Features Of Delirium Research Articles

Definition of agitation following traumatic brain injury: I. a survey of the brain injury special interest group of the american academy of physical medicine and rehabilitation

Objective: To determine national patterns of defining agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors. Design: A random sample of 70% of the members of the Brain Injury Special Interest Group (SIG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) were surveyed by telephone. Results: The 129 members who responded yielded an 82% response rate. Respondents rated 18 characteristics from established rating scales on a 5-point scale according to each characteristic's relation to its clinical definition of agitation. Physical aggression, explosive anger, increased psychomotor activity, impulsivity, verbal aggression, disorganized thinking, perceptual disturbances, and reduced ability to maintain or appropriately shift attention were rated by at least 50% of the sample as very important or essential to agitation. Delirium, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been proposed as a standard definition of agitation. The degree to which all characteristics from the 3rd revised edition of the DSM (DSM-IIIR), considered together, were perceived to relate to agitation predicted 24% of the degree to which the term “delirium” was perceived to relate to agitation (Canonical correlation r = .48, p = .0002). Physicians' ratings of individual delirium characteristics from the DSM-IIIR were examined to determine if a sufficient number were similarly ranked to fulfill the diagnostic criteria for delirium. A significant number of physicians rated diagnostic criteria for delirium in one direction, yet did not rank the term “delirium” accordingly (McNemar's p = .04). Conclusions: There is considerable variation among physiatrists in their rating of characteristics that define agitation. Many define agitation during the acute recovery phase as posttraumatic amnesia plus an excess of behavior such as aggression, disinhibition, and/or emotional lability. Less support was given to defining agitation by the DSM-IIIR or DSM-IV diagnostic criteria for delirium. Delirium appears related to, but is not sufficient for, a diagnosis of agitation.

The neuropathogenesis of delirium

Delirium is a common and serious complication of acute illness in people admitted to hospital. Recent evidence suggests that delirium is associated with an increased subsequent risk of developing dementia, although it is unclear whether delirium merely serves as a marker of a preexisting risk or whether it may of itself provoke or facilitate development of permanent brain damage (1). Despite the importance of delirium, relatively little is known about the neuropathogenesis of the disorder. The main hypothesis at present is that delirium represents the clinical manifestation of diffuse, reversible impairment of neurotransmission and of cerebral oxidative metabolism. This hypothesis explains the relatively stereotyped nature of the response to a wide range of insults and the characteristic generalized slowing of the EEG trace in most cases of delirium. However, there is little direct evidence of impaired cerebral oxidative metabolism in delirium. The finding of delirium as a feature of some strokes suggests that more focal disturbances can also cause delirium. Conflicting findings have been reported from the few studies using positron emission tomography or single photon emission tomography in delirious patients. Various neurotransmitter systems have been implicated in the pathogenesis of delirium. The cholinergic hypothesis has attracted most attention. This proposes that reduced synthesis of acetylcholine is a final common pathway for development of delirium. Anticholinergic drugs are a potent cause of delirium, and anticholinergic toxicity is an established animal model for delirium at present; also, anticholinergic pathways are involved in regulation of attentiveness, disruption of which is a cardinal feature of delirium. However, there is a wide number of other candidate neurotransmitters including dopamine, serotonin GABA, glutamate, opioids and noradrenaline, and it is unlikely that changes in a single neurotransmitter can explain the protean features and aetiological factors of delirium. The existence of distinct behavioural subtypes may provide additional clues to the pathogenesis of delirium. Two characteristic subtypes are described: an agitated (hyperactive-hyperalert) variant, typified by delirium tremens, and a retarded (hypoactive-hypoalert) variant, typified by the metabolic encephalopathies. However, many patients switch between hypoactivity and hyperactivity and many aetiological factors, such as infection, can cause either variant. Also, although delirium tremens is classically associated with EEG fast wave activity, slow wave activity is more characteristic of agitated delirium due to anticholinergic medications or traumatic brain injury. Nevertheless, different subtypes may involve different neurotransmitter pathways, and require different treatments. It has been proposed that delirium might be a stress reaction in the elderly due to increased levels of glucocorticoids or an increased vulnerability to their effects (2). Hypothalamic-pituitary-adrenal (HPA) activation is related to cognitive impairment in depression and dementia, and increased glucocorticoid levels can cause hippocampal damage. Cushing’s syndrome and exogenous glucocorticoids can cause delirium (as can sudden cessation of glucocorticoid therapy). Glucocorticoids cause prominent deficits in selective attention; such deficits are a characteristic feature of delirium but not usually of dementia. In demented patients, the greatest slow wave EEG activity occurs in patients with highest resting cortisol levels. A number of studies have now demonstrated HPA activation in delirious patients. For example, in stroke patients, post-dexamethasone cortisol levels were associated with delirium, independently of the site and severity of the stroke (3). It remains unclear whether hypercortisolaemia is of pathogenetic significance in delirious patients or is simply a result of the stress of delirium or of the underlying illness. Even if HPA activation results from rather than causes delirium, it is possible that excessive cortisol secretion might mediate damage to hippocampal neurons thereby producing permanent brain damage and cognitive loss. Other interactions between the nervous and immune systems have also been implicated in the pathogenesis of delirium. Interleukin-1 released from macrophages or microglia can induce activation of

