Delirium Rating Scale Research Articles

Comparative Study of Delirium in Emergency and Consultation Liaison- A Tertiary Care Hospital Based Study in Northern India.

Delirium is an acute and often fluctuating disturbance in level of consciousness and thought process (cognition) that develops over a short period of time and is a significant change from previous level of functioning. Its prevalence increases with age, complexity of medical co- morbidities and number of medications prescribed. To compare the cause and severity of delirium in patients in emergency and consultation liaison psychiatry group. A cross-sectional, tertiary care hospital based study was conducted on the patients who presented with delirium from emergency department (50) and consultation-liaison psychiatry groups (50), over a period of one year. The diagnosis was made on the basis of DSM- 5 criteria. The Delirium Rating Scale (DRS-R-98) was applied to know the severity of delirium, cognitive and non-cognitive symptoms of delirium in patients. The results were subjected to appropriate statistical analysis. In emergency group, 42% patients had metabolic abnormalities, while in consultation-liaison, 38% patients had hyponatremia and hypokalemia and the difference was found to be statistically non-significant (p>0.05). In emergency group, 21(42%) patients were diagnosed as delirium due to other medical condition, followed by 13 (26%) and 8(16%) patients, who were diagnosed as delirium due to multiple aetiologies and substance intoxication each respectively. In only 33(66%) cases in consultation liaison group patients had delirium secondary to other medical conditions. As per DRS-R98 Scale, mean severity score was found to be statistically significant (p<0.05) in consultation liaison group as compared to emergency department group (p> 0.05). Delirium is multifactorial aetiological disease, with variable but preventable outcome. Approach should be aimed at finding the treatable causes to reduce morbidity and mortality.

Predictors for Post- Stroke Delirium Outcome

Background:There have been only a small number of studies that have evaluated the outcome of post-stroke delirium.Objectives:To evaluate the effects of gender, age, stroke localization, delirium severity, previous illnesses, associated medical complications on delirium outcome as well as, to determine effects of delirium on cognitive functioning one year after stroke.Patients and Methods:Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glazgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State.Results:Patients who developed post-stroke delirium had significantly more complications (p = 0.0005). Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The strongest predictor of outcome was age, mean age ≥ 65 years with a odds ratio (OR) 4.9. Cox’s regression survival was conducted to assess the impact of multiple factors on survival. The accompanying medical complications were the strongest predictor of respondents poore outcome with Hazard-risk 3.3. Cognitive assessments including Mini Mental State score have showen that post-stroke delirium patients had significant cognitive impairment, three (p = 0.0005), six months (p = 0.0005) and one year (p = 0.0005) after stroke, compared to patients without delirium.Conclusion:Patient gender, age, localization of stroke, severity of delirium, chronic diseases and emerging complications significantly affect the outcome of post- stroke delirium. Delirium significantly reduced cognitive functioning of after stroke patients.

Prevalence of psychiatric morbidity among cancer patients - hospital-based, cross-sectional survey.

Aim:To study the prevalence of Psychiatric disorders in cancer patients and to find out the factors associated with Psychiatric disorders in Cancer Patients.Settings and Design:Department of Radiotherapy, Medical College, Thiruvananthapuram, cross sectional survey design was used.Methods and Material:Adult patients (18 years of age and above), having a diagnosis of carcinoma were selected by consecutive sampling method.A questionnaire which included back ground data, socio economic variables, treatment variables like type of malignancy, exposure to radiation & chemotherapy prior to the evaluation and current treatment, co occurring medical illness & treatment and past & family history of psychiatric illness was used to collect data. Delirium rating scale and MINI International neuropsychiatric interview were used to assess Psychiatric disorders and delirium.Statistical Analysis Used:Chi square and logistics regression tests were used for analysis.Results:Of the 384 assessed, 160(41.7%) had psychiatric disorders. Adjustment disorders were seen in 22.6%. 10.9% of subjects had major depressive disorder. Thus a total of 33.5% of patients had a diagnosis of either anxiety or depressive disorder. Proportion of patients having delirium was 6.5%. Hypomania was seen in small (1.6%) of patients. Multivariate analysis for various parameters for psychiatric disorders showed that age, past history of chemotherapy, past history of radiotherapy, & surgical treatment of carcinomas are significant predictors of psychiatric disorders.Conclusions:Psychiatric disorders are seen in a significant proportion of Psychiatric patients.

