- Email: [email protected]
Delirium: Acute confusional states
Book Reviews
Delirium: Acute Confusional States. By Z. J. Lipowski. Cary, N. C., Oxford University Press, 1990 ($69.50), 490 pp.
Delirium is a topic of increasing interest to both geriatric and consultation-liaison psychiatrists as well as to geriatric neurologists, and geriatricians in internal medicine and family practice. The increased interest is due to many factors: the aging of the population (since age is associated with a higher incidence of delirium), the movement of psychiatry toward more biological or medical approaches, and the writings of Dr. Lipowski (a distinguished consultation-liaison psychiatrist and Associate Editor of this journal) in psychiatric and medical journals over the last 20 years. Recent years have also seen the appearance of large-scale empirical research on delirium [l-8]. Some of these recent publications are cited, but even a book as comprehensive as this one written by a single author cannot keep up with the latest research findings. Lipowski has provided an extraordinarily comprehensive review of almost any article or book published in the last 2000 years with any bearing on the subject of delirium. This makes this volume an unusually rich reference work. The book is divided into three parts. Part I is a lengthy description of delirium as “an organic mental syndrome.” It consists of chapters on the history of the concept going back to the ancient Greeks and Romans; a definition of the terms used to describe the syndrome; the incidence and prevalence of the disorder; clinical features, course, and outcome; psychopathology; etiology; pathogenesis and pathophysiology; diagnosis; differential diagnosis; and treatment. Part II expands on the earlier discussion of etiology with detailed chapters on the various organic causes of delirium including: intoxication with medical drugs; poisons; alcohol and drug General Hosyrtal Psychiutry 13, 347-352, 1991 8 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
withdrawal; metabolic disorders (encephalopathies); infections; vascular diseases; head injury, epilepsy, and brain tumor. Part III discusses delirium in special patient populations with one chapter on geriatric patients and the other on delirium after surgery, burns, and childbirth. Dr. Lipowski has done the field a tremendous service by pulling all of this material together in one reference work. General hospital psychiatrists should be well-versed in the diagnosis and management of delirious patients. Researchers will want to build on this background information and explore the nature, pathogenesis, and treatment of this disorder. One is left with a clear message about the importance of the syndrome and the need for more research. BENJAMIN
LIPTZIN,
M.D.
Springfield, Massachusetts
References 1. Liptzin B, Levkoff SE, Cleary I’D, et al: Diagnostic
2. 3. 4.
5.
6.
criteria for delirium: An empirical study. A J Psychiatry 1991, in press Gustafson Y, Berggren D, Branstrom B, et al: Acute confusional states in elderly patients treated for femoral neck fracture. A Geriatr Sot 36:525-530, 1988. Rogers MI’, Liang MH, Daltroy LH, et al: Delirium after elective orthopedic surgery: Risk factors and natural history. Int J Psychiatry Med 19:109-121, 1989. Koponen H, Stenback U, Mattila E, et al: Delirium among elderly persons admitted to a psychiatric hospital: Clinical course during the acute stage and oneyear follow-up. Acta Psychiatr Stand 79:579-585, 1989. Thomas RI, Cameron DJ, Fahs MC: A prospective study of delirium and prolonged hospital stay: Exploratory study. Arch Gen Psychiatry 45:937-940, 1988. Francis J, Martin D, Kapoor WN: A prospective study of delirium in hospitalized elderly. JAMA 263:10971101, 1990. 347 ISSN 0163.8343/91/$3.50
Book Reviews
7. Cameron DJ, Thomas RI, Mulvihill M, et al: Delirium: A test of the Diagnostic and Statistical Manual-III criteria on medical inpatients. J Am Geriatr Sot 35:10071010, 1987. 8. Johnson JC, Gottlieb GL, Sullivan E, et al: Using DSMIII criteria to diagnose delirium in elderly general medical patients. J Gerontol Med Sci 45:M113-M116, 1990
Manual of Psychiatric Consultation. By Nada L. Stotland and T. R. Garrick. Washington, D.C., American Psychiatric Press, Inc., 1990 ($23.00, wirebound), 232 pp.