Manic pseudo-delirium - two case reports.

We wish to report two cases which illustrate a subtype of bipolar affective disorder and suggest that it should be termed Manic Pseudo-Delirium (MP-D) as it incorporates features of both mania and delirium. This will facilitate consistent recognition and characterization since mania remains the primary diagnosis and delirium is not thought to co-exist with functional psychoses. Extensive investigations were done to exclude underlying medical causes for the delirium. Possible explanations for MP-D are put forward for their heuristic value in the hope that further research will improve understanding of the pathophysiology of both mania and delirium.

Manic Pseudo-Delirium–Two Case Reports

We wish to report two cases which illustrate a subtype of bipolar affective disorder and suggest that it should be termed Manic Pseudo-Delirium (MP-D) as it incorporates features of both mania and delirium. This will facilitate consistent recognition and characterization since mania remains the primary diagnosis and delirium is not thought to co-exist with functional psychoses. Extensive investigations were done to exclude underlying medical causes for the delirium. Possible explanations for MP-D are put forward for their heuristic value in the hope that further research will improve understanding of the pathophysiology of both mania and delirium.

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity.

To determine the presentation, course and duration of delirium in hospitalized older people. Observational cohort study. Inpatient surgical and medical wards at a university hospital. 432 people over the age of 65. All participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. About 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (P = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. Delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

The Use of Environmental Strategies and Psychotropic Medication in the Management of Delirium

This paper examines the pattern and frequency of implementation of environmental strategies and the use of psychotropic medication in the management of patients with delirium in an acute hospital setting. The study involved 46 consecutive referrals to a consultation psychiatry service each of whom met ICD-10 criteria for delirium. Patients were subdivided into hyperactive, hypoactive and mixed subtypes of delirium and assessed regarding severity of delirium, the use of psychotropic medication prior to consultation and the implementation of environmental measures in their management. Mean age was 60.1 years. Thirty per cent of patients were of the hyperactive subtype, 24% hypoactive and 46% mixed. Psychotropic medication was given to 56.5% prior to consultation and this is significantly associated with severity of delirium and in particular, with hyperactive delirium subtype. Of eight environmental strategies only four were instituted in over 50% of the patients prior to consultation. The application of these strategies was associated with overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance. It was not significantly associated with severity of disorientation or with disturbed perception/thinking. Simple environmental strategies such as limiting changes in staff, minimising noise levels and involving relatives in re-orientation are frequently overlooked in the management of patients with delirium. Our study suggests that the implementation of environmental strategies occurs primarily in responses to behavioural challenges rather than to limit the core features of delirium.

Delirium

This article identifies the importance of delirium in general medical practice. Recent revisions in the diagnostic criteria for delirium are discussed, and the epidemiology of delirium is summarized, including the incidence and prevalence, risk factors, origins, course, and outcomes. Studies of the pathophysiological features of delirium are reviewed and recommendations are made for treatment of patients with delirium and future research.

