Cases Of Delirium Research Articles

A tale of two methods: chart and interview methods for identifying delirium.

To compare chart- and interview-based methods for identification of delirium. Prospective cohort study. Two academic medical centers. Individuals aged 70 and older undergoing major elective surgery (N = 300) (majority orthopedic surgery). Participants were interviewed daily during hospitalization for delirium using the Confusion Assessment Method (CAM; interview-based method), and their medical charts were reviewed for delirium using a validated chart-review method (chart-based method). Rate of agreement of the two methods and characteristics of those identified using each approach were examined. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a criterion standard, predictive value could not be calculated. The cumulative incidence of delirium was 23% (n = 68) according to the interview-based method, 12% (n = 35) according to the chart-based method, and 27% (n = 82) according to the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart-based method missed delirium in individuals that the CAM identified who were lacking features of psychomotor agitation or inappropriate behavior. The CAM-based method missed chart-identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. Interview- and chart-based methods have specific strengths for identification of delirium. A combined approach captures the largest number and broadest range of delirium cases.

A Comparative Study On 136 Opioid Abusers In India and Nepal

Background: Though opioid abuse is a common clinical entity, only few published articles are available in Nepal. Aim: To compare the pattern of drugs and opioid abuse amongst patients at two de-addiction centres in India and Nepal Methods: Seventy-six opioid abusers at CIP, Ranchi, India and 60 opioid abusers at UCMS, Bhairahawa, Nepal were recruited for the present study. Demographic and clinical profiles of patients at these two places are studied and compared. Results: Mean age of patients at Bhairahawa, Nepal was significantly lower than their counterpart in Ranchi. While majority of patients at Ranchi reported alone for treatment, patients at Bhairahawa were mostly accompanied by their guardians/relatives or friends. Patients at Ranchi had more lifetime diagnosis of opioid abuse while patients at Nepal had more lifetime diagnosis of poly-substance abuse. Patients at Bhairahawa, Nepal had significantly more history of Injectable drug abuse and had more history of IDU related side effects. Approximately 40% of opioid abusers in Nepal centre responded that the opportunity to work abroad was the highest motivating factor for seeking treatment. Opioid withdrawal delirium appeared to a valid clinical entity with history of 5 cases and 2 cases of withdrawal delirium in Ranchi and Bhairahawa center respectively. Symptom of "Koro" during opioid withdrawal period was reported by at least one patient each at Ranchi and Nepal center. Conclusions: Opioid abusers at both the centres appear to have similar social and clinical characteristics except on few social and clinical parameters. DOI: http://dx.doi.org/10.3126/jpan.v2i2.9719 J Psychiatrists’ Association of Nepal Vol.2, No.2, 2013 11-17

The Phenomenology of Delirium: Presence, Severity, and Relationship between Symptoms

Objective. To examine the phenomenological characteristics of delirium based on the Memorial Delirium Assessment Scale (MDAS) in order to explore the presence, severity of, and relationship between symptoms. Methods. An analysis of 100 cases of delirium recruited at Memorial Sloan Kettering Cancer Center (MSKCC) was performed. Sociodemographic and medical variables, the Memorial Delirium Assessment Scale (MDAS) subitems, and Karnofsky Performance Status scale (KPS) were analyzed of respect of the phenomenological characteristics and their interrelationship. Results. The most severe and frequent symptoms were recorded in the cognitive domain, psychomotor behavior, sleep-wake cycle, and disturbance of consciousness. Within the cognitive domain, concentration was the most severely affected task. The severity of impairment in most domains increased with delirium severity, whereas perceptual disturbances and delusions were independent of delirium severity. Advanced age and the prevalence of dementia increased with delirium severity in contrast to the functional status which declined. The presence of perceptual disturbances and delusions was independent of cognitive impairment and psychomotor abnormality, however, associated with the disturbances of consciousness and attention. Conclusion. Cognition, in particular concentration, was the most severely affected domain. Advanced age and the prevalence of dementia contributed to more severe delirium. Perceptual disturbances and delusions were independent of delirium severity; however, they were associated with disturbances of consciousness and attention.