At present, about 60% of all psychiatric patient care occurs in the general hospital setting. While a large proportion of this care takes place in specialized psychiatric inpatient and outpatient settings, psychiatric consultation in the “special arena” of medical and surgical inpatient units requires a rather different approach. Recognizing these facts, the Residency Review Committee in Psychiatry now requires all accredited residencies to provide a period of training in consultation-liaison psychiatry. Drs. Stotland and Garrick, both experienced consultation-liaison psychiatrists and teachers, have now supplied a helpful, thoughtful, and portable manual to guide any psychiatrist who is beginning to do consultation-liaison work. This manual is stuffed with clinical observations obviously collected through hard experience. It includes such nuggets of wisdom as, “A clerk who has met and feels friendly toward a consultant is more likely to persist in trying to make contact when the consultant is not immediately available.” A succinct remark such as, “The psychiatrist’s job is to take the patient’s account seriously but neutrally,” summarizes many years of experience in defusing conflict-laden situations on the medical wards. “The ability to make change in the grocery store is more important than the accuracy of serial seven subtraction,” offers a way to begin to assess the patient’s ability to manage at home. The authors have also maintained a consistent viewpoint: that they are providing a manual, a how-to-go-about-it guide, rather than a textbook. After an introductory chapter on the historical basis of consultation-liaison psychiatry, which mentions current economic topics, the manual proceeds with “Setting the Stage, ” “Initiating the Consultation,” 348
and so on through the entire undertaking. After Follow-Up, and Chapter 10, “Follow-Through, Closing the Consultation,” two timely chapters tie up the loose ends. Chapter 11, “Role of the Consultation-Liaison Psychiatrist as a Medical Educator,” points out that the psychiatric consultation opens up the usually private psychiatrist-patient encounter to observation by others, and is thereby wonderfully useful for training all physicians, at all levels of experience. Chapter 12, “ConsultationLiaison in a Changing World of Psychiatry,” covers many of the liveliest issues facing medicine todayissues of cost control, quality assurance, and informed consent, among others. The major weakness of this manual is, however, that it is not a text. Much of the work that consultation-liaison psychiatrists do-evaluating suicide risk, assessing the interaction of drugs on the nervous system, or dealing with issues of competency-is informed by clinical and basic medical research. Usually, a “manual” includes some easily accessible and tabular material that justifies its portability. Including data such as basic signs and symptoms of drug withdrawal, a basic mini-mental status exam, or a table of strength equivalents for e.g., the benzodiazepines, would have made this book even more valuable as a ready reference. Any psychiatrist, practicing or trainee, who proposes to venture out (or back) to the medical and surgical services would profit by reading this manual. Other books will provide information on drug interactions or on the course of postpartum depression; many of the basic texts and articles in consultation psychiatry are referenced at the end of each chapter. This book offers comfort, direction, reassurance, and a helpful way of approaching the “special arena” where many of us work. There are four full pages on “Finding Out Who Is Taking Care of the Patient,” and careful instructions on writing up the consultation, suggesting further evaluations, and other important issues. The emphasis throughout is on clear and helpful communications among all concerned parties. In that area, it is an indispensable resource for all of us in our communications with the larger medical community.
E. DEBORAH
Springfield,
GILMAN,
M.D.
Massachusetts
Delirium: Acute Confusional States. By Z. J. Lipowski. Cary, N. C., Oxford University Press, 1990 ($69.50), 490 pp.
Delirium is a topic of increasing interest to both geriatric and consultation-liaison psychiatrists as well as to geriatric neurologists, and geriatricians in internal medicine and family practice. The increased interest is due to many factors: the aging of the population (since age is associated with a higher incidence of delirium), the movement of psychiatry toward more biological or medical approaches, and the writings of Dr. Lipowski (a distinguished consultation-liaison psychiatrist and Associate Editor of this journal) in psychiatric and medical journals over the last 20 years. Recent years have also seen the appearance of large-scale empirical research on delirium [l-8]. Some of these recent publications are cited, but even a book as comprehensive as this one written by a single author cannot keep up with the latest research findings. Lipowski has provided an extraordinarily comprehensive review of almost any article or book published in the last 2000 years with any bearing on the subject of delirium. This makes this volume an unusually rich reference work. The book is divided into three parts. Part I is a lengthy description of delirium as “an organic mental syndrome.” It consists of chapters on the history of the concept going back to the ancient Greeks and Romans; a definition of the terms used to describe the syndrome; the incidence and prevalence of the disorder; clinical features, course, and outcome; psychopathology; etiology; pathogenesis and pathophysiology; diagnosis; differential diagnosis; and treatment. Part II expands on the earlier discussion of etiology with detailed chapters on the various organic causes of delirium including: intoxication with medical drugs; poisons; alcohol and drug General Hosyrtal Psychiutry 13, 347-352, 1991 8 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
withdrawal; metabolic disorders (encephalopathies); infections; vascular diseases; head injury, epilepsy, and brain tumor. Part III discusses delirium in special patient populations with one chapter on geriatric patients and the other on delirium after surgery, burns, and childbirth. Dr. Lipowski has done the field a tremendous service by pulling all of this material together in one reference work. General hospital psychiatrists should be well-versed in the diagnosis and management of delirious patients. Researchers will want to build on this background information and explore the nature, pathogenesis, and treatment of this disorder. One is left with a clear message about the importance of the syndrome and the need for more research. BENJAMIN
LIPTZIN,
M.D.
Springfield, Massachusetts
References 1. Liptzin B, Levkoff SE, Cleary I’D, et al: Diagnostic
2. 3. 4.
5.