Concordance between the delirium motor subtyping scale (DMSS) and the abbreviated version (DMSS-4) over longitudinal assessment in elderly medical inpatients.

Delirium is a common neuropsychiatric syndrome that includes clinical subtypes identified by the Delirium Motor Subtyping Scale (DMSS). We explored the concordance between the DMSS and an abbreviated 4-item version in elderly medical inpatients. Elderly general medical admissions (n = 145) were assessed for delirium using the Revised Delirium Rating scale (DRS-R98). Clinical subtype was assessed with the DMSS (which includes the four items included in the DMSS-4). Motor subtypes were generated for all patient assessments using both versions of the scale. The concordance of the original and abbreviated DMSS was examined. The agreement between the DMSS and DMSS-4 was high, both at initial and subsequent assessments (κ range 0.75-0.91). Intraclass Correlation Coefficient (ICC) for all three raters for the DMSS was high (0.70) and for DMSS-4 was moderate (0.59). Analysis of the agreement between raters for individual DMSS items found higher concordance in respect of hypoactive features compared to hyperactive. The DMSS-4 allows for rapid assessment of clinical subtype in delirium and has high concordance with the longer and well-validated DMSS, including over longitudinal assessment. There is good inter-rater reliability between medical and nursing staff. More consistent clinical subtyping can facilitate better delirium management and more focused research effort.

Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients.

Delirium occurs commonly in hospitalized older patients but is poorly recognized. Although there are a plethora of validated delirium screening tools, it is unclear which tool best suits particular populations. To evaluate validation studies of delirium screening tools in non-critically ill hospital inpatients and provide guidance on the choice of screening tool. The MEDLINE, CINAHL, and PsychInfo databases were searched for studies comparing delirium bedside screening tools with either the Diagnostic and Statistical Manual or International Classification of Diseases defined diagnosis of delirium in hospital inpatients. Information was also drawn from conference proceedings and discussion with delirium researchers. Thirty-one studies describing 21 delirium screening tools were included in the systematic review. The majority of studies were conducted across a broad range of inpatient settings internationally in elderly inpatients, including patients with dementia but most excluded nonnative language speakers. The Confusion Assessment Method was the most widely used instrument to identify delirium, however, specific training is required to ensure optimum performance. The Delirium Rating Scale and its revised version performed best in the psychogeriatric population but requires an operator with psychiatric training. The Nurses' Delirium Screening Checklist appears best suited to the surgical and recovery room setting. The Single Question in Delirium shows promise in oncology patients. The Memorial Delirium Assessment Scale, while demonstrating good measures of validity in the surgical and palliative care setting, may be better used a measure of delirium severity. The 4As Test performed well when delirium was superimposed on dementia, but it requires further study.

Review of delirium in the pediatric intensive care unit

Delirium is an acute neuropsychiatric syndrome reflecting serious cerebral dysfunction. The characteristic core symptoms of delirium include the inability to direct, focus, sustain, and shift attention; abnormalities of the sleep-wake cycle; impaired consciousness and awareness; disturbance of thought processes; and behavioral dyscontrol. Delirium is particularly prevalent in critically ill and post-operative patients in the intensive care unit, and may result from hypoxia or infection. It is most likely in the most severely ill, and length of stay is prolonged, and morbidity and mortality and higher with delirium. A variety of clinical instruments have been developed to facilitate the diagnosis of delirium. The Delirium Rating Scale, and its 1998 revision (DRS and DRS-R98) are for psychiatrists to use and are based on DSM criteria. The Pediatric Confusion Assessment Method, adapted for pediatric patients in the ICU (pCAM-ICU), is designed for non-psychiatrists and nurses in the intensive care unit. The Pediatric Anesthesia Emergence Delirium scale (PAED) is the basis for the Cornell Assessment of Pediatric Delirium (CAP-D), and both are for nurses and doctors in the pediatric ICU to use to identify delirium in their patients. Delirium is typically multifactorial and its pathogenesis reflects neurotransmitter changes associated with metabolic and inflammatory processes. Benzodiazepines and anticholinergic drugs, including opioids and antihistamines, are widely used in the pediatric ICU and may precipitate or exacerbate delirium. Benzodiazepines especially are best used sparingly, in the lowest dose possible, if at all. The treatment of delirium is predicated on detecting and addressing its underlying cause, which usually results in its rapid resolution. Environmental interventions may ameliorate the risk for delirium, and drugs which may precipitate or worsen delirium should be avoided. Antipsychotics can provide benefit in managing agitation, perceptual disturbances, sleep-wake cycle abnormalities, and behavioral dyscontrol. Atypical antipsychotics, including olanzapine, risperidone, and quetiapine, have largely replaced haloperidol in newer approaches to management because of lower risk for adverse side effects. The risk for delirium may be mitigated by vigilance, and awareness of its presentation, pathogenesis, and management. Its prevention will be of significant benefit in reducing morbidity, improving outcome, and providing comfort to these very ill and fragile children.

