Subtypes Of Delirium Research Articles

A Continuous Wavelet Transform and Classification Method for Delirium Motoric Subtyping

The usefulness of motor subtypes of delirium is unclear due to inconsistency in subtyping methods and a lack of validation with objective measures of activity. The activity of 40 patients was measured over 24 h with a discrete accelerometer-based activity monitor. The continuous wavelet transform (CWT) with various mother wavelets were applied to accelerometry data from three randomly selected patients with DSM-IV delirium that were readily divided into hyperactive, hypoactive, and mixed motor subtypes. A classification tree used the periods of overall movement as measured by the discrete accelerometer-based monitor as determining factors for which to classify these delirious patients. This data used to create the classification tree were based upon the minimum, maximum, standard deviation, and number of coefficient values, generated over a range of scales by the CWT. The classification tree was subsequently used to define the remaining motoric subtypes. The use of a classification system shows how delirium subtypes can be categorized in relation to overall motoric behavior. The classification system was also implemented to successfully define other patient motoric subtypes. Motor subtypes of delirium defined by observed ward behavior differ in electronically measured activity levels.

Phenomenological Subtypes of Delirium in Older Persons: Patterns, Prevalence, and Prognosis

Delirium is an acute confusional state that is common, preventable, and life-threatening. The authors investigated the phenomenology of delirium severity as measured with the Memorial Delirium Assessment Scale among 441 older patients (age 65 and older) admitted with delirium in post-acute care. Using latent class analysis, they identified four classes of psychomotor-severity subtypes of delirium: 1) hypoactive/mild; 2) hypoactive/severe; 3) mixed, with hyperactive features/severe; and 4) normal/mild. Among those with dementia (N=166), the hypoactive/mild class was associated with a higher risk of mortality. Among those without dementia (N=275), greater severity was associated with mortality, regardless of psychomotor features, when compared with the normal/mild class. The data suggest that instruments measuring delirium severity and psychomotor features provide important prognostic information and should be integrated into the assessment of delirium.

Motor subtypes of delirium: Past, present and future

Clinical subtyping of delirium according to motor-activity profile has considerable potential to account for the heterogeneity of this complex and multifactorial syndrome. Previous work has identified a range of clinically important differences between motor subtypes in relation to detection, causation, treatment experience and prognosis, but studies have been hampered by inconsistent methodology, especially in relation to definition of subtypes. This article considers research to date, including a number of recent studies that have attempted to address these issues and identify a means of achieving greater consistency in approaches to subtyping. Possibilities for future work are discussed and a research plan for the field is outlined.

Behavioral observations reflected on consultation requests from primary medical-surgical services: Are they predictive of delirium diagnosis and outcomes?

Objective We studied 405 patients evaluated by the Psychosomatics Service to investigate whether the behavioral description as reflected on consultation request from primary medical–surgical teams could be utilized to predict the final clinical diagnosis of delirium. We explored whether outcomes differed in patient with delirium with different consultation requests. Methods Patients with delirium ( n=114) were divided into subtypes based on consultation requests for the management for cognitive dysfunction [altered mental status (AMS), n=46], for agitation or behavior disturbance (BEH, n=26), for depression (DEP, n=18), and for all other reasons (MISC, n=33). Adjusted multivariate regression models were used to examine group differences. Results Consult requests for AMS had a high likelihood ratio (LR+=14.22) and requests for BEH had moderately high likelihood ratio (LR+=4.79) of receiving a diagnosis of delirium. The DEP group ( n=18) tended to be younger and had higher 30-day readmission rates. The BEH group ( n=26) had more comorbid systemic medical conditions, higher rate of being discharged to home, and lower mortality rate. Delirium subtypes did not show any significant difference in clinical outcomes. Conclusion Behavioral observations on consultation requests as formulated by primary medical–surgical teams may be useful in the classification of patients with delirium. Whether the behavioral observations on the request may be used to predict delirium outcomes deserves further research.

Etiologies of Delirium and Their Relationship to Reversibility and Motor Subtype in Cancer Patients

Delirium is one of the most commonly encountered complications in patients with cancer. The etiology of delirium in cancer is often multi-factorial, and few reports have examined the causes of delirium. This study investigated the causes of delirium and their association with reversibility and motor subtypes of delirium in cancer patients. The subjects were inpatients with cancer who had been referred to our Department of Psychiatry and diagnosed with delirium by psychiatrists. The causes of delirium were determined using standard operationalized criteria. The association between delirium reversibility and each clinical factor was examined in detail and longitudinally. Data were available from a total of 100 patients. Among them, 58% had hyperactive delirium and 14% had hypoactive delirium. Delirium improved in 56% of the patients after 1 week of standard treatment. The most frequent causes of delirium were opioids (29%), inflammation (27%), dehydration and/or sodium level abnormalities (15%). While two or more causes were identified in 40% or more of the cases, the cause of delirium was not identified in 20% of the patients. Neither reversibility nor motor subtypes of delirium was associated with any specific etiological factor. When treating delirium, prevalences of the causes of delirium, as identified in this study, should be kept in mind. Further research is required to investigate what specific treatments may facilitate the prompt recovery from delirium among cancer patients.

