Download - Annals of Delirium March 2012
Editorial
Spring 2012 and momentum is building up as delirium features more
often and more prominently in published medical literature. Last
month the British Medical Journal published the largest intensive care
unit (ICU) delirium study to date. In the accompanying editorial I
tried to make the point that the science is clear: failing to detect and
manage delirium adequately is failing the patients. Professor
MacLullich went further in a personal communication “excellence in
delirium care should be the expectation in all ICUs; anything less,
given the resources and expertise in ICU, is frankly unacceptable.”
Delirium in UK critical care patients has been particularly topical in
the lay press with a videocast and an article from Times columnist
David Aaronovitch describing his own experience then the Scottish
newspaper, Sunday Post, publishing an interview with Peter Gibb of
ICUsteps. Consequently the website www.icudelirium.co.uk has had
an increase in patients sharing their own experiences relieved to
know they are not “going mad”. Will this lead to patients and relatives
wanting to know more about delirium and what we, the health care
professionals are going to do about it?
How can we influence this? Let us gather our previously low ranking
cards into a winning hand. I believe we need to keep doing what we
are all doing already, making a difference one patient at a time. In
addition if we each aim to inform two clinicians a month one or two
facts about delirium, and they inform two other clinicians a month, by
the end of 10 months each of us could be responsible for an additional
500 clinicians knowing more about delirium!
This bumper edition includes a collaborative article highlighting the
importance of subsyndromal delirium, Dr Davis tells us all we need to
know (and we do need to know) about epidemiology and Dr Wilson
has provided an inspiring descriptive piece about altering the ward
environment for at risk patients with dementia. The news section will
bring you up to date with events and initiatives including the first
European Delirium Survey and an announcement for the next annual
meeting.
Finally, I am pleased to announce that Dr Andrew Teodorczuk will be
a co-editor of the Annals of Delirium from the next edition.
Contributions all welcome for the summer edition – prose or poetry!
Valerie Page
Capturing psychiatric phenomena: what delirium
researchers can learn from dementia epidemiologists
Daniel Davis and Carol Brayne
Institute of Public Health, University of Cambridge
At delirium conferences, we often hear the call for ‘more research on
the epidemiology of delirium’. There have been very few studies on
delirium prevalence in the general population. Perhaps this is because
such studies are difficult to undertake and is compounded by
problems of how to define psychiatric syndromes in epidemiology.
Research in dementia has faced similar obstacles – what lessons have
been learned?
What do we mean by ‘population’? Epidemiology is concerned with the inter-relationship between
populations, exposures and outcomes. Intrinsic to this is the problem
of definitions and how they are conceived, framed and articulated. In
considering the importance of defining a population, we are asking: Is
the chosen population one that is relevant to the full spectrum of
persons with delirium? How does the approach to sampling enable a
valid capture of the chosen population? These are critical questions as
the provenance of the sample population has the potential to
systematically bias findings both in magnitude and direction.
The majority of studies in delirium have been undertaken in hospital
settings, and these have been comprehensively reviewed.1 These
studies indicate that delirium is a common problem in inpatients with
serious adverse outcomes. However, there are two limitations to the
inferences that can be drawn about delirium as a whole. Firstly, one
cannot assume that all persons with delirium will actually present to
hospital. Secondly, once in hospital, there is only retrospective (and
therefore limited) information of a person’s cognitive and
performance function before the onset of delirium. Ideally, one would
start with a broad, unselected denominator (i.e. a true population-
based study) followed-up with serial cognitive assessments. This
would represent a comprehensive range of symptoms (and severities),
but also identify what happens, to whom, and when. This is essential if
we are to understand the determinants and effects of delirium most
completely. A working definition for population-based study might be:
‘a study where all subgroups of the population are sampled, regardless
of disease or residential status’.2 Of course, ensuring that a study
population is comprehensive in this way requires substantial effort,
but there are gains of equal degree in terms of achieving results with
external generalisability.
Psychiatric epidemiology: a problem of standardisation
In order to reliably track states of health in populations, looking for
emerging patterns and trends, one must be able to define exposures
and outcomes of interest in a standardised way. All diseases can be
nosologically classified, each with their ‘reference-standard’
definitions. However, where these conditions are psychiatric
syndromes, the reference-standard is necessarily a set of clinically
agreed descriptions of psychopathology rather than any objective
quantities.
There are two different approaches for neuropsychiatric definitions,
the International Classification of Diseases (World Health
Organization) and the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association). There are some
differences between these two systems (see references for a
discussion on how these might affect case-ascertainment in dementia3
and delirium4). However, both are subject to common problems.
Firstly, these definitions are not stable over time (ICD-9 vs 10, DSM-
III-R vs DSM-IV, with further iterations in evolution). Nor are these
definitions easily transferrable across cultural contexts. Yet more
problematic is that these clinical criteria have the potential to vary,
and so can be interpreted differently by different clinicians. An
example is how the definition might be applied to persons of different
ages depending on the expectations of normality for that age group. In
other words, the threshold for abnormal cognitive or functional
impairment may decrease with age, in line with a belief that some
impairment is to a degree expected (and therefore not abnormal) in
older age.5 Finally, in the research setting, a core problem is how to
operationalise these criteria so that case-ascertainment can be
achieved in a consistent manner.