Olanzapine reduces delirium symptoms in the critically ill pediatric patient.

Delirium is a neuropsychiatric disorder characterized by acute disturbances in attention, consciousness, cognitive processing, perception, and the sleep-wake cycle. The few studies investigating treatment of delirium in critically ill children and adolescents have used differing diagnostic criteria, and have not employed control groups or procedures to blind observations. The objective of this study was to examine the efficacy of olanzapine for the treatment of delirium in the pediatric intensive care unit (ICU) using methodological procedures to reduce bias and allow greater generalization. Psychiatric records of 59 patients admitted to the pediatric ICU or cardiothoracic ICU over a 4 yr period with the diagnosis of delirium were examined. The delirium rating scale was used to assess delirium severity at the time of initial psychiatric evaluation and five days later. Raters were blinded to medication administration. Patients who were diagnosed with delirium, but did not receive olanzapine, or any other antipsychotic medication, served as the control group. Greater improvement of delirium symptoms was found for the olanzapine group (n = 31) than the control group (n = 28) (F (1,40) = 4.86, r = 0.33, 95% confidence interval = 0.020-0.58). This finding remained statistically significant after controlling for initial delirium severity (F (1, 20) = 28.62, r = 0.77, 95% confidence interval = 0.50-0.90). This study demonstrates patients with delirium administered olanzapine had greater reduction of delirium symptom severity than controls. It supplements the existing literature by using a study design that reduces expectancy effects and allows examination of the natural history of delirium symptoms without medication administration.

PRospective Observational POLIsh Study on post-stroke delirium (PROPOLIS): methodology of hospital-based cohort study on delirium prevalence, predictors and diagnostic tools.

BackgroundBetween 10 % to 48 % of patients develop delirium in acute phase of stroke. Delirium determinants and its association with other neuropsychiatric disturbances in stroke are poorly understood. The wildly accepted predictive model of post-stroke delirium is still lacking.Methods/designThis is a prospective, observational, single-center study in patients with acute phase of stroke. We aim to include 750 patients ≥18 years with acute stroke or transient ischemic attack admitted to the stroke unit within 48 hours after stroke onset. The goals of the study are: 1) to determine frequency of delirium and subsyndromal delirium in Polish stroke patients within 7 days after admission to the hospital; 2) to determine factors associated with incidence, severity and duration of delirium and subsyndromal delirium and to create a predictive model for post-stroke delirium; 3) to determine the association between delirium and its cognitive, psychiatric, behavioral and functional short and long-term consequences; 4) to validate scales used for delirium diagnosis in stroke population.Patients will be screened for delirium on daily basis. The diagnosis of delirium will be based on DSM-V criteria. Abbreviated version of Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit will be used for delirium and sub-delirium screening. Severity of delirium symptoms will be assessed by Delirium Rating Scale Revised 98 and Cognitive Test for Delirium. Patients who survive will undergo extensive neuropsychological, neuropsychiatric and functional assessment 3 and 12 months after the stroke.DiscussionThis study is designed to provide information on clinical manifestation, diagnostic methods and determinants of delirium spectrum disorders in acute stroke phase and their short and long-term consequences. Collected information allow us to create a predictive model for post-stroke delirium.

