Hypoactive Subtype Research Articles

Delirium and Dementia: Bedside Assessment of Confusional States

Inpatient assessments evaluating the possible diagnoses of delirium or dementia often involve a team approach and can be considered complex, multifaceted processes. Identification and immediate attention to delirium is especially important, as it is a commonly underdiagnosed and potentially life-threatening disorder with numerous possible etiological contributors. Identification of delirium may be especially difficult when it manifests with its most prevalent, hypoactive subtype or when superimposed on another major neurocognitive disorder. A careful review of the patient's medical chart and a detailed history review, familiarity with dementia and delirium clinical features, and implementation of bedside screening assessments may facilitate diagnostic accuracy and appropriate treatment. This article reviews evidence-based bedside assessments for delirium and dementia as well as indications for more thorough neuropsychological testing. [ Psychiatr Ann . 2017;47(4):177–183.]

Hyperactive and hypoactive psychomotor subtypes of delirium in demented and nondemented elderly patients with hip fractures: systematic review and meta-analysis

Background: The occurrence of delirium superimposed on dementia (DSD) in patients with hip fracture may have many life-threatening complications, especially if unrecognized and untreated. Objectives: To estimate the prevalence and outcomes of DSD in hospitalized elderly adults with dementia and hip fracture, and clinical symptoms of delirium with and without dementia. Methods: The review process followed guidelines consisting of 5 steps suggested for systematic reviews. Relevant studies between January 2000 to December 2014 were obtained from electronic databases, and 2 trained reviewers independently analyzed them. Comprehensive Meta-Analysis software (Biostat) was used to assess and combine the data across studies. Results: We identified 15 articles for meta-analysis. Prevalence of DSD after hip fracture was 69.7% (95% confidence interval [CI] = 60.4%-77.7%). People with dementia after hip fracture had a 6.03 times higher likelihood of sustaining delirium than those without dementia (95% CI = 3.63%-10.04%). The symptoms of delirium in a person without dementia was more often any hyperactivity (ES = 2.27, 95% CI = 1.17-4.41, P = 0.015), but those lacking dementia were more often hypoactive (ES = 2.22, 95% CI = 1.15-4.56, P = 0.018). There was limited evidence of publication bias, and there was substantial selective reporting bias in articles. Conclusions: The review demonstrates the high prevalence of DSD and highlights the differences in motor subtypes of delirium between delirium with and without dementia, but there is concern about these results given the high risk of bias. Keywords: Delirium, dementia, hip fracture

Variability of Delirium Motor Subtype Scale–Defined Delirium Motor Subtypes in Elderly Adults with Hip Fracture: A Longitudinal Study

To examine changes in motor subtype profile in individuals with delirium. Observational, longitudinal study; substudy of a multicenter, randomized controlled trial. Departments of surgery and orthopedics, Academic Medical Center and Tergooi Hospital, the Netherlands. Elderly adults acutely admitted for hip fracture surgery who developed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for 2 days or longer (n = 76, aged 86.4 ± 6.1, 68.4% female). Delirium Motor Subtype Scale (DMSS), Delirium Rating Scale R98 (DRS-R98), comorbidity, and function. Median delirium duration was 3 days (interquartile range 2.0 days). At first assessment, the hyperactive motor subtype was most common (44.7%), followed by hypoactive motor subtype (28.9%), mixed motor subtype (19.7%), and no motor subtype (6.6%). Participants with no motor subtype had lower DRS-R98 scores than those with the other subtypes (P < .001). The DMSS-defined motor subtype of 47 (61.8%) participants changed over time. Katz Index of Activities of Daily Living, Charlson Comorbidity Index, cognitive impairment, age, sex, and delirium duration or severity were not associated with change in motor subtype. Motor subtype profile was variable in the majority of participants, although changes that occurred were often related to changes from or to no motor subtype, suggesting evolving or resolving delirium. Changes appeared not be associated with demographic or clinical characteristics, suggesting that evidence from cross-sectional studies of motor subtypes could be applied to many individuals with delirium. Further longitudinal studies should be performed to clarify the stability of motor subtypes in different clinical populations.

Delirium as a complication of the surgical intensive care.