Delirium in Patients with Substance Abuse: A Case-Series

Severe agitation in patients with delirium may be difficult for clinicians’ management because of problems of differential diagnosis and treatment. Regrettably, theory and guidelines concerning this issue may fail to cover the incredible complexity of clinical practice. Our aim is to describe three cases of delirium from our real-life clinical experience, with a specific focus on their complexity as far as differential diagnosis and psychopharmacological treatment are concerned. In clinical practice, as shown by the three cases we describe, the etiology of delirium is various and mixed, lab analysis are not specific and it is not possible to exactly assess which kind of substances were used by patients. New drugs and smart drugs are not yet detectable by our urine analysis, and their effects, interaction with prescription drugs and pharmacokinetics are not well known. With the aim to obtain a successful sedation and to calm the patient, in our cases, we needed to use a pharmacological combined approach (benzodiazepines, first and second generation antipsychotics) with different routes of administration and, when inevitable, physical restraint.

難治性嘔吐に対しオランザピンを使用した経過途中にせん妄, 痙攣が生じた1例

難治性嘔吐に対しオランザピンを使用した経過途中にせん妄, 痙攣が生じた1例

Can Improved Intra- and Inter-team Communication Reduce Missed Delirium?

To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2% of 47 cases compared to 41.3 and 43.6% of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.

Cocaine-Induced Agitated Delirium

Cocaine use continues to be a major public health problem in the United States. Although many of the initial signs and symptoms of cocaine intoxication result from increased stimulation of the sympathetic nervous system, this condition can present as a spectrum of acuity from hypertension and tachycardia to multiorgan system failure. Classic features of acute intoxication include tachycardia, arterial vasoconstriction, enhanced thrombus formation, mydriasis, psychomotor agitation, and altered level of consciousness. At the extreme end of this toxidrome is a rare condition known as cocaine-induced agitated delirium. This syndrome is characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death. We report a case of cocaine-induced agitated delirium in a man who presented to our institution in a paradoxical form of circulatory shock. Rapid evaluation, recognition, and proper management enabled our patient not only to survive but also to leave the hospital without neurologic sequelae.

Onset, Risk Factors, and Impact of Delirium in Patients with Traumatic Spinal Cord Injury

Delirium is a commonly reported acute care adverse event in patients with traumatic spinal cord injury (TSCI), but studies specifically investigating it in this population are lacking. The purpose of this study was to characterize the onset, risk factors, and impact of delirium in patients with TSCI. Patients discharged between 2008 and 2010 were identified from a prospective registry in an acute SCI center. Controls were matched to delirium cases based on date of discharge from acute care. Patient characteristics, risk factors, and the hospital unit (intensive care, spine step-down, spine ward) in which delirium occurred were collected retrospectively. Length of stay (LOS) was calculated and compared between cases and controls. A predictive model was built for patient characteristics and risk factors associated with delirium using logistical regression. There were 192 patients identified from the study group; 34 (17.7%) were delirium cases and 34 were selected as controls. Most delirious episodes were reported during high acuity care (76.5%). The median time interval between injury and delirium identification was 8.5 days (interquartile range=5-31). Age at injury (p<0.01) and initial motor score (p<0.05) were significantly associated with delirium. Patients with delirium had significantly greater LOS than controls (median LOS=46.9 vs. 15.3 days respectively, p<0.0001). Elderly patients who sustain a TSCI and have a low motor score on admission are at increased risk of delirium. These results could contribute to the development of a screening program to address the problem of delirium in the TSCI population.

Patient with insidious hypoactive delirium associated with pregabalin

AbstractPregabalin has favorable effects on several types of neurological pain, but can cause side‐effects including dizziness, somnolence and delirium. Delirium presents as two variants in terms of psychomotor disturbance: the hyperactive type, showing agitation and vigilance; and the hypoactive type, showing lethargy and decreased motor activity. Patients with delirium associated with pregabalin therapy have been reported to experience hyperactive delirium. Here, we report the case of a 68‐year‐old patient with insidious hypoactive delirium caused by pregabalin therapy for postherpetic neuralgia. Delirium improved after discontinuation of pregabalin. Hypoactive delirium is considered to be more common than the hyperactive type in older adults, and is likely to be overlooked. Attention should thus be paid to latent cases of hypoactive delirium associated with pregabalin therapy in elderly individuals.