The utility of the clock drawing test in detection of delirium in elderly hospitalised patients

Objectives: Delirium is common neuropsychiatric condition among elderly inpatients. The clock drawing test (CDT) has been used widely as bedside screening tool in assessing cognitive impairment in elderly people. Previous studies which evaluate its usefulness in delirium reported conflicting results. The objective of this study was to evaluate the utility of CDT to detect delirium in elderly medical patients.Method: Prospective, observational, longitudinal study. All acute medical admissions 70 years of age and above were approached within 72 hours of admission for recruitment. Patients eligible for inclusion were assessed four times, twice weekly during admission. Assessment included Confusion Assessment Method (CAM), Delirium Rating Scale (DRS-98R), Montreal Cognitive Assessment (MoCA), Acute Physiology and Chronic Health Evaluation II (APACHE) II, and CDT. Data was analysed using a linear mixed effect model.Results: Three hundred and twenty-three assessments with the CDT were performed on 200 subjects (50% male, mean age 81.13; standard deviation: 6.45). The overall rate of delirium (CAM+) during hospitalisation was 23%. There was a significant negative correlation between the CDT and DRS-R98 scores (Pearson correlation r = −0.618, p < 0.001), CDT and CAM (Spearman's rho = −0.402, p < 0.001) and CDT and total MoCA score (Pearson's r = 0.767, p < 0.001). However, when the data were analysed longitudinally controlling for all the factors, we found that cognitive function and age were significant factors associated with CDT scores (p < .0001): neither the presence nor the severity of delirium had an additional significant effect on the CDT.Conclusion: CDT score reflects cognitive impairment, independently of the presence or severity of delirium. The CDT is not a suitable test for delirium in hospitalised elderly patients.

Study of Delerium and Its Subtypes in Medically Ill Hospitalised Patients

Introduction A multitude of terms are used to describe delirium, including encephalopathy, acute brain failure, acute confusional state and post-operative or intensive care unit psychosis, essentially it is defined as a relatively acute decline in cognitions that fluctuates over hours or days. There are two broad clinical categories have been described -hyperactive and hypoactive subtypes;that are based on differential psycho-motor features. A possible neuro-inflammatory basis for delirium is emerging and low levels of IGF-1 have recently been found as a risk factor for delirium. Acute phase reactant C-RP has been used as a marker of inflammation may also be implicated in the cause and outcome of delirium. Aims and Objectives 1) To study the prevalence of various subtypes of delirium in medically ill hospitalised patients. 2) To test C-RP as predictor of delirium and recovery from delirium as part of preliminary observational study. Methodology This is a cross-sectional study of descriptive and explorative design conducted at JSS Hospital, Mysore. A total of 113 patients were taken for the study and Patients who were admitted to ICU were assessed within 3 days of admission with 1) A standard bedside test of cognitive function, the MMSE(Mini Mental State Examination) 2) The Confusion Assessment Method(CAM) to determine the presence or absence of delirium. 3) The acute physiological score of APACHE-2,to measure the severity of acute physical illness. 4) Delirium Rating Scale. 5) C-RP was measured routinely along with other routine ICU investigations in all acute admissions. Results of the study The study is still being done in the hospital. Hence, the results will be presented during oral presentation in the conference.

Preoperative brain magnetic resonance imaging and postoperative delirium after off-pump coronary artery bypass grafting: a prospective cohort study.

Delirium after cardiac surgery is a serious complication, increasing morbidity and mortality. Despite its high expectations, off-pump coronary artery bypass grafting (OPCAB) has largely failed to reduce the incidence of postoperative neurological complications. To further investigate the reasons for this failure, we used perioperative brain magnetic resonance imaging (MRI) to determine the relation between MRI findings and postoperative delirium. Altogether, 98 patients undergoing elective OPCAB were enrolled in this prospective observational study. Patients underwent brain MRI and magnetic resonance angiography (MRA) before and after surgery to identify cerebral infarction, white matter lesions, and intracranial artery stenosis. Postoperative delirium in the intensive care unit was measured using the delirium rating scale. The relation between postoperative delirium and MRI findings was examined using logistic regression. Magnetic resonance imaging and MRA was completed in 88 (90%) of the patients. New ischemic lesions were present in seven (7.9%) patients. Delirium rating scale scores of 0, 1-7, and ≥ 8 were found in 25 (31%), 48 (60%), and seven (9%) patients, respectively. Multivariate logistic regression analysis revealed that new ischemic lesions (odds ratio [OR] 11.07, 95% confidence interval [CI]: 1.53 to 80.03; P=0.017), carotid artery stenosis (OR 7.06, 95% CI: 1.59 to 31.13; P=0.010), history of myocardial infarction (OR 3.78, 95% CI: 1.05 to 13.65; P=0.043), and deep subcortical white matter hyperintensity (OR 3.04, 95% CI: 1.14 to 8.12; P=0.027) were significantly associated with postoperative delirium. Magnetic resonance imaging findings of new cerebral ischemic lesions, carotid stenosis, and deep subcortical white matter hyperintensity correlated significantly with postoperative delirium in patients who had undergone OPCAB surgery.

