Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0182 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY14. George J, Bleasdale S, Singleton SJ. Causes and prognosis of deliriumin elderly patients admitted to a district general hospital. Age Ageing1997; 26(6): 423–7.15. Inouye SK,Van Dyck C, Alessi CA et al. Clarifying confusion: theconfusion assessment method. A new method for detection ofdelirium. Ann Intern Med 1990; 113: 941–8.Delirium in InstitutionsBarbara Kamholz and Christopher ColendaMichigan State University, East Lansing, MI, USAThe prevalence of delirium is approximately 10–40% of patientson acute medical and surgical units. The incidence for newlyadmitted patients ranges from 25% to 60% 1 . Delirium iscommonly misdiagnosed as depression; up to 41.8% of inpatientpsychiatry consultations for depression actually result in adiagnosis of delirium 2,3 . Delirium has a number of adverseoutcomes, and may itself be looked upon as a ‘‘symptom’’ ofproblems in the delivery of hospital services 8 . It is the single mostimportant factor contributing to in-hospital complications, suchas falls and pressure sores 4 . It has a significant impact onincreasing hospital length of stay 4,5 and upon the need fordischarge to long-term care institutions 6 . It is the single strongestpredictor of impaired daily function (AFL) at 6 months 7 ,although most studies have found surprising little impact onmortality 4,7 . Delirium may not be as reversible as previouslythought; Levkoff found that only 17.6% of all new symptoms ofdelirium had cleared fully at 6 month follow-up 5 . Delirium is themost frequent complication of hospitalization in older patients.DIAGNOSISCareful diagnosis of delirium is essential, as up to 66% of casesare missed 1 . Delirium can be systematically diagnosed using theFolstein Mini-Mental State Examination (MMSE) 9 in combinationwith the Confusion Assessment Method 1 , with the optimaltechnique using several observation points 10 . Inattention is acritical criterion of delirium and is essential in differentiating itfrom depression and dementia. A recent model developed byInouye and colleagues 1 at the Yale University Elder Life Programdemonstrates that the probability of developing delirium issomewhat predictable among a population of vulnerable patientscharacterized by older age, high medical co-morbidity, sensory(visual/hearing) impairment and baseline cognitive impairment.Among this vulnerable group, the introduction of specificprecipitating causes of delirium (such as indwelling catheter, useof restraints, and new medical complications) has been shown toincrease the probability of delirium in proportion to the numberof precipitating factors present.TREATMENTAs yet, despite promising evidence that neuroleptics may improvethe course of delirium itself 11 and that cholinesterase inhibitorsmay be effective 12 , there are as yet no specific recommendedpharmacological treatments for delirium. However, there is morehopeful evidence that delirium may be prevented. An interventionbased on Inouye’s approach provides: sensory correction aids (e.g.glasses and hearing aids); reorientation; therapeutic cognitiveactivities; a non-pharmacological sleep protocol; a dehydrationprotocol; and an early-mobilization protocol. This resulted in asignificant reduction in new cases of delirium among patients atintermediate baseline risk for delirium. It is notable that thisstrategy had no impact on ‘‘delirium in progress’; its primaryclinical impact lay in prevention 13 . Further work on interventionsfor delirium will clearly be of vital importance to the reduction ofthe risks for delirium in institutions and for its treatment. Thecosts incurred by early detection may well be more than offset bysavings in decreased length of stay, decreased rates of institutionalizationand decreased rates of in-hospital complications 8 .REFERENCES1. Inouye S. Delirium in hospitalized older patients: recognition and riskfactors. J Geriat Psychiat Neurol 1998; 11: 118–25.2. Farrell KE, Ganzini L. Misdiagnosing delirium as depression inmedically ill elderly patients. Arch Intern Med 1995; 155: 2459–64.3. Boland RJ, Diaz S, Lamdan R et al. Overdiagnosis of depression inthe general hospital. Gen Hosp Psychiat 1996; 18: 28–35.4. O’Keeffe S, Lavan J. The prognostic significance of delirium in olderhospitalized patients. J Am Geriat Soc 1997; 45: 174–8.5. Levkoff SE, Evans DA, Liptzin B et al. Delirium: the occurrence andpersistence of symptoms among elderly hospitalized patients. ArchIntern Med 1992; 152: 334–40.6. Inouye SK, Rushing JT, Foreman MD et al. Does delirium contributeto poor hospital outcomes? A three-site epidemiological study. J GenIntern Med 1998; 13: 234–42.7. Francis J, Kapoor WN. Prognosis after hospital discharge of oldermedical patients with delirium. J Am Geriat Soc 1992; 40: 601–6.8. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of howhospital care is failing older persons and a window to improve qualityof hospital care. Am J Med 1999; 106: 565–73.9. Folstein MF et al. The Mini-Mental State Examination. Arch GenPsychiat 1983; 40(7): 812.10. Zou Y, Cole MG, Primeau FJ et al. Detection and diagnosis ofdelirium in the elderly: psychiatrist diagnosis, confusion assessmentmethod, or consensus diagnosis? Int Psychogeriat 1998; 10(3): 303–8.11. Breitbart W et al. A double-blind trial of haloperidol,chlorpromazine, and lorazepam in the treament of delirium inhospitalized AIDS patients. Am J Psychiat 1996; 2: 231–7.12. Wengel SP, Roccaforte WH, Burke WJ. Donepezil improvessymptoms of delirium in dementia: implications for future research.J Gen Psychiat Neurol 1998; 11(3): 159–61.13. Inouye SK, Bogardus ST, Charpentier PA et al. A multicomponentintervention to prevent delirium in hospitalized older patients. N EnglJMed1999; 340(9): 669–76.