Underlying these difficulties is the problem of how to agree the
boundaries for a spectrum of psychiatric symptoms. While there is
relatively little disagreement about moderate and severe dementia,
studies that include milder cognitive deficits lead to much less
consistent estimates of prevalence (see references for review6). Mild
cognitive impairment (MCI) has been regarded to be of possible
relevance to dementia, but applying the MCI construct to population-
based cohorts has not been straightforward.7, 8 The equivalent entity
in delirium – i.e. subsyndromal delirium – also needs to be considered
in light of these issues.
Dementia epidemiology: some approaches
Dementia is clinically defined by identifying progressive deficits in
two or more cognitive domains sufficient to impair function in
activities of daily living. Three population-based studies can be used
as examples to illustrate the different ways in which this definition has
been operationalised in the context of research (Table 1). Vantaa 85+
defined dementia cases through the agreement of two neurologists at
clinical examination.9 While this is more reliable than assessment by a
single clinician, there remain difficulties with inter-rater reliability
and this can hamper cross-study comparisons. In the City of
Cambridge over-75 Cohort (CC75C),10 as well as other studies in both
Europe11 and North America,12 this has been addressed through the
agreement of dementia diagnoses at multidisciplinary consensus
meetings, held after all study information becomes available. This
method of case-ascertainment is labour-intensive and so limits the
breadth of coverage to some extent.
In parallel to the development of the multidisciplinary conference to
standardise case-ascertainment, use of the Present State Examination
(PSE)13 led to the possibility of creating diagnostic categories through
algorithms. The PSE – and the version validated in older persons, the
Geriatric Mental State (GMS)14 – is a systematic operationalisation of
the psychiatric mental state examination. It uses answers generated
from the interview to group symptom clusters which can then be used
to derive diagnostic groups. Once these categories have been validated
against clinician-applied diagnoses, this algorithm approach can be
automated and applied by non-medical interviewers. The MRC
Cognitive Function and Ageing Study (MRC-CFAS) used such an
approach with the Automated Geriatric Examination for Computer
Assisted Taxonomy (AGECAT).15 This allowed for much greater
numbers of persons to be studied and MRC-CFAS remains one of the
largest population-based studies of dementia incidence ever to be
conducted. The algorithm diagnosis has been considered again more
recently by studies such as the Health and Retirement Study, mainly
driven by attempts to reduce the cost of case-ascertainment.16 In
addition, an algorithm approach has been applied to the consensus
diagnosis itself, with the aim of making the process more time-
efficient.17
Accounting for attrition
Loss to follow-up is common to all longitudinal studies of older
persons. Usually, this is due to death between interviews. This is also
known as censoring – where people contribute to the observed period
of follow-up, but where loss to follow-up means that case-status
cannot be ascertained. This information must still be included in the
analysis because it is still useful to know that persons weren’t cases
until the point they were last observed.
One of the underlying assumptions of this type of cohort analysis
(known as survival or time-to-event analysis) is that censoring is ‘non-
informative’. This means that characteristics of persons retained in
follow-up are similar to those that are lost. Particularly for studies of
ageing, this assumption is overly strong. It is clear that attrition in
ageing studies does not occur at random, and lower cognitive and
functional scores at last interview predict drop out. While this makes
intuitive sense, very few studies explicitly use statistical techniques
such as ‘last observation carried forward’ to account for missing data.
These approaches have been important in the dementia field18-20 but
have yet to be systematically applied to follow-up studies in delirium
and almost certainly under estimate the effect of drop out.
Case-ascertainment in delirium epidemiology
There are a handful of population-based studies in delirium. In each of
these, the diagnosis of delirium was based on the DSM criteria, though
again operationalised in different ways (Table 2). The East Baltimore
Survey and Girona studies used validated interview schedules
(Standardised Psychiatric Examination and Cambridge Mental
Disorders of the Elderly Examination respectively), whereas the
Canadian Study of Health and Ageing (CSHA) applied diagnoses
through consensus meetings. None used an algorithm
operationalisation.
There is a consistent finding that community prevalence of delirium is
relatively low, but it remains a condition with poor prognosis,
comparable to hospital series. Nonetheless, it is important to note that
intercurrent illness and/or delirium might well reduce response rates
in epidemiological surveys. In this regard, while these studies have
also reported characteristics of participants and nonparticipants, none
have related these to acute illness and estimates of delirium
prevalence.
The Vantaa 85+ did ascertain delirium. To apply a retrospective
diagnosis, participants were assessed along with their informant(s)
for a history of any episodes of delirium, specifically assessing:
changes in cognitive functioning, level of alertness and psychotic
symptoms, as an operationalisation of the DSM-III-R criteria.21 The
reported history and number of episodes of delirium were
corroborated with hospital case notes that were available at the time
of assessment. As noted above, there are problems with the reliability
of determining both delirium and dementia. However, it remains an
important study because it is the only population-based cohort to
have specifically attempted to relate history of delirium with dementia
outcomes.