Influence of preexisting cognitive deficits on symptom profile and motoric subtypes of delirium

Aim: To compare the symptom profile of patients with delirium without preexisting cognitive deficits and those experiencing delirium in the background of preexisting cognitive deficits. Materials and Methods: A total of 107 patients aged ≥60 years with diagnosis of delirium as per the Diagnostic and Statistical Manual, IV text revision criteria were evaluated on Short Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE), Delirium Rating Scale Revised 98 version (DRS-R98), amended delirium motor symptom scale, and delirium etiology checklist and risk factor checklist. On the basis of short IQCODE score, the study sample was divided into those with (≥3.5) and without cognitive deficits and were compared for the symptom profile, motor subtype, risk factors, and etiologies. Results: Based on the short IQCODE scores, the patients were divided into those with (≥3.5) and without cognitive deficits ( Conclusion: There is no difference in the symptom profile of those with and without preexisting cognitive deficits.

Feasibility of prophylactic haloperidol to prevent delirium in cancer patients.

232 Background: Approximately 2.5 million cancer patients are hospitalized annually and 25-40% of them will suffer from delirium; yet the majority of delirium is not diagnosed or treated. Delirium rates vary by age and reason for hospitalization and can be as high as 70% in hematopoietic stem cell transplant (HSCT) patients post-transplantation. Delirium can have devastating short and long-term complications and research is ongoing to see if it can be prevented. This study aims to: 1) demonstrate the feasibility of using prophylactic haloperidol in HSCT patients; 2) determine the side effects of oral haloperidol in HSCT patients; and 3) explore the hypothesis that prophylactic haloperidol will reduce the rate of delirium following HCST. Methods: All cognitively intact HSCT patients at a large academic institution were approached for study inclusion. Patients with delirium at time of screening or antipsychotic use in the previous 30 days were excluded. All participants received 5 mg oral haloperidol the night prior to transplant and nightly for 2 weeks post-transplant. Participants were seen daily to evaluate for side effects and every other day to evaluate for delirium using the Delirium Rating Scale (DRS-98). Results: Of the 19 patients who enrolled: 5 withdrew; 9 completed the full (2 week) study; and 5 completed a portion of the study. 22% (2 of 9) patients developed delirium (compared to a historical rate of 43% on our unit). Haloperidol was well tolerated with no evidence of major side effects (1 report of mild restlessness and 1 patient had transient evidence of sedation). Conclusions: Oral haloperidol was well tolerated in HSCT patients. While this study was not designed to detect differences in delirium incidence it provides promising evidence that prophylactic haloperidol may decrease delirium post-HSCT.

Pre-Operative, High-IL-6 Blood Level is a Risk Factor of Post-Operative Delirium Onset in Old Patients.

Background: Post-operative delirium (POD) is a common complication in elderly patients undergoing surgery, but the underpinning causes are not clear. We hypothesized that inflammaging, the subclinical low and chronic grade inflammation characteristic of old people, can contribute to POD onset. Accordingly, we investigated the association of pre-operative and circulating cytokines in elderly patients (>65 years), admitted for elective and emergency surgery.Methods: This is a secondary analysis of a sub-cohort of patients belonging to a previous large case–control study, where 351 patients were clinically and cognitively thoroughly characterized, together with the assessment of POD (47 patients) by confusion assessment method and delirium rating scale. Seventy-four pre-operative plasma samples were selected from a larger bio-bank and they included 37 subjects with POD and 37 without POD. Inflammaging related cytokines, i.e., IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α, were assayed by ELISA in pre-operative blood samples; univariate and multivariable analyses have been applied to identify cytokines independently associated to POD. Associations of cytokine levels with functional status, cognitive decline, intra-hospital mortality, and comorbidity were also analyzed independently of POD onset.Results: High IL-6 and low-IL-2 levels were significantly associated with POD. After adjustment for potential confounders in multivariate analysis, high level of pre-operative IL-6 was confirmed to be significantly associated with risk of POD onset. High level of IL-6 was also associated with several baseline features (including poor functional status, cognitive impairment, emergency admission, and higher comorbidity burden) and intra-hospital mortality.Conclusion: Pre-operative, high-plasma level of IL-6 (≥9 pg/mL) was significantly associated with POD onset. We propose IL-6 as an additional risk factor of POD onset together with the previously identified factors. Discovery of all risk factors contributing to POD onset will permit to improve hospitalized patient management and the decrease of healthcare cost.