The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly.

To determine the value of the cerebrospinal fluid examination in the evaluation of hospitalized; elderly patients with delirium and fever. A retrospective case series of consecutive events during a 15-month period. Tertiary care center. Elderly patients admitted to the University of Cincinnati (Ohio) Hospital between July 1, 1988, and October 1, 1989, who had a lumbar puncture and cerebrospinal fluid evaluation to evaluate fever and mental status changes. Primary intracranial causes and the clinical characteristics of delirium and fever. Eighty-one hospital admissions were reviewed. Fifty-seven (70%) of the lumbar punctures were performed as part of the admitting workup, and the remaining 24 (30%) were performed during the hospitalization. Eighty of the 81 cerebrospinal fluid cultures were negative for bacterial growth. The primary origins for fever and delirium included urinary tract infections (25%), pneumonia (22%), viral causes (17%), and metabolic causes/dehydration (14%). One case of bacterial meningitis was diagnosed in an alcoholic, 73-year-old man who was unresponsive in the emergency department. One case of presumed aseptic meningitis was diagnosed in a 65-year-old man who presented with fever and headaches and a blood pressure of 230/100 mm Hg. Most hospitalized, older patients with fever and delirium have primary causes of the confusion outside the central nervous system and may not require a routine evaluation of their cerebrospinal fluid.

Quantitative electroencephalography: a report on the present state of computerized EEG techniques. American Psychiatric Association Task Force on Quantitative Electrophysiological Assessment

The American Psychiatric Association established the Task Force on Quantitative Electrophysiological Assessment in May 1989 to consider several questions of interest to psychiatrists. From the inception of techniques for quantitative electroencephalography (qEEG), the possibility was raised that it would substantially assist in the diagnosis of brain disorders. However, controversy exists over the scientific basis for such approaches and the training necessary for interpretation of computerized records. The task force's charge was to report 1) the present state of scientific knowledge about qEEG, 2) the role of qEEG in clinical psychiatric practice at the present time, 3) the training necessary for the use of qEEG techniques, and 4) the possible future of the technique in the study of mental disorders. The task force concluded that qEEG is particularly useful for the detection of abnormalities in slow waves, which are a feature of delirium, dementia, intoxication, and other syndromes involving gross CNS dysfunction. The ability of qEEG to help in the diagnosis of other disorders, such as schizophrenia or depression, is not yet established. Clinical replications and sharing of normative and patient data bases are necessary for the advancement of this field. Proper use of this technique requires extensive training in a center experienced in its use. Standards for training and for using the technology in psychiatry are urgently needed. This report was approved by the Board of Trustees in December 1990.

Clarifying Confusion: The Confusion Assessment Method

To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Prospective validation study. Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

Senility reconsidered. Treatment possibilities for mental impairment in the elderly. Task force sponsored by the National Institute on Aging

The brain is particularly vulnerable to insults occurring anywhere in the body. In some older persons, the brain may respond to insult by slowly developing impairment of intellectual functions (dementia) or abruptly showing significant changes in mental state (delirium). Sometimes the two coincide, producing a variable clinical picture with features of both dementia and delirium. It is crucial for health professionals, public planners, and lay persons to recognize that many curable physical and psychological diseases in the elderly produce intellectual impairment that may be hard to distinguish from irreversible brain disease.

Basilar artery branch occlusion: a cause of pontine infarction.