Combining these approaches for delirium epidemiology
It is clear that standardisation is a complex issue in psychiatric
epidemiology. One general consequence of not identifying delirium
accurately is a reduction in the observed effect size between the
intervention and control groups (known as non-differential
misclassification bias). Thus insufficient attention to standardising
case-ascertainment results in loss of power in trials. At the very least,
we can conclude that clinical delirium research would benefit from
case-ascertainment consensus conferences and/or algorithmic
operationalisation. It should not be considered sufficient for case-
ascertainment to be decided by single assessors. Scores for individual
diagnostic items – and their temporal fluctuations – should be
submitted for agreement at the level of a consensus panel. At the same
time, there is potential to develop algorithm diagnoses in delirium.
Already there are semi-automated some neuropsychological tests (e.g.
the Edinburgh Delirium Test Box for attentional deficits22), and it
would be logical to incorporate these. These new approaches will
require careful validation studies. This shift toward better-informed
epidemiological techniques may seem daunting, but must be regarded
as essential for generating valid clinical research in delirium. The
future may bring innovative approaches, as has been proposed for
dementia: improving coverage through proxy / participant telephone
interviews (validated against face-to-face interviews); newer versions
of algorithm-generated computer information; online consensus
conferences.16 Some delirium collaborations are beginning to adopt
these ideas.23
Even these measures will not be enough. The challenges for delirium
epidemiology are greater than those for dementia. There are
particular features of the syndrome that make standardisation even
more complicated. Fluctuating symptoms are a core feature of
delirium, and this will not be reliably captured without specific
attention to how this is to contribute to case-ascertainment. There is
scope for delirium research to benefit from approaches in other fields
within neuroepidemiology, particularly acute conditions such as
stroke or epilepsy. These efforts will be rewarded by generating
methodologically rigorous clinical data applicable to the broad
generality of patients with delirium.
Table 1. Characteristics of studies comprising the EClipSE
database.
Making Marjory Warren Proud
Marjory Warren ward is a 30-bedded inpatient ward at Kings College
Hospital in South East London, named after the founder of modern
geriatric medicine. I am lucky enough to share the consultant duties
with Dr Catherine Bryant and as we both have interests in cognitive
disorders the ward attracts a high number of patients with dementia,
delirium or both. I have tried to write a descriptive piece that tells the
story of the transformation of the ward to make it a more suitable
environment for patients with cognitive problems. I make no
apologies for the relatively few specific mentions of delirium. We
wanted to create neither a delirium ward nor dementia ward, but a
more inclusive place where expertise in managing frailty in the
context of a wide range of cognitive disorders would prevent and
reduce harm from delirium as one of many facets improving patient
care.
Before I go further however, a disclaimer. I am extremely proud to
have been part of the project I am about to describe, but I want to take
no credit for its inception or realisation. The transformation was
due entirely to Emma Ouldred our Dementia Nurse Specialist at Kings
and a team of nurses working with her. The transformation certainly
would not have happened without their tireless optimism,
commitment and unerring belief that the patients we treat deserve to
be cared for in an environment that is not just practical and functional
but welcoming, safe, orientating and stimulating.
Since 2000 the King’s Fund has been supporting a number of projects
in UK hospitals under the umbrella “Enhancing the Healing
Environment”. There are a range of projects and in 2009 some funding
was specifically directed towards projects that improved the
experience of patients with dementia. We applied for a second tranche
of funds made available in 2010. The initial ambition was to
transform the day room on one of our Gerontology wards into a
sensory room that would provide a healing environment for patients
with dementia, recognising that this might help treat and prevent
other cognitive problems including delirium. We would promote
activities such as reminiscence, in a newly designed, uncluttered room
with lighting and furnishing that encouraged patients to use a space
that had become increasingly used by staff to host professional
meetings. Sensory equipment and memory boxes that were also
portable would be available to be taken to the beds of less mobile
patients.
The views from our 7th floor ward are stunning, looking across to the
city of London (St Paul’s, the London Eye) as well as the local area. By
introducing interpretation panels that described the views we hoped
to stimulate conversation and reminiscence. Along with an easily
operated multi-media centre we intended build a library of music and
films that patients could enjoy. The projector could be used to play
other moving images (a roaring log fire was particularly popular over
Christmas when the plans finally became realised) as well as stills
from a staff photography competition that was run during the
redesign project.
During the early stages of this transformation it became clear that to
focus on one room on Marjory Warren ward would not be enough to
truly enhance the environment for our patients. Rather than be
limited by the money (a not insignificant £50,000) from the Kings
fund, supported by a further £15,000 from the hospital, the initial
plans became a springboard for a complete redesign of the ward and
its entrance area. Patients past and present along with their carers, as
well as nursing and therapy leads and our hospital estates and
communications teams all contributed to lively meetings.
Redecorating the whole ward with colourful (and colour coded)
simple designs, and clearly labelling bed numbers in bays and rooms
was proposed. We wished to replace the highly polished, plastic
flooring as patients told us they often thought the floor looked wet,
leading to fear of falling. Other important equipment such as cardiac
arrest trolleys and clinical waste bins needed to be housed discreetly
whilst remaining clinically accessible. Artwork was proposed that was
relevant to our local population (a fantastically ethnically and socially
diverse population) and projects were set up that the patients could
contribute to during their activity groups or therapy sessions. Dulwich
Picture Gallery, (Britain’s first public art gallery founded in 1811)
brought their experience from an “Art For Older People” project and
commissioned an artist to help patients, carers, visitors and staff
create an embroidered panel fittingly titled “The Urban Jungle” that
now sits in the entrance of the ward.