Time‐Course of Cytokines During Delirium in Elderly Patients with Hip Fractures

To compare the time-course of cytokine levels in patients with and without delirium and investigate differences in cytokine concentrations in delirium subtypes. Prospective cohort study. Academic Medical Center, Amsterdam, 2005 through 2007. Patients aged 65 and older admitted for surgery after hip fracture. Experienced geriatric physicians used the Confusion Assessment Method to assess delirium and the Delirium Symptom Interview to assess delirium subtype. Tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-1beta, IL-6, IL-8, IL-10, and IL-12 were assayed in repeated serum samples using a cytometric bead array immunoassay. Of 221 admitted patients, 98 (mean age 84, 50 patients with delirium) were included, resulting in a total of 324 samples. Ninety-six percent of these samples had TNF-alpha, IL-1beta, and IL-10 levels below the reliable detection level. Differences between patients with and without delirium were observed in IL-6 (median 51 vs 36 pg/mL, P=.01) and IL-8 (median 15 vs 9 pg/mL, P=.03) levels. Changes over time in IL-6 and IL-8 levels in patients with delirium differed significantly from changes in levels in patients without delirium. The highest levels of IL-6 were present during delirium, and the highest levels of IL-8 were present before the development of delirium. Patients with the hyperactive (median 71 pg/mL) or mixed (median 73 pg/mL) subtype of delirium had higher IL-6 levels than patients with hypoactive delirium (median 16 pg/mL) (P=.02). IL-6 and IL-8 may contribute to the pathogenesis of postoperative delirium in elderly people. IL-6 may play a role in the hyperactive behavior of delirium.

The impact of delirium recollection (DR) on the level of distress in patients (P) with advanced cancer and their family caregivers (CG)

9529 Background: Delirium is the most frequent neuro-psychiatric complication in patients with advanced cancer. The frequency of DR and its impact on P and CG distress level are not well understood. Method: In this exploratory study, we included inpatient with advanced cancer who completely recovered from an acute delirium episode within 3 days (Memorial Delirium Assessment Scale <13), and their CG who were at bedside during delirium. The Delirium Experience Questionnaire was conducted in P. In addition, we assessed recall of specific delirium symptoms and related distress in P, CG, bedside nurse (RN) and palliative care specialist (PCS). Results: A total of 99 P/CG dyads participated in the study. Delirium subtype included hypoactive (20%), hyperactive (13%) and mixed (67%). DR in 99 patients included confusion (73%), time disorientation (58%), psychomotor agitation (56%), space disorientation (53%), delusion (33%) and hallucinations (visual 51%, auditory 18%, and tactile 12%). There was significant univ...

A New Data-Based Motor Subtype Schema for Delirium

A New Data-Based Motor Subtype Schema for Delirium

Treatment of delirium in supportive and palliative care

The past few years have witnessed increased research into delirium treatment and related issues, leading to better management (e.g. improved detection) and better understanding of phenomenology and pathophysiology. Many treatment and prevention trials have been conducted. Delirium phenomenology studies revealed that even subsyndromal presentations may bear a poor prognosis. Varied pathophysiology may lead to different delirium subtypes with implications for treatment, especially the hypoactive subtype, for which systematic neuroleptic treatment remains controversial. The high prevalence of delirium has led to improved use of validated instruments and better trials. Nonpharmacological interventions remain an essential step in delirium management and have yielded positive results, especially in prevention. Two trials of haloperidol prophylaxis identified reduced severity and duration of delirium in one and reduced incidence in the other. Trials comparing haloperidol with atypical antipsychotics, mainly risperidone and olanzapine, found equal efficacy but more side effects with haloperidol. Use of validated detection instruments is now standard procedure in both specialized clinical practice and research. Although haloperidol remains the mainstay of treatment, recent trials have begun to discriminate between the use of different agents and pharmacological approaches.

