wake cycle.1,2 It commonly follows a fluctuating course. The disturbances in brain activity are secondary to another insult although the nature of the presentation is rarely a reliable indicator of the underlying cause. Delirium should be distinguished from dementia, although cognitive impairment is seen in both, and an underlying dementia might be a predisposing factor for delirium.3 Dementia typically has an insidious onset over months or years whilst delirium runs an acute and fluctuating course.4 Attention is often normal in dementia but impaired in delirium. In the early stages of dementia, orientation and working memory are normal and psychosis rarely seen – this is not true for delirium (see also pages 467–470).
Precipitating factors
Post-operative Drug side effect New cerebrovascular event Myocardial infarction Infection • Urinary tract • Respiratory • Meningitis • Osteomyelitis • Endocarditis Hypoxia Metabolic disturbance • ↑↓ sodium/potassium/calcium • ↑↓ glucose Terminal illness Constipation
Max Henderson MSc MRCP MRCPsych is MRC Research Training Fellow in the Department of Psychological Medicine at the Institute of Psychiatry, King’s College London, UK. Competing interests: none declared.
MEDICINE 36:9
Table 1
463
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
delirium threshold, i.e. make one more vulnerable to delirium. Precipitating factors are insults which result in someone becoming confused.
Tests of attention Reverse digit span Give the patient a series of numbers, spoken in a consistent rhythm, and ask the patient to repeat them to you in reverse order 1-4-6 6-4-1 2-7-4-8 8-4-7-2 3-1-9-2-5 5-2-9-1-3 Serial subtraction Ask the patient to start at 100 (or 20) and ask the patient to subtract 7 (or 3), then subtract a further 7 from the result and so on. Record what they actually say
Clinical features Delirium is a syndrome with a range of abnormalities including cognitive, perceptual, motor, affective, and sleep disturbances (Table 2).12 The most common feature is inattention, which is a failure to focus or concentrate, present in 97% of cases. The level of inattention correlates with other aspects of cognitive impairment, but not other abnormalities, such as motoric state or the presence of psychosis. Disorientation is one of the least common problems, so therefore the Mini Mental State Examination (MMSE)13 is a poor screening tool for delirium (see also pages 393–398). Hallucinations occur in half of cases but are prominent in only 20%.12 They are most commonly visual or auditory. Paranoid delusions and disordered thinking also occur. Affective disturbances range from manic presentations with high levels of arousal, elation and irritability to an apparently depressive picture with isolative behaviour, poor eye contact and paucity of spontaneous movement. One symptom commonly overlooked is anxiety. The bewildering experiences of the delirious patient can be terrifying. Disturbances, especially reversal, of the sleep–wake cycle are often seen. Motor disturbance is a prominent feature of delirium. Hyperactive delirium is the most easily recognized subtype, characterized by high levels of arousal, restlessness, distractibility and wandering. In contrast, the hypoactive subtype includes the ‘faceto- the-wall’ patients with reduced or slowed movement, reduced or absent speech, apparently reduced awareness and apathy.14,15 About 50% of cases are of the hypoactive subtype, and a further 30% present with a mix of both. The hyperactive presentation is the least common. Furthermore there is no association between the motoric subtype and psychosis – the hypoactive patient is just as likely to be hallucinating.12
Table 3
via its impact on memory is also possible – examples include remembering the examiner’s name after 2 minutes or recalling specific objects identified by the examiner. Standardized instruments can be useful. However, it is vital to be clear whether they have been designed for screening (e.g. Clock Drawing Test17; Table 4), diagnosis (e.g. Confusion Assessment Method18) or to assess severity (e.g. Memorial Delirium Assessment Scale19). One simple screening tool is the Clock Drawing Test which has been validated in several settings.20 It is quick, easy and non-threatening, although the physical requirements limit its use in those with a stroke or motor neurone disease. The Abbreviated Mental Test Score is also widely used.21 The Confusion Assessment Method18 is one of the best validated and most widely used. It is relatively brief, non-threatening and is designed to be used by non-psychiatrists.
Management Prevention Two quite different approaches to primary prevention have been reported. The Yale Delirium Prevention Trial was based on the predisposing/precipitating model of causation already described.22 Strategies to optimize the patient’s condition with special attention paid to orientation, hydration, correcting visual and hearing impairment, and minimizing sleep–wake cycle disturbance by reducing night-time noise from movement, telephones and bleeps reduced the incidence of delirium on the intervention ward by a third. Kalisvaart attempted a different approach on a high-risk group of patients.23 The severity of delirium was reduced in patients randomized to 1.5 mg haloperidol starting pre-operatively and continuing up to day 3 post-operatively. Furthermore, the length
Assessment Many episodes of delirium are missed, often because the hypoactive presentation does not prompt a consideration of delirium as a differential diagnosis. Hence, the first step is a low threshold for considering the diagnosis. Gentle exploration for the key features can follow. Impaired attention has been identified as a core feature. This can be assessed using the reverse digit span,16 serial 7s (from 100) or serial 3s (from 20) (Table 3). Assessing attention
Diagnostic criteria for delirium
Clock drawing test
ICD-10 criteria4 Impairment in consciousness or attention Global cognitive impairment Psychomotor disturbance Sleep–wake cycle disturbance Emotional disturbance
• Give the patient a sheet of paper with a large circle drawn on it • Ask the patient to add in the numbers to create a clock-face • Ask the patient to add the hands so show a time you tell them • Several scoring systems have been described
Table 2
MEDICINE 36:9
Table 4
464
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
features of delirium, which is anxiety.27 Others are concerned about the possibility of over-sedation and the paradoxical reaction where patients can become more rather than less agitated. There are several case reports of cholinesterase inhibitors such as donepezil and rivastigmine which appear well tolerated. There is insufficient evidence however to recommend them more widely.28
of each episode was on average halved and there was a reduction in the length of hospital stay. Treatment There are two clear and distinct goals for the treatment of delirium: • The identification and correction of the underlying insult. • The amelioration of the worst symptoms of the delirium, so as to make the patient more comfortable until the underlying problem has been resolved. Investigation of the underlying insult should be guided by information about the individual patient (including current and recent medications), the results of a thorough clinical examination and evidence from previous investigations. The general rule of starting with the least invasive investigations still applies (Table 5). When considering symptomatic treatment it should be remembered that the patient’s most distressing symptoms may not be the most obvious or the easiest to treat. Drug treatment is not always needed – there is no drug treatment for a wandering patient.