MMSE items that predict incident delirium and hypoactive subtype in older medical inpatients

Because hypoactive delirium is especially under-recognized, we analyzed which Mini-Mental State Examination (MMSE) items predicted incident delirium and its hypoactive motor presentation. Over a 1-year period, older medical inpatients (n=291) were consecutively screened on admission with the Confusion Assessment Method-Spanish (CAM-S) to exclude prevalent delirium. Nondelirious patients were evaluated the same day with the MMSE, followed by daily ratings with the CAM-S. Those who became CAM-S positive were rated using the Delirium Rating Scale—Revised-98 to assess severity and motor subtype. Disorientation to time (OR 4.4, 95% CI 1.7–11.1) and place (OR 3.8, 95% CI 1.7–8.2) at admission were risk factors for delirium at follow-up and together correctly classified 88.3% of subjects as to delirium status. Disorientation to time and place, and visuoconstructional impairment were each associated with either hypoactive or mixed subtype (p<0.05 χ2 test). Simple bedside evaluation of cognitive function in nondelirious patients revealed deficits that detected patients at risk for developing incident delirium at follow-up (especially hypoactive or mixed). We recommend patients with orientation deficits be monitored closely for emergence of delirium. A separate evaluation for possible dementia or other causes of cognitive impairment at admission should be considered too.

Prospective Observational Study of Delirium Recovery Trajectories and Associated Short‐Term Outcomes in Older Adults Admitted to a Specialized Delirium Unit

To describe the recovery trajectories of delirium and to determine factors predicting the course of recovery and adverse outcome. A prospective observational study. Geriatric monitoring unit (GMU), a five-bed unit specializing in managing older adults with delirium. Individuals admitted to the GMU between December 2010 and August 2012 (N=234; mean age 84.1±7.4). Information was collected on demographic characteristics; comorbidities; severity of illness; functional status; and daily cognitive, Delirium Rating Scale, Revised-98 (DRS-R98) severity, and functional scoring. Resolution of delirium, and thus GMU discharge, was determined according to clinical assessment. The primary outcome was residual subsyndromal delirium (SSD) (DRS-R98 severity ≥13) upon GMU discharge. Univariate and multivariate methods were used to determine the predictors of residual SSD and adverse outcomes (inpatient mortality and incident nursing home admission upon discharge). Participants with residual SSD had a slower recovery in terms of delirium severity, cognition, and functional status than those with no residual SSD. Residual SSD predictors included underlying dementia, admission DRS-R98 severity, DRS-R98 severity on Day 1 minus Day 3 of GMU stay, and admission modified Barthel Index. Only presence of residual SSD at discharge predicted adverse outcomes (odds ratio=5.27, 95% confidence interval=1.43-19.47). Individuals with residual SSD had prolonged recovery trajectory of delirium. These new insights into the recovery trajectories of delirium may help formulate early discharge planning and provide the basis for future research on delirium treatment.

Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial.