A case of delirium due to severe hypomagnesemia occurred during long-term PPIs treatment

A case of delirium due to severe hypomagnesemia occurred during long-term PPIs treatment

Levofloxacin-Induced Delirium in a Patient Suffering from Schizoaffective Disorder and Multiple Sclerosis

Levofloxacin induced psychiatric adverse effects are rare, although they can be serious. There are just five cases of fluoroquinolone-induced delirium published in the medical literature. To our best knowledge, none of them occurred in psychotic patients. We report a case of a 38-year-old Caucasian man diagnosed with schizoaffective disorder and multiple sclerosis who developed delirium and visual hallucinations after initiating levofloxacin therapy. In psychiatric patients, suspecting levofloxacin could be responsible for the symptoms can be a diagnostic challenge, since they could be interpreted like worsening of the mental state as well. Although levofloxacin-induced delirium is a rare adverse event, physicians should be aware of the occurrence of this serious, but potentially reversible CNS complication of levofloxacin, even in psychotic patients.

A case of prolonged delirium tremens

We present a case of delirium tremens lasting for five weeks in an alcohol-dependent individual. The patient required high-dose benzodiazepines, which is atypical and rare. The clinical presentation and management of this patient is discussed.

Delirium as a result of vitamin B12 deficiency in a vegetarian female patient

Vitamin B12 deficiency can manifest with haematological, gastrointestinal and neuropsychiatric signs. The neuropsychiatric symptoms may be concurrent or precede the other symptoms. The reported case is a clinical case of delirium due to vitamin B12 deficiency in a female vegetarian patient. The patient was treated with vitamin B12 supplementation. Initially, it was difficult to diagnose this patient, who presented with delirium that could have been due to multiple causes. The finding underlines the importance of conducting a complete laboratory test panel for delirium, including the blood levels of vitamin B12.

Intensive care delirium: the new black

Intensive care delirium: the new black

Delirium in elderly patients hospitalized in internal medicine wards

A prospective observational study was conducted to evaluate the impact of delirium on geriatric inpatients in internal medical wards and to identify predisposing factors for the development of delirium. The study included all patients aged 65years and older, who were consecutively admitted to the internal medicine wards of two public hospitals in Florence, Italy. On admission, 29 baseline risk factors were examined, cognitive impairment was evaluated by Short Portable Mental Status Questionnaire, and prevalent delirium cases were diagnosed by Confusion Assessment Method (CAM). Enrolled patients were evaluated daily with CAM to detect incident delirium cases. Among the 560 included patients, 19 (3%) had delirium on admission (prevalent) and 44 (8%) developed delirium during hospitalization (incident). Prevalent delirium cases were excluded from the statistical analysis. Incident delirium was associated with increased length of hospital stay (p<0.01) and institutionalization (p<0.01, OR 3.026). Multivariate analysis found that cognitive impairment on admission (p<0.0002), diabetes (p<0.05, OR1.936), chronic kidney failure (p<0.05, OR2.078) and male gender (p<0.05, OR2.178) was significantly associated with the development of delirium during hospitalization. Results show that delirium impact is relevant to older patients hospitalized in internal medicine wards. The present study confirms cognitive impairment as a risk factor for incident delirium. The cognitive evaluation proved to be an important instrument to improve identification of patients at high risk for delirium. In this context, our study may contribute to improve application of preventive strategies.