6.
criteria for delirium: An empirical study. A J Psychiatry 1991, in press Gustafson Y, Berggren D, Branstrom B, et al: Acute confusional states in elderly patients treated for femoral neck fracture. A Geriatr Sot 36:525-530, 1988. Rogers MI’, Liang MH, Daltroy LH, et al: Delirium after elective orthopedic surgery: Risk factors and natural history. Int J Psychiatry Med 19:109-121, 1989. Koponen H, Stenback U, Mattila E, et al: Delirium among elderly persons admitted to a psychiatric hospital: Clinical course during the acute stage and oneyear follow-up. Acta Psychiatr Stand 79:579-585, 1989. Thomas RI, Cameron DJ, Fahs MC: A prospective study of delirium and prolonged hospital stay: Exploratory study. Arch Gen Psychiatry 45:937-940, 1988. Francis J, Martin D, Kapoor WN: A prospective study of delirium in hospitalized elderly. JAMA 263:10971101, 1990. 347 ISSN 0163.8343/91/$3.50
Book Reviews
7. Cameron DJ, Thomas RI, Mulvihill M, et al: Delirium: A test of the Diagnostic and Statistical Manual-III criteria on medical inpatients. J Am Geriatr Sot 35:10071010, 1987. 8. Johnson JC, Gottlieb GL, Sullivan E, et al: Using DSMIII criteria to diagnose delirium in elderly general medical patients. J Gerontol Med Sci 45:M113-M116, 1990
Manual of Psychiatric Consultation. By Nada L. Stotland and T. R. Garrick. Washington, D.C., American Psychiatric Press, Inc., 1990 ($23.00, wirebound), 232 pp.
At present, about 60% of all psychiatric patient care occurs in the general hospital setting. While a large proportion of this care takes place in specialized psychiatric inpatient and outpatient settings, psychiatric consultation in the “special arena” of medical and surgical inpatient units requires a rather different approach. Recognizing these facts, the Residency Review Committee in Psychiatry now requires all accredited residencies to provide a period of training in consultation-liaison psychiatry. Drs. Stotland and Garrick, both experienced consultation-liaison psychiatrists and teachers, have now supplied a helpful, thoughtful, and portable manual to guide any psychiatrist who is beginning to do consultation-liaison work. This manual is stuffed with clinical observations obviously collected through hard experience. It includes such nuggets of wisdom as, “A clerk who has met and feels friendly toward a consultant is more likely to persist in trying to make contact when the consultant is not immediately available.” A succinct remark such as, “The psychiatrist’s job is to take the patient’s account seriously but neutrally,” summarizes many years of experience in defusing conflict-laden situations on the medical wards. “The ability to make change in the grocery store is more important than the accuracy of serial seven subtraction,” offers a way to begin to assess the patient’s ability to manage at home. The authors have also maintained a consistent viewpoint: that they are providing a manual, a how-to-go-about-it guide, rather than a textbook. After an introductory chapter on the historical basis of consultation-liaison psychiatry, which mentions current economic topics, the manual proceeds with “Setting the Stage, ” “Initiating the Consultation,” 348
and so on through the entire undertaking. After Follow-Up, and Chapter 10, “Follow-Through, Closing the Consultation,” two timely chapters tie up the loose ends. Chapter 11, “Role of the Consultation-Liaison Psychiatrist as a Medical Educator,” points out that the psychiatric consultation opens up the usually private psychiatrist-patient encounter to observation by others, and is thereby wonderfully useful for training all physicians, at all levels of experience. Chapter 12, “ConsultationLiaison in a Changing World of Psychiatry,” covers many of the liveliest issues facing medicine todayissues of cost control, quality assurance, and informed consent, among others. The major weakness of this manual is, however, that it is not a text. Much of the work that consultation-liaison psychiatrists do-evaluating suicide risk, assessing the interaction of drugs on the nervous system, or dealing with issues of competency-is informed by clinical and basic medical research. Usually, a “manual” includes some easily accessible and tabular material that justifies its portability. Including data such as basic signs and symptoms of drug withdrawal, a basic mini-mental status exam, or a table of strength equivalents for e.g., the benzodiazepines, would have made this book even more valuable as a ready reference. Any psychiatrist, practicing or trainee, who proposes to venture out (or back) to the medical and surgical services would profit by reading this manual. Other books will provide information on drug interactions or on the course of postpartum depression; many of the basic texts and articles in consultation psychiatry are referenced at the end of each chapter. This book offers comfort, direction, reassurance, and a helpful way of approaching the “special arena” where many of us work. There are four full pages on “Finding Out Who Is Taking Care of the Patient,” and careful instructions on writing up the consultation, suggesting further evaluations, and other important issues. The emphasis throughout is on clear and helpful communications among all concerned parties. In that area, it is an indispensable resource for all of us in our communications with the larger medical community.
E. DEBORAH
Springfield,
GILMAN,
M.D.
Massachusetts