Conclusions Delirium is a common and distressing condition. A classical presentation is rare and many episodes go undiagnosed and untreated. Improved care must start with the diagnosis being considered more readily. Good evidence exists for the prevention of delirium both by pharmacological and non-pharmacological methods and these should be employed more widely. Treatment should focus on the individual needs of the patient rather than the most prominent symptoms and both antipsychotic and anxiolytic medications are widely used. ◆
Antipsychotic medications are the most commonly used although there is little evidence to support this. The most recent Cochrane systematic review found only three small studies of sufficient quality.24 One study compared haloperidol, chlorpromazine and lorazepam in patients with HIV and showed a clear advantage for haloperidol.25 However, this is only one study in a very select group and so we need to be aware of risk of over-generalization. Haloperidol is well tolerated with few extrapyramidal side effects at low doses. It is relatively non-sedative, but hypotension can be a problem. More recent studies have used newer atypical antipsychotics such as risperidone and quetiapine. There is no evidence at present that they are more effective.26
References 1 Young J, Inouye SK. Delirium in older people. BMJ 2007; 334: 842–46. 2 Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004; 75: 362–67. 3 Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev 2004; 14: 87–98. 4 World Health Organization. International classification of diseases 10th revison. Geneva: World Health Organization, 1993. 5 Dunn N, Cook CC. Psychiatric aspects of alcohol misuse. Hosp Med 1999; 60: 169–72. 6 Folstein MF, Bassett SS, Romanoski AJ, Nestadt G. The epidemiology of delirium in the community: the Eastern Baltimore Mental Health Survey. Int Psychogeriatr 1991; 3: 169–76. 7 Lindesay J, Rockwood K, Rolfson D. The epidemiology of delirium. In: Lindesay J, Rockwood K, McDonald A, eds. Delirium. Oxford: Oxford University Press, 2002. 8 Ilechukwu ST. Psychiatry of the medically ill in the burn unit. Psychiatr Clin North Am 2002; 25: 129–47. 9 Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 2000; 160: 786–94. 10 Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for intensive care delirium: a systematic review. Intensive Crit Care Nurs 2008; 24: 98–107. 11 Inouye SK. Predisposing and precipitating factors for delirium in hospitalized older patients. Dement Geriatr Cogn Disord 1999; 10: 393–400. 12 Meagher DJ, Moran M, Raju B, et al. Phenomenology of delirium. Assessment of 100 adult cases using standardised measures. Br J Psychiatry 2007; 190: 135–41. 13 Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Arch Gen Psychiatry 1983; 40: 812. 14 Lipowski Z. Delirium: acute confusional states. New York: Oxford University Press, 1990.
Other drug treatments: a number of alternatives to antipsychotics may be used. Several authors advocate the use of benzodiazepines on the grounds that that they are short-acting, reversible, well tolerated and specifically treat one of the most unpleasant
Possible investigations in delirium • Urinalysis ○ Microscopy ○ Culture • Sputum culture • Full blood count • Urea & electrolytes • Serum calcium • Serum glucose • Liver function tests • Chest X-Ray • ECG • MRI brain • Cardiac ultrasound • Electroencephalogram (EEG) • Lumbar puncture Table 5
MEDICINE 36:9
465
© 2008 Elsevier Ltd. All rights reserved.
Psychiatric aspects of general medicine
delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153: 231–37. 26 Boettger S, Breitbart W. Atypical antipsychotics in the management of delirium: a review of the empirical literature. Palliat Support Care 2005; 3: 227–37. 27 Meagher DJ. Delirium: optimising management. BMJ 2001; 322: 144–49. 28 Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev 2008(1): CD005317.
15 Stagno D, Gibson C, Breitbart W. The delirium subtypes: a review of prevalence, phenomenology, pathophysiology, and treatment response. Palliat Support Care 2004; 2: 171–79. 16 Hodges J. Cognitive assessment for clinicians. Oxford: Oxford University Press, 1994. 17 Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000; 15: 548–61. 18 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: 941–48. 19 Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997; 13: 128–37. 20 Henderson M, Hotopf M. Use of the clock-drawing test in a hospice population. Palliat med 2007; 21: 559–65. 21 Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age ageing 1972; 1: 233–38. 22 Inouye SK, Bogardus Jr ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76. 23 Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658–66. 24 Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev 2007(2): CD005594. 25 Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of
MEDICINE 36:9
Practice points • Disorientation is one of the least common problems • The mini mental state examination (MMSE) is a poor screening tool for delirium • Hypoactive state is more common than hyperactive • Motoric state is not a guide to the presence of psychosis • The underlying cause should be sought and treated appropriately • Fear and anxiety are common and are often overlooked yet easily managed • Drug treatment for the delirium is not always needed – there is no drug treatment for a wandering patient
466
© 2008 Elsevier Ltd. All rights reserved.