The Kings Fund and hospital were delighted with the ambition
encouraging Emma to apply for more funding without concerns that
their own contribution might in any way become diluted or stifled. We
were extremely lucky that the Friends of King’s Charity had been left a
£200,000 legacy that the trustees felt was ideal to support this project.
Now a much broader transformation could take place. We continued
with the proposals mentioned above (the flooring is now a matt, non-
slip wood effect to provide a more homely feel). Panels of pictures
around the corridors of the ward reflect the London skyline outside,
and new hand rails and regularly spaced seats mean patients can
wander more safely and have recognisable images to look at, enjoy
and discuss. More seating nearer to the two nursing stations and a
very open plan design means patients at high risk of falls or those in
need of company and conversation can be closer to the staff. At one
end of the ward are also some sensory panels that are very simple in
design for those with more advanced cognitive problems to interact
with. The experience, from ward entrance, around the ward and into
the sensory room is now part of a sensory walk for patients, their
carers, and staff which shows the range of the transformation which
can now be experienced as a whole or in smaller chunks.
Of course there is more to this than ambition and a loose sense that
change was just needed and would inevitably be for the good. We tried
to look for guiding principles to inform the design, though
interestingly there is little out there that is “evidence-based”. We
tapped the University of Stirling’s Dementia Services Development
centre, utilised extensive resources provided by the King’s Fund, and
Dr Jim George’s experience from the delirium unit at Carlisle.
Architects who have been involved in designing hospital and care
home environments for those who are frail and with cognitive
problems were consulted, as were the Alzheimer’s Society. We are
aware that much of what we have done “just makes sense” to us as
experts in dementia and delirium care. We hope the lessons we learn
form the transformation will contribute to a future evidence base to
inform others.
We are also aware that changing an environment alone will not be
sufficient to improve patient care. Fortunately there seems to already
be an appreciable change in both the patients and the staff working on
the ward. We have also seen an increase in nursing and therapy staff
expressing a desire to work on Marjory Warren. Formally measuring
and evaluating both patient and staff outcomes are therefore key. We
also need to continue other work we were already doing in the
education and training of staff and carers about frailty and particularly
dementia and delirium.
Some early indicators are promising. Patient satisfaction in all areas,
both clinical and environmental, measured in our “How Are We Doing”
survey has been consistently higher for the last three months since the
project was completed, exceeding our internal benchmarks. Even
before completion, with some building work still going on around the
patients, our length of stay had fallen. Of course the environmental
effect will be difficult to prove emphatically as this is not a randomised
trial. More specific indicators around delirium rates or intensity,
reduction in special one: one nursing or use of more extreme
measures such as sedation will take more time to collect and analyse.
What does the future hold other than evaluation? Our Activities
Coordinators continue to try and expand the range of groups they
hold, to use art, music, reminiscence as well as tea parties or bingo
mornings to engage patients. The current Occupational Therapists are
setting up a lunch club and even the junior doctors have committed to
helping with that! We now have some volunteers too who provide
vital support for the patients on the ward. We are meeting a film
company who do stop-motion animation (the same technique used to
make “The Wrong Trousers”). They would like to make a film,
facilitating the patients on the ward to create a story and direct their
own piece of work.
These are therefore exciting times at Kings and the potential to
influence the care of frail patients more widely (both within the
hospital and outside) will hopefully come from this. We launched the
ward in mid-December 2011 in a week when a high profile report on
dementia care in the NHS was published. Marjory Warren ward was
chosen as an exemplar for both local and national news coverage. We
are very aware that with such publicity comes the need for great
responsibility, to our patients first, but also to those who have backed
us both financially and with moral support. We know we are one of
many transformative projects and we have been exceptionally lucky to
get the money we secured.
We would encourage visitors, feedback and opportunities to
collaborate and share experience.
Sensory Room with log fire projection
Nurses Station Before
Nurses Station After
Ward Before
Ward After
Fathers with delirium
My Dad was diagnosed with lymphoma and was admitted with
a huge blood clot in his arm. The pain was terrible. He was
given morphine which initially resolved the acute pain.
However within hours he was staring at the ceiling counting
the dots. He became quiet and withdrawn and it was hard for
him to break his stare to look at us. I told the nurse that I
believed my Dad was suffering from delirium and she said she
would call the GP. She obviously did not know the symptoms
of delirium.
My Dad, an Anglican priest in the community where he was in
hospital (i.e. well known) had terrible dreams about robbers
attacking him in his hospital bed, and he climbed out of bed in
the night. After that he was physically restrained, had his
glasses taken away, and he was given just 0.5 mg haloperidol
IV twice a day for nausea! The delirium was never addressed
by the GP because when my dad spoke to the GP, he was polite,
and quiet. He wouldn’t share his fears with him. The GP paid
no attention to our complaints.
My Dad stayed in that state for 5 weeks. He was confused,
irritable and ended up in diapers because no one wanted to go
near him. When a pain doctor came to visit my Dad (he
happened to play golf with my Dad and saw he was in
hospital), he immediately recognized the delirium and just
changed the narcotic to a fentanyl patch. My Dad became
reasonable again. Sadly, he died 10 days later of an aspiration
pneumonia following chemotherapy.