The Syndrome of Excited Delirium Following Use of “Bath Salts”

Article AbstractBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.To the Editor: In their case report "Bath Salts-Induced Psychosis and Serotonin Toxicity," Joksovic et al provide a detailed description of a case of intoxication delirium associated with use of synthetic cathinones, or "bath salts," a popular substitute for stimulant drugs. The illustrated toxidrome has been described in a subset of recreational users of these substances, presenting as both a medical and a psychiatric emergency.While the primary substance reported with cases of cathinone-related reactions in the European literature has been mephedrone (4-methylmethcathinone), all cases reported in the United States in which laboratory confirmation has been obtained have identified the cathinone derivative involved as methylenedioxypyrovalerone (MDPV).

Does haloperidol prophylaxis reduce ketamine-induced emergence delirium in children?

Ketamine is a non-barbiturate agent with rapid action onset that induces profound sedation; however, some emergency physicians tend not to use ketamine because of the risk of emergence delirium (ED). This study aimed to evaluate the effectiveness of haloperidol prophylaxis in postoperative ketamine delirium in children. Prospective data relating to any emergence dreams, delirium, hallucinations, agitation, crying, altered perceptions, and necessary interventions were recorded in consecutive cases of ketamine delirium in patients attending Mansoura University Hospital, Egypt, from June 2010 to May 2011. A total of 537 records were available for analysis. Of those, 267 received prophylactic haloperidol (49.7%). There were significant differences between the two groups regarding post-anaesthetic care unit behaviour. The ketamine-haloperidol groups included more patients who were sleepy, calm (P ≤0.01) and less irritable (P ≤0.01), with a lower incidence of crying (P ≤0.01) and disorientation (P ≤0.01). We found that preoperative administration of haloperidol decreases the incidence of postoperative delirium in a sample of Egyptian children undergoing minor surgery. This is congruent with earlier work conducted in adults. This work carries great hope to decrease and even prevent ED in hospitalised, non-surgical patients.

A Case of Isoniazid-Induced Delirium

A Case of Isoniazid-Induced Delirium

Prolonged Delirium with Psychotic Features from Omega Conotoxin Toxicity

To the Editor: Patients with neuropathic pain constitute a considerable proportion of the population of patients with chronic pain for which there are less than optimal treatment options. The scientific literature provides information on omega conotoxin efficacy and safety in the management of chronic pain conditions ⇓. A synthetic version, ziconotide, is a first line intrathecal (IT) alternative agent to opioids in the management of cancer pain ⇓. We describe a case of prolonged delirium with psychotic features in a patient with peripheral neuropathy on a gradual escalating dose of ziconotide. A 37-year-old man with a history of idiopathic small fiber peripheral neuropathy unresponsive to usual treatment with opiate analgesics was started on IT ziconotide for better pain control 1 year before he presented to our center with a 3-day history of confusion, hallucination, and tremor. These symptoms started a day after his home was sprayed with insecticide. He had associated symptoms of loss of appetite, …

Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial

Clinical practice guidelines have been developed to improve screening, prevention and management of delirium. To implement delirium guidelines in general medical patients to reduce incidence and duration of delirium and improve outcomes in delirious patients. Implementation was led by a multidisciplinary team of clinicians and project staff on one medical ward. Evaluation was undertaken as a controlled trial in patients aged 65 years or older with/at risk of delirium, compared with a control medical ward. Interventions included risk screening, delirium detection, multidisciplinary education, ward modifications including a four-bed delirium bay, behaviour and medication protocols, and use of nursing assistant and volunteers. Primary outcome measures were incidence and duration of delirium; secondary outcomes were length of stay, mortality, falls and discharge destination in delirious subgroup. Process measures included ward moves, use of neuroleptics, allied health review and delirium bay use. Of 206 consenting older medical patients, 22% were delirious at admission and 44% were at risk. No incident cases of delirium were identified. In the delirious subgroup, significantly fewer intervention participants were discharged with persistent delirium (32% vs 71%, P = 0.016), with trends to reduced inpatient mortality (0% vs 18.5%, P = 0.07) and falls (11% vs 22%, P = 0.16), at the expense of a longer medical ward stay (16 days vs 8 days, P = 0.01). Low incidence of new delirium may reflect the established interdisciplinary care environment. Improved outcomes in the delirious group are encouraging although implementation was costly, including increased length of acute ward stay.