BackgroundDelirium is associated with substantial morbidity and mortality rates in elderly hospitalised patients, and a growing problem due to increase in life expectancy. Implementation of standardised non-pharmacological delirium prevention strategies is challenging and adherence remains low. Pharmacological delirium prevention with haloperidol, currently the drug of choice for delirium, seems promising. However, the generalisability of randomised controlled trial results is questionable since studies have only been performed in selected postoperative hip-surgery and intensive care unit patient populations. We therefore present the design of the multicenter, randomised, double-blind, placebo-controlled clinical trial on early pharmacological intervention to prevent delirium: haloperidol prophylaxis in older emergency department patients (The HARPOON study).Methods/DesignIn six Dutch hospitals, at-risk patients aged 70 years or older acutely admitted through the emergency department for general medicine and surgical specialties are randomised (n = 390) for treatment with prophylactic haloperidol 1 mg or placebo twice daily for a maximum of seven consecutive days. Primary outcome measure is the incidence of in-hospital delirium within seven days of start of the study intervention, diagnosed with the Confusion Assessment Method, and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for delirium. Secondary outcome measures include delirium severity and duration assessed with the Delirium Rating Scale Revised 98; number of delirium-free days; adverse events; hospital length-of-stay; all-cause mortality; new institutionalisation; (Instrumental) Activities of Daily Living assessed with the Katz Index of ADL, and Lawton IADL scale; cognitive function assessed with the Six-item Cognitive Impairment Test, and the Dutch short form Informant Questionnaire on Cognitive Decline in the Elderly. Patients will be contacted by telephone three and six months post-discharge to collect data on cognitive- and physical function, home residency, all-cause hospital admissions, and all-cause mortality.DiscussionThe HARPOON study will provide relevant information on the efficacy and safety of prophylactic haloperidol treatment for in-hospital delirium and its effects on relevant clinical outcomes in elderly at-risk medical and surgical patients.Trial registrationEudraCT Number: 201100476215; ClinicalTrials.gov Identifier: NCT01530308; Dutch Clinical Trial Registry: NTR3207

A comparison of the revised Delirium Rating Scale (DRS-R98) and the Memorial Delirium Assessment Scale (MDAS) in a palliative care cohort with DSM-IV delirium.

Assessment of delirium is performed with a variety of instruments, making comparisons between studies difficult. A conversion rule between commonly used instruments would aid such comparisons. The present study aimed to compare the revised Delirium Rating Scale (DRS-R98) and Memorial Delirium Assessment Scale (MDAS) in a palliative care population and derive conversion rules between the two scales. Both instruments were employed to assess 77 consecutive patients with DSM-IV delirium, and the measures were repeated at three-day intervals. Conversion rules were derived from the data at initial assessment and tested on subsequent data. There was substantial overall agreement between the two scales [concordance correlation coefficient (CCC) = 0.70 (CI 95 = 0.60-0.78)] and between most common items (weighted κ ranging from 0.63 to 0.86). Although the two scales overlap considerably, there were some subtle differences with only modest agreement between the attention (weighted κ = 0.42) and thought process (weighted κ = 0.61) items. The conversion rule from total MDAS score to DRS-R98 severity scores demonstrated an almost perfect level of agreement (r = 0.86, CCC = 0.86; CI 95 = 0.79-0.91), similar to the conversion rule from DRS-R98 to MDAS. Overall, the derived conversion rules demonstrated promising accuracy in this palliative care population, but further testing in other populations is certainly needed.

Practical Assessment of Delirium in Palliative Care

ContextDelirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging. ObjectivesThis review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings. MethodsIn addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990–2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care. ResultsOf the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes. ConclusionGiven the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.

A Study of prevalence and determinants of delirium in a tertiary care hospital

Aims and objectives To assess the prevalence types and course of delirium in Sri ManakulaVinayagar Medical College Hospital a tertiary care teaching hospital in Puducherry. The factors associated with delirium from demographic to possible determinants were also analyzed.Methodology Convenience sampling method was used for this study. Consecutive patients admitted to either psychiatry ward or any other medical or surgical wards fulfilling the inclusion and exclusion criteria were selected for the study. Diagnosis of delirium was ascertained by Confusion Assessment 13 14 Method CAM first its severity by Delirium Rating Scale DRS daily till recovery or death and Motor sub-typing subscale of Memorial Delirium Assessment 15 Scale MDAS for classifying delirium based on motor activity.Results Of the 36 cases studied 28 were males 77 and 8 females 23. The age ranged from 45 years to 82 years. Delirium accounted for 4.7 of cases seen by psychiatrists during the study period. Major determinants associated with delirium were alcohol withdrawal 47 major trauma 16 and sepsis 11. Electrolyte imbalance Hyponatremia and Hypokalemia were found in almost 70 of the cases. Hyperactive 44 type was more common followed by mixed 33 and hypoactive 22 at the initial presentation. Recovery was complete in 95 of cases with an average of 8 days whereas 2 patients expired Major Trauma ndash Head injury Sepsis.Conclusion Multiple factors were found in any case of delirium. Alcohol withdrawal was noted in a significant number of cases and they were mostly hyperactive in nature.