My mother grieves for him, and feels such a sense of loss for
those 5 weeks when my Dad was so confused and afraid. I am
an ICU nurse with many years of treating delirium. I was so
frustrated by the lack of knowledge the GP seemed to have
about delirium, even though he was the most responsible
physician, I was powerless to convince him that he was
witnessing delirium related to narcotics. I will always regret
not making a big enough stink to get help for my Dad. Maybe
this testimonial will help some readers understand the impact
of delirium on patients and families. It was so unnecessary that
my Dad had such an end of life experience when the treatment
seemed to be so simple.
Authors name withheld, posted on www.icudelirium.co.uk
My Father’s Delirium A routine hip operation. But he looks quiet now. The earlier rage all whimpered away. A ravaged body, emptied and spent. A living husk that somewhat recalls, A happier memory: a father. A routine hip operation. An apologetic limp into the ward. A nervous smile, polite handshake. An anxious curiosity of who, And what, and when. A perfectly, perfect person, Extends his gift of trust. This is routine stuff for us! “We badge you, stamp, and wrap you. Then cut you, mend and dispatch you.” All proclaimed with a smile, But the eyes are distant, detached. Another day, another hip. The operation was quite routine. But my father somehow troubled, Subtly not there; with us, but not of us. Tea cups lie untested; Stagnant and dismal. And a restless fidget speaks of unease. A routine hip operation. But my father visibly shrivels, Into a secret, deep, inner space. “Dehydration, infection and constipation.”
So we are told. An oddly innocent litany, To inflict so grave an ill. And surely foreseen, and …….. preventable? A routine hip operation. Now an imprisonment within an internal world, Of blazing, crazy hues. Of ghostly faces, horrid forms. Evil voices murmuring evil thoughts, Shimmering moments in bewilderment. A soul adrift, sinking, sinking, Into the unseen, the in-between. But that was yesterday, And those several days before. A perfectly, perfect man, utterly undone. “Dehydration, infection and constipation.” The mantra plays and plays. A well oiled machine, all spoiled, For a wink of humanity. The merest pinch of care! It was…….a routine hip operation. John Young Bradford Royal Infirmary, UK
Subsyndromal delirium: Relevance to dementia
Elizabeta B. Mukaetova-Ladinska, Joaquim Cerejeira, Andrew
Teodorczuk
Institute for Ageing and Health, Campus for Ageing and Vitality,
Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
Introduction
With the newly published National Dementia Strategy (2009)
and the recent RCPsych Dementia Audit (2011), we expect routine
screening for cognitive impairment and dementia in general hospitals
to increase. This will put pressure on both medical and mental health
services looking after the wellbeing of the older adults to have readily
access to adequate services for older adults with dementia.
Only during the last year, our Liaison Old Age Psychiatry team
has noted a high increase in referrals for dementia diagnosis for older
adults from various medical and surgical wards in the Newcastle area,
with many of them referred either shortly after their admission on
medical wards in the absence of delirium symptomatology, or after a
‘resolved’ delirium episode (still with some clinical symptoms of
delirium) and having problems in numerous cognitive domains. Yet,
not all of them will fulfil the DSM-IV criteria either for delirium or
dementia. This raises a number of clinical issues regarding the
management of such patients on medical wards, including both
pharmacological and non-pharmacological treatments, further
investigations of their cognitive decline, discharge plans, as well as
involvement of various support services to facilitate the latter.
Although several parameters have been associated with full recovery
of delirium (e.g. lack of apoE 4 allele, being female and lower levels of
IGF-1), severity of delirium, underlying presence of dementia and/or
advanced age do not appear to be relevant for the full recovery from
delirium (Adamis et al, 2007), thus further arguing for the seriousness
in managing of this clinical syndrome. The purpose of this opinion
piece is to explore the interface between subsyndromal delirium and
dementia and make recommendations for future research.
Clinical symptomatology of sybsyndromal delirium
The most recent study on sybsyndromal delirium (SSD) in
medically ill patients reported presence of 27% in all subjects post
delirium (Maegher et al, 2012). However this figure came from a
heterogeneous sample of subjects with delirium, ranging from 36-90
years of age, of which only 27% had known dementia. Marcantonio et
al (2005) reported higher prevalence rates of SSD in older adults (up
to 51%), and especially those with pre-existing dementia, similar to
the older subjects with delirium. In one of our studies, we have
highlighted the problems in diagnosing delirium in older subjects with
advanced dementia (Yates et al, 2007). We propose that delirium,
including SSD, may go largely under-diagnosed in many older adults
with dementia.
The clinical symptoms of SSD are characterised by less severe,
especially motor activity, disturbances (e.g. less agitation and
hyperactivity), less psychotic symptoms (e.g. delusions and
hallucinatory experiences), higher level of thinking, and higher
cognitive performance (e.g. attention, orientation, better working and
long-term memory) (Meagher et al, 2012) (table 1). Longitudinal
studies have also shown that SSD is not characterised by unstable
circadian (Meagher et al, 2012), and the lack of overt fluctuating level
of consciousness and symptomatology, makes the differentiation
between SSD and dementia even more difficult. This is especially so in
the light of lack of adequate clinical tools and peripheral biomarkers
that may aid the clinical differentiation, and thus help with the clinical
management of subjects with SSD.