Prevalence, Detection and Treatment of Delirium in Terminal Cancer Inpatients: A Prospective Survey

Delirium is a common syndrome in terminal cancer patients. However, its detection and treatment by palliative care teams are not well documented. This survey aimed to determine the prevalence, detection and treatment of delirium in terminal cancer inpatients. The survey was conducted in Mackay Hospice and Palliative Care Center, Taiwan, from August 2006 to January 2007. All terminal cancer inpatients were invited to participate. The Delirium Rating Scale-Chinese Version was used by a research assistant as the screening instrument. Patients detected by screening were reviewed by psychiatrists to verify the diagnosis and determine the sub-type of delirium. The palliative care team members were asked to evaluate all the participants weekly. The medications used for delirium were obtained by a medical chart review. Result Two hundred and twenty eight participants (49.9%) among 457 inpatients were screened. The prevalence of delirium was 46.9% (n = 107). Of these, the most common subtype was hypoactive (68.2%, 95% confidence interval (CI): 59.4-77.0%). The mortality rate of inpatients with delirium (77.6%, 95% CI: 69.7-85.5%) was higher (P < 0.0001) than those without delirium (50.9%, 95% CI: 44.4-57.4%). The overall detection rate by any member of the palliative team was 44.9% (n = 48) (95% CI: 35.5-54.3%). The detection rate of the hypoactive subtype was only 20.5% (95% CI: 11.2-29.8%), which was significantly lower than that of the hyperactive/mixed subtypes (P < 0.0001). Therapy for delirium was prescribed in 42.1% (n = 45) (95% CI: 32.7-51.5%) with haloperidol being the most common medication. The prevalence of delirium was high, but the rates of detection and treatment were low. Interventions are recommended to improve the diagnosis and treatment of delirium in palliative care units.

Motion Analysis in Delirium: A Novel Method of Clarifying Motoric Subtypes

The usefulness of motor subtypes of delirium is unclear due to inconsistency in subtyping methods and a lack of validation with objective measures of motor activity levels. We studied patients with hyperactive, hypoactive, and mixed presentations of delirium were studied with 24-h accelerometer-based monitoring. The procedures were well tolerated and motor presentations were readily distinguished using the accelerometer-based measurements. The system was capable of identifying static versus dynamic activity and the frequency of changes in posture. Electronic motion analysis concurs with observed gross movement and can distinguish motorically defined subtypes according to quantitative and qualitative aspects of movement.

The association between delirium and the apolipoprotein E ε4 allele in the elderly

As not all patients with similar risk factors and eliciting conditions develop delirium; it may be hypothesized that genetic variation may play a role in the risk of delirium. On the basis of the relationship between dementia, respectively reduced cholinergic activity, and the APOE epsilon4-allele, and the similarities between dementia and delirium in reduced cholinergic activity, the APOE epsilon4-allele is a rational candidate-gene for delirium. This study examined the association between APOE epsilon4-allele and delirium in elderly patients. Acutely admitted patients to the Department of Medicine of 65 years and over were included during a 27-month time period. Delirium was scored by the confusion assessment method. Cognitive impairment was diagnosed by Mini Mental State Examination and informant questionnaire on cognitive decline. Genotyping was done with matrix-assisted laser-desorption/ionization time-of flight mass spectrometry. Of 415 included patients, a random sample of 264 patients was genotyped for APOE. The patients who met the criteria for delirium (35%) were significantly older and more frequently had preexisting functional and cognitive impairment. APOE genotype was borderline significantly associated with cognitive impairment in patients below 75 years (P=0.057). The odds ratio for carriers of an APOE epsilon4-allele compared with patients without an APOE epsilon4-allele for developing delirium was 1.17 (95% confidence interval (CI): 0.49-2.78) in the cognitively intact patients and 0.42 (95% CI: 0.14-1.30) in the cognitively impaired patients. No relation existed between the total number of APOE epsilon4-alleles and the different delirium subtypes (P=0.12). We found no convincing evidence that carriers of the APOE epsilon4-allele have a higher risk of delirium.

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients. Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10[Symbol: see text]days or until ICU discharge. A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death. Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%). The prevalence of the hypoactive or "quiet" subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated.

Association Between Psychomotor Activity Delirium Subtypes and Mortality Among Newly Admitted Postacute Facility Patients