<h3>Objective</h3> To present a case in which ACE inhibitors were found to be the cause for a patient9s visual hallucinations and to explore the different reasons that led to this adverse effect. <h3>Method</h3> Case report and literature review. <h3>Results</h3> Our patient developed visual hallucinations in the absence of other features of delirium, soon after her ACE inhibitor therapy had been increased. She had a background of ischaemic and haemorrhagic stroke. Her symptom disappeared when the ACE inhibitor was stopped. There have been two case reports of visual hallucinations caused by ACE inhibitors published, and also reports in pharmacovigilance documents, however this side effect is not recognised in the British National Formulary. Three different physiological pathways have been suggested as possible causes for the neuropsychiatric symptoms (visual hallucinations and others, such as severe depression and enhancement of cognition) in the case of ACE inhibitors: A protease action over the enzyme encephalinase, an action over the Corticotrophin Releasing Factor leading to the increase of cortisol and finally, through the direct effect of the suppression of the ACE enzyme in the brain, that can affect circulating levels of Acetylcholine. <h3>Conclusion</h3> ACE inhibitors have central actions that can account for a variety of neurocognitive symptoms, including visual hallucinations. Stopping therapy can sometimes result in the resolution of these symptoms. Clinicians should be aware of this rare but serious adverse effect associated with this commonly used drug.

The chemopsychotherapeutics of geriatric sedation.

Abstract:This article indicates some of the social, emotional, organic factors involved in disturbing the balance of the geriatric psychological equilibrium and outlines the need for an appropriate rationale of treatment with modern tranquillisers and sedatives. Both the problem of individual variation to treatment and the need for delineation of contributory organic factors are emphasised. Some features of senile psychoses, delirium, and depression are considered. Reference is made to the principles of sedation and tranquillisation and a number of the more widely used agents are reviewed. Some of the more notable side effects are briefly outlined.Several clinical group studies involving the use of sedatives and tranquillisers were made on 143 patients from a general‐hospital geriatric unit and 41 geriatric patients from a psychiatric hospital. The presence of mental illness in geriatric patients was not associated with long‐term need for nocturnal sedatives but did tend to increase the duration of hospitalisation and reduce the chances of rehabilitation. It was found possible to manage all types of patients in the geriatric range without barbiturates, which are contraindicated. The need for a more flexible approach to medication in the psychiatric geriatric population is indicated. Some of the currently available chemopsychotherapeutic agents, although useful, are of only limited value in aiding the more disturbed patients.

TWO CASES OF WITHDRAWAL FROM ETHCHLORVYNOL.

Two cases of withdrawal from chronic addiction to ethchlorvynol are reported. The withdrawal syndrome is characterized by a latent period of 6 to 10 days and by a delirium which, in addition to the classical characteristics of delirium, has many features suggestive of a schizophrenic reaction. Clearing of the schizophreniform symptoms occurs first followed by clearing of the confusion.

Delirium, a syndrome of cerebral insufficiency

The thesis is presented that a derangement in the general functional metabolism of the brain underlies all instances of delirium and that this is reflected at the clinical level by a characteristic disturbance in cognitive functions and at the physiologic level by a characteristic generalized slowing of the electroencephalogram. As background for this thesis are summarized the studies of a large number of patients exhibiting delirium in the setting of a wide variety of physiologic and biochemical derangements as well as instances of delirium experimentally induced by techniques known to affect cerebral metabolism adversely. The clinical characteristics of delirium are carefully delineated and the basis established for the identification of delirium and its differentiation from other types of psychologic disturbance commonly seen in organically ill patients.

MYELOPATHIA ALCOHOLICA ASSOCIATED WITH ENCEPHALOPATHIA ALCOHOLICA

Recent studies in encephalopathia alcoholica by Schilder and myself 1 showed five different clinical pictures, depending on whether the most prominent features were: (1) clouding of the consciousness with changing rigidities in the limbs, (2) cerebellar disturbances, (3) catatonia-like condition, (4) prolonged delirium or (5) polyneuritic features. In the clinical study the symptoms associated with cerebral, cerebellar and brain stem disturbances were emphasized, while those associated with lesions of the spinal cord or of the peripehral nerves were mentioned only in passing. Postmortem neuropathologic studies were made in seven of the cases with findings that correlated with the clinical groupings. The lesions always occurred in parts of the central nervous system adjacent to the spinal fluid. It was essentially a reactive, productive, invasive ependymitis of all the ventricular surfaces, and a marginal gliosis of all the surfaces of the brain and brain stem with an underlying proliferative hemorrhagic disturbance of