How to diagnose subsyndromal delirium: use of clinical
and peripheral blood biomarkers
People with SSD have worse outcomes in terms of hospital
readmissions and mortality, they are less likely to return back to the
community within 30 days of admission have longer hospital stays
and overall more medical complications, including higher risk for falls
(Marcantonio et al, 2005), lower cognitive and functional level at
follow-up (Cole et al, 2003) compared to subjects devoid of delirium.
In the light of the numerous poor outcomes, there is a need not only to
improve the clinical recognition of SSD, but also its proactive
management.
Sadly, many of the subjects with SSD will be either referred to
the Liaison Psychiatry Services for diagnosis of dementia, or will be
misdiagnosed for dementia rather early in the course of their delirium
recovery. Since SSD can coexist with dementia, having good collateral
information about baseline functioning is an imperative. However, in
many of the SSD subjects this information will be unavailable. In the
absence of reliable collateral history, the diagnosis of the syndrome
largely relies on clinicians’ skills. However, since the latter are not
always in place, increase in awareness, education as well as
improvement of currently available diagnostic tools are urgently
needed.
Future challenges and areas for further investigation
In addition to the above, a number of SSD topics still remain
largely unknown:
the predictive value of individual symptoms in respect to poor
prognosis at short and long term;
the natural course of subsyndromal delirium and its temporal
interrelation with syndromal delirium, severe or otherwise;
the impact of non-pharmacological or pharmacological
interventions on individual symptoms of delirium.
An additional problem for SSD management is the current
widespread clinical culture refusing to acknowledge presence of the
syndrome once the causes of delirium are treated and the laboratory
findings are normalised. Thus, although elevated CRP levels are
largely associated with delirium (both prevalent and incident
delirium; McDonald et al, 2007), these findings have not been
replicated in further studies (White et al, 2008, van den Boogaard et
al, 2011), and even opposite findings have been reported for older
adults with co-existing dementia (Yates et al, 2009). Similarly, the
values of serum albumin and blood urea appear not to be useful in
discriminating between subjects with and without SSD (Cole et al,
2003, Yates et al, 2009).
Although various biomarkers have been associated with
delirium (van den Boogaard et al, 2011) their relevance to SSD legs
behind. Elevated levels of homocysteine are not only associated with
dementia, but also with alcohol withdrawal (Bleich et al, 2000),
suggesting that values of homocysteine above the 14µmol/l values
maybe indicative of SSD. Lower levels of esterases preoperatively also
help distinguish people at risk to develop delirium post-operatively
(Cerejeira et al, 2011), and this may also help identify SSD in clinical
setting. However, further work is needed in older adults with co-
existing dementia to validate the above findings.
Conclusion
The importance of correct diagnosis of the SSD in older adults,
especially those with a previous diagnosis of dementia, is highlighted
daily in clinical setting. One crucial question to clinicians is to
determine if subtle changes in mental status (e.g. level of
consciousness, disorientation) not fulfilling all the criteria for delirium
should be a relevant and meaningful target for clinical attention and
intervention. There are two good reasons to believe so. Firstly, in the
absence of a peripheral, non-invasive and easy test to guide clinicians,
SSD is the only available way to recognize early signs of brain
dysfunction which has enormous clinical relevance. For example, in
acute systemic inflammatory conditions, the delay between insult and
neuroinflammatory events associated with full-blown delirium offers
a window of opportunity to implement therapeutic interventions.
Secondly, many non-pharmacological interventions are "good clinical
practice" that should be always implemented and have no associated
risks.
However, in the current climate of diminishing resources,
lowering the threshold for clinical significance of symptoms of
delirium can impose a very high burden of work for the Liaison
Psychiatry services if education on medical wards, as well as nursing
homes and community, is not adequately implemented. Similarly,
further research into the clinical course and outcomes of SSD is
urgently required. We can conceptualise SSD treatment as being
similar to treating early psychosis in mental health units, and, if
resourced adequately, we may even have early intervention in
delirium teams. In the absence of adequate peripheral blood
biomarkers at present, one of the research goals needs to be further
development of novel blood peripheral biomarkers to aid the
diagnosis.
References:
1. Adamis D, Treloar A, martin FC, Gregson N, Hamilton G,
Macdonald AJD: APOE and cytokines as biological markers for
recovery of prevalent delirium in elderly medical inpatients.
Int J Geriatr Psychiatry 2007; 22: 688-94.
2. Bleich S, Degner D, Wiltfang J, Maler JM, Niedmann P, Cohrs S,
Mangholz A, Porzig J, Sprung R, Rüther E, Kornhuber J:
Elevated homocysteine levels in alcohol withdrawl.
Alcol&Alcoholism 2000; 35: 351-4.
3. Cerejeira J, Batista P, Nogueira V, Firmino H, Vaz-Serra A,
Mukaetova-Ladinska EB. Low preoperative plasma
cholinesterase activity as a risk marker of postoperative
delirium in elderly patients. Age Ageing 2011; 40: 621-6.
4. Cole M, McCusker J, Dendukuri N, Han L: The prognostic
significance of subsyndromal delirium in elderly Medical
inpatients. J Am Geriatr Soc 2003; 51: 754-60.
5. Department of Health: Living well with dementia: A National
Dementia Strategy. 2009.
6. Macdonald A, Adamis D, Treloar A, Martin F. C-reactive
protein levels predict the incidence of delirium and recovery
from it. Age Ageing 2007; 36: 222-5.
