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 0-470-84641-0DELIRIUM—AN OVERVIEW 183Prognosis of DeliriumA. TreloarMemorial Hospital, London, UKStudies of outcome have started to challenge the assumptionthat delirium is a truly reversible disorder with a good prognosis.Prospective outcome studies of delirium are required to describeits prognosis. Using change in MMSE 1 score as the outcomemeasure, Fields et al. 2 found that by no means all patientsimprove, and some get worse. Treloar and Macdonald 3 foundthat although many acute patients had reversible cognitivedysfunction, few regained normal cognition. Some patients tookthe full 3 month time-course of the study to start theirrecoveries. Studies based upon standard diagnoses of deliriumhave also reported poor recovery at follow-up 4 . Kolbeinsson andJonsson 5 found that elderly patients with DSM-III-R 6 deliriumbut not dementia at outset, had dementia at follow-up in 70% ofcases. Cole et al. 7 found that less than 50% recovered mentallyat follow-up. Rudberg et al. 8 showed delirium lasting overperiods of several weeks (even though patients did not meetDelirium Rating Scale 9 criteria for delirium continuously).Cognitive deficits and behavioural abnormalities persisted inthe majority of patients for at least 6 months 10 Kaponen et al. 11found infrequent good cognitive outcome following delirium atone year.Delirious patients stay longer in hospital than those withoutdelirium. Diagnosis-related group length of stay of 13 days forpatients with delirium compares with 3.3 days for those withdementia 12 . Physical morbidity may be exacerbated by psychiatricco-morbidity. Delirium is associated with death in up to 33% 13 .Itis frequently asserted that mortality is purely the result of thephysical illness, but this is a difficult hypothesis to test. It would bevery surprising if the stupor, retardation and poor compliancewith treatments seen in delirious patients did not contribute tomortality from physical illness. Patients with delirium after hipfracture surgery are at greater risk of incontinence, urinary tractinfections and pressure sores 14 . Delirium in patients with hipfractures also predicts higher long-term mortality and poorfunctional recovery 14–16 . Francis and Kapoor 17 found thatdelirium predicted a doubling of mortality attributable tofunctional impairment, and in survivors predicted loss of abilityto live independently. Levkoff et al. 10 found that new symptoms ofdelirium resolve at 6 months in only 17.7%.The prognosis of delirium is almost certainly not, therefore, oneof early full recovery. Rather, delirium is a condition with a slowrecovery and one which often fails to resolve completely.REFERENCES1. Folstein M, Folstein S, McHugh P. Mini-Mental State, a practicalmethod for grading the cognitive state of patients for the clinician. JPsychiat Res 1975; 12: 189–98.2. Fields S, Mackensie R, Charlson M, Perry S. Reversibility ofcognitive impairment in medical inpatients. Arch Intern Med 1986;146: 1593–6.3. Treloar A, Macdonald AJ. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the reversiblecognitive dysfunction scale among acute geriatric inpatients. Int JGeriat Psychiat 1997; 12: 609–13.4. Jacobson SA. Delirium in the elderly. Psychiat Clin N Am 1997; 20(1):91–110.5. Kolbeinsson H, Jonsson A. Delirium and dementia in acute medicaladmissions of elderly patients in Iceland. Acta Psychiat Scand 1993;87: 123–7.6. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 3rd edn, revised (DSM-III-R). Washington,DC: American Psychiatric Association.7. Cole MG, Primeau FJ. Prognosis of delirium in elderly hospitalpatients. Can Med Assoc J 1993; 149(1): 41–6.8. Rudberg MA, Pompei P, Foreman M et al. The natural history ofdelirium in older hospitalised patients: a syndrome of heterogeneity.Age Ageing 1997; 26: 169–17.9. Trzepacz PT, Baker RW, Greenhouse J. A symptom rating sale fordelirium. Psychiat Res 1988; 23: 89–97.10. Levkoff SE, Evans DA, Liptzin B et al. Delirium: the occurrence andpersistence of symptoms among elderly hospitalised patients. ArchIntern Med 1992; 152: 334–40.11. Kaponen H, Stenbeck U, Mattila et al. Delirium among elderlypatients admitted to a psychiatric hospital: clinical course and oneyear follow-up. Acta Psychiat Scand 1989; 79: 579–85.12. Thomas R, Cameron D, Fahs M. A prospective study of delirium andprolonged hospital stay. Arch Gen Psychiat 1988; 45: 937–40.13. Rabins P, Folstein M. Delirium and dementia: diagnostic criteria andfatality rates. Br J Psychiat 1982; 140: 149–53.14. Gustafson Y, Berggren D, Brannstrom B et al. Acute confusionalstates in elderly patients treated for femoral neck fracture. J AmGeriat Soc 1988; 36: 525–30.15. Magaziner J, Simonsick EM, Kashner TM et al. Survival experienceof aged hip fracture patients. Am J Publ Health 1989; 79: 274–8.16. Magaziner J, Simonsick EM, Kashner TM et al. Predictors offunctional recovery one year following hospital discharge for hipfracture: a prospective study. J Gerontol 1990; 5: M101–7.17. Francis J, Kapoor W. Prognosis after hospital discharge of oldermedical patients with delirium. J Am Geriat Soc 1992; 40: 601–6.