Delirium is common among hospitalized elders and may persist for months. Therefore, the adverse impact of delirium on independence often occurs in the post acute care (PAC) setting. The effect of psychomotor subtypes on delirium remains uncertain. The purpose of this study is to examine the association between psychomotor activity delirium subtypes and 1-year mortality among 457 newly admitted delirious PAC patients. Patients were screened for delirium on admission to PAC facilities after an acute hospitalization, and patients with "Confusion Assessment Method"-defined delirium were enrolled. Psychomotor activity was assessed using the Memorial Delirium Assessment Scale, and patients were classified as to their delirium subtype (hyperactive, hypoactive, mixed, or normal). One-year mortality data were obtained from the National Death Index. A Kaplan-Meier survival analysis and a proportional hazards analysis using indicator (dummy) variables with normal psychomotor activity as the referent were performed. The normal psychomotor activity group had the lowest 1-year mortality rate, followed by the hyperactive, mixed, then hypoactive groups in increasing order. Independent of age, gender, comorbidity, dementia, and delirium severity, hypoactive patients were 1.60 (95% confidence interval [CI], 1.09-2.35) times more likely to die during the 1-year follow-up period than were patients with normal psychomotor activity. The hyperactive (hazard ratio = 1.30; 95% CI, 0.73-2.31) and mixed (hazard ratio = 1.25; 95% CI, 0.72-2.17) psychomotor groups had nonsignificant elevated risks relative to the normal psychomotor behavior group. All three psychomotor disturbance subtypes had an elevated risk of dying during the 1-year follow-up relative to the normal psychomotor group, though the hypoactive group had the highest mortality risk and was the only group with a statistically significantly elevated risk relative to the normal group.

Delirium subtype identification and the validation of the Delirium Rating Scale—Revised‐98 (Dutch version) in hospitalized elderly patients

Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. The Dutch version of the Delirium Rating Scale-Revised-98 (DRS-R-98) appears to be a reliable method to classify delirium. The aim of this study was to determine the validity and reliability of the DRS-R-98 and to study clinical subtypes of delirium using the DRS-R-98. Patients received the Dutch version of the DRS-R-98, the Mini-Mental State Examination, the Confusion Assessment Method, and a clinical diagnosis of delirium according to DSM-IV criteria, and their relatives the Informant Questionnaire Cognitive Decline in the Elderly. The DRS-R-98 validation cohort (n=65) consisted of 23 patients with delirium, 22 patients with dementia, and 20 non-psychiatric comparison patients. For the delirium subtype study, a second cohort comprising 54 delirious patients was investigated. Median DRS-R-98 scores significantly distinguished delirium from dementia and no psychiatric disorder. Inter-rater reliability (intra-class correlation 0.97) and internal consistency (Crohnbach's alpha 0.94) were high. Positive scores of DRS-R-98 item 4 (affect liability) and item 7 (motor agitation) predicted the presence of non-hypoactive delirium, with a specificity of 89% and a sensitivity of 57%. The results show that the Dutch version of the DRS-R-98 is a valid and reliable measure of delirium severity and distinguishes patients with delirium from patients with dementia and comparison patients. Furthermore, the DRS-R-98 is able to exclude hypoactive delirium.

Differences in Characteristics and Outcome of Delirium as Based on Referral Patterns

The authors studied factors associated with referral of delirium patients to psychiatry consultation and its outcome implications. Characteristics and treatment outcomes of delirium patients referred to psychiatry were compared with those not referred. Referred patients were younger, had a more hyperactive subtype, greater substance abuse, less comorbid dementia, were more likely to be recognized as having delirium, and be prescribed medications. Improvement in referred patients was indicated by lower readmission rate postdischarge. No differences were noted in length of stay, discharge status, or mortality within 1 year of the index episode. Psychiatric interventions were moderately helpful. Patients' characteristics and delirium subtypes may influence referral and should inform future liaison efforts.

Delirium and Its Motoric Subtypes: A Study of 614 Critically Ill Patients

To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. Prospective cohort study. The medical intensive care unit (MICU) of a tertiary care academic medical center. Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care

Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.

Incidence, Clinical Features and Subtypes of Delirium in Elderly Patients Treated for Hip Fractures

Objective: To describe the incidence, risk factors and clinical features (subtypes) of delirium during the postoperative period after hip fracture surgery in elderly patients. Design: Prospective study. Methods: Thirty-four consecutive patients (9 men and 25 women) were included in this study between June 16 to July 14, 2003. All patients underwent surgery for a fractured neck of femur and were pre- and postoperatively cared for at a combined geriatric/orthopedic ward. Assessment: The diagnosis of delirium was based on the criteria of the DSM-IV and the Confusion Assessment Method Scale. Subtypes of delirium were classified according to the criteria proposed by Lipowski: hyperactive-hyperalert (or agitated), hypoactive-hypoalert (somnolent) and mixed delirium. Results: Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The development of delirium was associated with the medication midazolam taken perioperatively. Nine (47%) of the delirious patients had a hyperactive type of delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed type. We did not find any association among subtypes of delirium and clinical features. Conclusions: Delirium is a common complication in the postoperative period of elderly patients treated for hip fractures. The use of midazolam in the perioperative period increased the risk of developing postoperative delirium. Thehyperactive type of delirium was the most common subtype of delirium.