7. Maegher D, Adamis D, Trzepacs P, Leonard M. Features of
subsyndromal and persistent delirium. Br J Psychiatry 2012;
200: 37-40.
8. Marcantonio ER, Kiely DK, Simon SE, Orav EJ, Jones RN,
Murphy KM, Bergmann MA. Outcomes of older people
admitted to postacute facilities with delirium. JAGS 2005; 53:
963-9.
9. Royal College of Psychiatrists: National Audit of Dementia:
Report of the first round of the National Audit of Dementia.
2011
10. van den Boogaard M, Kox M, Quinn KL, van Achterberg T, van
der Hoeven JG, Schoonhoven L, Pickkers P. Biomarkers
associated with delirium in critically ill patients and their
relation with long-term subjective cognitive dysfunction;
indications for different pathways governing delirium in
inflamed and non-inflamed patients. Crit Care. 2011;15:R297.
[Epub ahead of print]
11. White S, Eeles E, O’Mahony S, Bayer A. Delirium and C-
reactive protein. Age Ageing 2008, 37: 123-4.
12. Yates C, Stanley N, Cerejeira JM, Jay R, Mukaetova-Ladinska
EB. Screening instruments for delirium in older people with
an acute medical illness. Age Ageing 2009; 38: 235-7.
Table 1: Symptoms of subsyndromal delirium. Please note that
subsyndromal delirium does not fulfil the DSM-IV defined criteria for
delirium (DSM-IV recognize subclinical presentations that precede or
follow delirium, as well as presentations that never progress to
delirium), and the clinical symptoms are less severe in relation to the
full-blown delirium. Maegher et al (2012) suggested DRS-R98 cut-off
scores of 16 for diagnosis of the syndrome. Modified according to Cole
et al (2003) and Maegher et al (2012).
Symptoms of subsyndromal delirium
1. Motor activity (restlessness, agitation, irritability, drowsiness,
hypersensitity to stimuli)
2. Higher cognitive functioning (reduced ability to think or
concentrate; impairment in attention, orientation, working
memory and long-term memory)
3. Perceptual and mood disturbances (anxiety, delusions and
hallucinatory experiences, nightmares)
4. Relatively stable circadian rhythm
5. ? Lack of overt fluctuating level of consciousness and
symptomatology
Announcing An Italian Textbook on Delirium
Alessandro Morandi, MD, MPH 1,2,3, E Wesley Ely, MD, MPH, 4,5,6,7,8 Marco
Trabucchi, MD9
1 Department of Rehabilitation and Aged Care Unit, Ancelle della Carità
Hospital, Cremona, Italy; 2Geriatric Research Group, Brescia, Italy; 3Center
for Quality of Aging, Vanderbilt Medical Center, Nashville, TN, USA;
4Center for Health Services Research, Vanderbilt Medical Center,
Nashville, TN, USA;5Division of Allergy/Pulmonary/Critical Care Medicine,
Vanderbilt Medical Center, Nashville, TN,USA; 6VA Tennessee Valley
Geriatric Research, Education and Clinical Center (GRECC), USA; 7
University of Tor Vergata, Rome, Italy
Delirium is a complex and multifaceted syndrome, and though it has a
long history in the annals of medicine, few textbooks are currently
available on this geriatric syndrome. Caraceni and Grassi1 published “The
Acute Confusional States in Palliative Medicine” specifically addressing
the concept of delirium in palliative care patients. Subsequently, Page and
Ely2 targeted a different setting focusing on “Delirium in Critical Care”.
Lindesay3 published a textbook evaluating delirium in the elderly:
“Delirium in the old age.” In the Italian literature there was an important
existing gap on this topic. In fact no textbook has been published to
inform health care providers on this important syndrome, which affects
thousands of patients every year. Therefore, we undertook the efforts to
create an Italian textbook on delirium, named “Il delirium.” 4 The book is
available to buy online
(http://www.vitaepensiero.it/volumi/9788834321591) and it is
structured in five chapters: 1) Epidemiology, classification and risk factors
of delirium in different clinical settings; 2) Pathogenesis of delirium; 3)
Clinical aspects of delirium; 4) Prevention and treatment of delirium; 5)
Future directions.
(1) Caraceni A, Grassi L. Delirium Acute confusional states in palliative
medicine. Second Edition ed. Oxford University Press, 2011.
(2) Page V, Ely EW. Delirium in Critical Care (Core Critical Care).
Cambridge University Press, 2011.
(3) Lindesay J, Rockwood K, MacDonald A. Delirium in Old Age. Oxford
Medical Publications. 2002
(4) Morandi A, Ely E.W., Trabucchi M. Il delirium. Vita e Pensiero, 2012.
Papers to look out for A: Dr Meera Agar Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and non-inflamed patients. van den Boogaard M, Kox M, Quinn KL et al
Crit Care. 2011 Dec 29;15(6):R297. [Epub ahead of print]
This is an exploratory observational study of 100 ICU patients with or without
delirium and with ("inflamed") and without ("non-inflamed") infection/SIRS.
