- Email: [email protected]
Lifeline
In Context
Lifeline Sharon K Inouye is a professor of medicine at Harvard Medical School, Boston, MA, USA, and Director of the Aging Brain Center at the Institute for Aging Research, Hebrew SeniorLife, also in Boston. The focus of her research is delirium and reversible contributors to cognitive decline. She aims to identify practical applications that will improve clinical care and quality of life for the elderly.
See Review page 823
What has been the greatest achievement of your career? I have had the extraordinary opportunity to develop the clinical field of delirium, creating the Confusion Assessment Method (CAM), which is now a standard in the field, and the Hospital Elder Life Program (HELP) for delirium prevention. What inspires you? I was originally drawn to delirium by my experience of caring for patients. Later when my father, a brilliant physician, developed delirium after cardiac surgery, I knew I had to work hard to change the system. What do you think is the most neglected field of science or medicine at the moment? Ageing and geriatric medicine are extremely important areas for scientific investigation and innovation, but receive little attention from funders and researchers. Who was your most influential teacher, and why? Constance Schneider, my English literature teacher in 12th grade, who instilled in me a love of literature, and encouraged me to read, write, and stretch myself. What is the most memorable comment from your school reports? “She is really bright but no one would ever know it … she is so quiet” (I was very shy as a child and still am at times). What is your favourite book, and why? Jane Austen’s Pride and Prejudice, because it is really about people’s capacity to change. I re-read the book every year. How do you relax? By hiking to the top of a mountain. What is your greatest regret? The deaths of my son Joshua (almost 3 years) and my brother Bradley (36 years). I miss them every single day. If you wrote an autobiography, what would be the title? First, Do No Harm; Second, Make a Difference. What is your greatest fear? That I will run out of time before I have a chance to make a real difference. What one discovery or invention would most improve your life? Hermione Granger’s time-turner with hour-reversal charm, so I can be in two places at once. That and the transporter from Star Trek. Beam me up, Scotty!
792
Focal point The hinterland of delirium The diagnostic criteria for delirium in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1 specify a disturbance in attention or change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia; development over a short period; and evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, is due to an intoxicating substance or medication use, or has more than one cause. Although this definition seems unequivocal, delirium is still commonly under-recognised.2 Descriptions of what we would now know as delirium date back to Classical Greece, with references found in the works of Hippocrates to hyperactive and hypoactive symptoms, which he described with the terms phrenitis (mental abnormalities caused by fever, poisoning, or head trauma) and lethargy (inertia and dulling of the senses). Celus, in the 1st century AD, is generally credited with being the first to use the term delirium to describe mental illness during fever or head trauma, although much debate remains about the etymology of the word.3 The medical literature throughout the Middle Ages and up to the 19th century is full of descriptions of delirium, although the terminology used varied widely throughout this period, with the designations phrenitis, phrensy, phrenesis, lethargy, paraphrensy, and paraphrenesis falling in and out of favour. During the 20th century, the focus moved away from looking at delirium as only a symptom and more towards understanding of the pathophysiology of the disorder itself. Engel and Romano led the way in this respect in 1959 by showing that delirium was a disturbance in the level of consciousness manifesting as cognitive attentional disturbances and was due to disruption of brain metabolism.4
Steven Goodrick 1
2
3
4
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association, 2013. Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye S. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14: 823–32. Adamis D, Treloar A, Martin FC, Macdonald AJD. A brief review of the history of delirum as a mental disorder. Hist Psychiatr 2007; 18: 459–69. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 1959; 9: 260–77.
www.thelancet.com/neurology Vol 14 August 2015
Lifeline Sharon K Inouye is a professor of medicine at Harvard Medical School, Boston, MA, USA, and Director of the Aging Brain Center at the Institute for Aging Research, Hebrew SeniorLife, also in Boston. The focus of her research is delirium and reversible contributors to cognitive decline. She aims to identify practical applications that will improve clinical care and quality of life for the elderly.
See Review page 823
What has been the greatest achievement of your career? I have had the extraordinary opportunity to develop the clinical field of delirium, creating the Confusion Assessment Method (CAM), which is now a standard in the field, and the Hospital Elder Life Program (HELP) for delirium prevention. What inspires you? I was originally drawn to delirium by my experience of caring for patients. Later when my father, a brilliant physician, developed delirium after cardiac surgery, I knew I had to work hard to change the system. What do you think is the most neglected field of science or medicine at the moment? Ageing and geriatric medicine are extremely important areas for scientific investigation and innovation, but receive little attention from funders and researchers. Who was your most influential teacher, and why? Constance Schneider, my English literature teacher in 12th grade, who instilled in me a love of literature, and encouraged me to read, write, and stretch myself. What is the most memorable comment from your school reports? “She is really bright but no one would ever know it … she is so quiet” (I was very shy as a child and still am at times). What is your favourite book, and why? Jane Austen’s Pride and Prejudice, because it is really about people’s capacity to change. I re-read the book every year. How do you relax? By hiking to the top of a mountain. What is your greatest regret? The deaths of my son Joshua (almost 3 years) and my brother Bradley (36 years). I miss them every single day. If you wrote an autobiography, what would be the title? First, Do No Harm; Second, Make a Difference. What is your greatest fear? That I will run out of time before I have a chance to make a real difference. What one discovery or invention would most improve your life? Hermione Granger’s time-turner with hour-reversal charm, so I can be in two places at once. That and the transporter from Star Trek. Beam me up, Scotty!
792
Focal point The hinterland of delirium The diagnostic criteria for delirium in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1 specify a disturbance in attention or change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia; development over a short period; and evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, is due to an intoxicating substance or medication use, or has more than one cause. Although this definition seems unequivocal, delirium is still commonly under-recognised.2 Descriptions of what we would now know as delirium date back to Classical Greece, with references found in the works of Hippocrates to hyperactive and hypoactive symptoms, which he described with the terms phrenitis (mental abnormalities caused by fever, poisoning, or head trauma) and lethargy (inertia and dulling of the senses). Celus, in the 1st century AD, is generally credited with being the first to use the term delirium to describe mental illness during fever or head trauma, although much debate remains about the etymology of the word.3 The medical literature throughout the Middle Ages and up to the 19th century is full of descriptions of delirium, although the terminology used varied widely throughout this period, with the designations phrenitis, phrensy, phrenesis, lethargy, paraphrensy, and paraphrenesis falling in and out of favour. During the 20th century, the focus moved away from looking at delirium as only a symptom and more towards understanding of the pathophysiology of the disorder itself. Engel and Romano led the way in this respect in 1959 by showing that delirium was a disturbance in the level of consciousness manifesting as cognitive attentional disturbances and was due to disruption of brain metabolism.4
Steven Goodrick 1
2
3
4
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association, 2013. Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye S. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14: 823–32. Adamis D, Treloar A, Martin FC, Macdonald AJD. A brief review of the history of delirum as a mental disorder. Hist Psychiatr 2007; 18: 459–69. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 1959; 9: 260–77.
www.thelancet.com/neurology Vol 14 August 2015