Delirium was diagnosed using the confusion assessment method-ICU (CAM-
ICU), and biomarker analysis occurred 24 hours following the onset of
delirium. In the non delirious group blood was taken at a similar time point as
the ICU length of stay at time of delirium in the delirium group. In
multivariate regression analysis this study found IL-8 was independently
associated (odds ratio 9.0; 95%CI 1.8-44.0) with delirium in inflamed patients
and IL-10 (OR 2.6; 95%CI 1.1 - 5.9) and A-beta1-42/40 (OR 0.03; 95%CI 0.002 -
0.50) with delirium in non-inflamed patients.
Full abstract available at:
http://www.ncbi.nlm.nih.gov/pubmed/22206727
Randomised control trials for delirium: Current evidence and statistical methods.
Tahir TA, Farewell D, Bisson J.
J Psychosom Res. 2012 Jan;72(1):84-5. Epub 2011 Nov 25.
This is a welcome discussion on the complexities of delirium RCT analyses,
and proposes some statistical methods and approaches which have been
undertaken. Well worth a read for those pondering trial design.
B: Editors Choice
Two papers with haloperidol in mind with results designed to confuse.
Differential risk of death in older residents in nursing homes
prescribed specific antipsychotic drugs: population based cohort
study
Huybrechts et al. British Medical Journal 2012;344:e977 (Published
23 February 2012)
Haloperidol prophylaxis decreases delirium incidence in elderly
patients after noncardiac surgery: A randomized controlled trial*.
Wang et al Critical Care Medicine 2012 Mar;40(3):731-9.
March news
Conferences
The Second Annual Meeting for the American Delirium
Society. Indianapolis, Indiana June 3-5, 2012
The second annual conference of the American Delirium Society in
Indianapolis, Indiana, June 3-5, 2012, promises to be a very exciting
program with the following two main goals:
• To disseminate knowledge on the state-of-the-art in delirium
identification, treatment, and prevention, and
• To discuss new directions for delirium identification, prevention and
treatment strategies.
Dr. Sharon Inouye, MD, MPH and Dr. Anne Kolanowski, PhD, RN as
keynote speakers will be discussing current knowledge and
innovations in delirium treatment and prevention from the
perspectives of both medicine and nursing. Sessions include the
following: 1) Pathophysiology of Delirium will examine work on
biomarkers for delirium diagnosis, prognosis, and therapy response;
2) Measurement of Delirium will focus on “cutting edge” research on
delirium identification tools; 3) Postoperative Delirium will review
issues pertaining to the brain undergoing the stress of surgery and
current research strategies regarding detection and treatment of
delirium following surgery; 4) Long-Term Outcomes of Delirium will
present current knowledge regarding the impact of delirium on
subsequent mood, cognition, morbidity and mortality; 5) Delirium
Care in the 21st Century will center on new prevention, evaluation
and treatment techniques; and 6) Clinical Trial Updates will highlight
new and ongoing treatment trials with regard to delirium and
delirium prevention.
Sorry about late notice but! March 15, 2012 – Abstract
Submission Deadline ~ submit abstracts in a Word document (for
formatting and publication purposes) to
For more information, please contact the ADS at
Videocast – Patient experience
David Aaronovitch on the “abject terror” of ICU psychosis. 2011. BBC
News
www.bbc.co.uk/news/health-15881720.
In this Annals – see how to take part in the first Europe-
wide delirium assessment survey!
Delirium and Dementia
The British Geriatric Society and Royal College of Physicians are
holding a joint conference on 26 June in London. The conference was
organised by Alasdair MacLullich. The keynote talk is by the excellent
Ed Marcantonio (Harvard) on delirium treatment. If you were unable
to get to last years European Delirium Association here is your chance
to hear him speak - along with our own experts including Professor
John Young, Chair of the NICE guideline committee.
http://events.rcplondon.ac.uk/details.aspx?e=2573
European Delirium Congress:
7th EDA Scientific Congress: 18-19 October 2012, Bielefeld, Germany
We are delighted to announce that our 7th annual meeting will be held
in Bielefeld, the principal city of Eastern Westphalia in the north west
of Germany. The programme will cover the full spectrum of the latest
advances in delirium research and clinical practice, from basic science
to clinical implementation. Details will follow shortly.
Bielefeld is easily accessible from all parts of Europe. Please see here
for more details: http://www.bielefeld.de/en/travel/
Announcing the first European Delirium Association
survey
Dear Colleague Although there have been many advances in our knowledge of
delirium there are still substantial uncertainties and a lack of
consensus over best practice. The European Delirium Association
(EDA) has been disseminating knowledge of delirium within the
European Union in the last several years. The EDA has decided to
conduct a survey to help understand the range of opinions among
mailing list members on various aspect of delirium care. We greatly
appreciate your expertise and we believe that this survey will provide
a significant advancement in our understanding of current practice.
The findings will inform future directions in education, training,
governance, and research.
The results will be presented at the next EDA conference. You can find
the survey following this link:
http://kwiksurveys.com?s=LODJNH_6c7dc879. The survey takes
about fifteen minutes to complete. We are extremely grateful for your
time.
Please send any queries to : morandi.alessandromail.com;
More information about the EDA can be found here:
www.europeandeliriumassociation.com
Kind Regards,
Alessandro Morandi, MD, MPH Board Member, EDA Daniel Davis, MB, MPhil Board Member, EDA Alasdair MacLullich, MRCP (UK), PhD President, EDA On behalf of the EDA