BackgroundThe aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery.Patients and methodsPatients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation–agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved.ResultsThe sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48%) admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12–240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal–Wallis test: 8.022; P<0.05). The duration of delirium was significantly correlated also with blood potassium levels (Pearson’s r=0.2189, P<0.05), hypotension (hypotension 40.41±30.23 hours versus normotension 70.47±54.98 hours; Mann–Whitney U=1,512; P<0.05), administration of antipsychotics compared to other drugs (antipsychotics 72.83±40.6, benzodiazepines 42.00±20.78, others drugs, mostly piracetam 46.96±18.42 hours; Kruskal–Wallis test: 17.39, P<0.0005), and history of alcohol abuse (with a history of abuse 73.63±45.20 hours, without a history of abuse 59.54±30.61 hours; Mann–Whitney U=1,840; P<0.05). One patient had suffered from complicated postoperative hypostatic pneumonia and died due to respiratory failure (patient with hypoactive subtype). According to the backward stepwise multiple regression, the best significant predictors of duration of the delirium were the hypotension, type of psychopharmacs, type of delirium, the daily dose of opioids, a combination of psychopharmacs, history of alcohol abuse, plasma level of potassium, anemia, hyperpyrexia, and plasma level of albumin, reaching statistical significance (analysis of variance: F=5.205; df=24; P<0.005; adjusted r2=0.637).ConclusionThe hyperactive type of delirium, hypotension, usage of antipsychotics, the higher daily dose of opioids, a combination of psychopharmacs, history of alcohol abuse, low blood levels of potassium, anemia, hyperpyrexia, and hypoalbuminemia in the CICUS were associated with longer duration of delirium.

Is cobalamin deficiency associated with increased risk of all subtypes of postoperative delirium?

Dear editor In a recent paper, Sevuk et al used the single-hospital-based database to investigate whether cobalamin (vitamin B12) deficiency increased the risk of postoperative delirium in patients aged >60 years undergoing cardiac surgery with cardiopulmonary bypass.1 In this retrospective study, the incidence of postoperative delirium in 100 patients with cobalamin deficiency was compared to 100 controls without cobalamin deficiency. Because the incidence of postoperative delirium in patients with cobalamin deficiency was significantly higher than that in the control group (P=0.017), the authors concluded that cobalamin deficiency may be associated with increased risk of delirium in elderly patients undergoing cardiac surgery. This article has drawn the attention of anesthesiologists who are involved in prevention and treatment of postoperative delirium. Apparently, the conclusion raises a plausible defect when all patients developing delirium were considered as one group. Delirium is a clinical diagnosis with a wide range of neuropsychiatric manifestations. The pathophysiology of delirium is not fully understood. Delirium is classified as hyperactive, hypoactive, or mixed forms.2 Etiologic diagnosis of the hyperactive and hypoactive subtypes of delirium may be different.3 Nutritional status has been suggested to play a role in predisposing or directly causing this acute cerebral dysfunction.4 A previous study reported that vitamin B12 supplementation for 40 weeks reduced delirium in demented patients aged over 60 years with low serum vitamin B12 (<200 pmol/L).5 In the model, a reasonable result was demonstrated because delirium is often reversible when the underlying cause of delirium is treated.4 It is well-known that patients with cobalamin deficiency may develop a wide range of neuropsychiatric manifestations such as restless, aggressiveness, delirium, cognitive impairment, depression, hallucination, and mania. Based on the literal reports, agitated manifestations seem to be more likely.6–8 Subtypes of delirium may be explained by different pathophysiologic mechanisms. Subgroup analysis by classifying delirious patients into hyperactive and hypoactive subtypes may be conducted to give the readers more information. The cause of delirium is often multifactorial.4 In patients with cobalamin deficiency, differences between delirium and nondelirium patients should be compared to identify additional risk factors such as chronic obstructive pulmonary disease and diabetes mellitus to help patients.9,10 Furthermore, a binary or trinary model in patients with cobalamin deficiency11 may be performed to assess the association between serum cobalamin levels and the incidence of delirium to support the conclusion with biological plausibility.4

Phenomenology of delirium among patients admitted to a coronary care unit

Aim: To study the phenomenology and motor sub-types of delirium in patients admitted in a Coronary Care Unit (CCU).Methods: Three hundred and nine consecutive patients were screened for delirium, and those found positive for the same were evaluated by a psychiatrist on DSM-IVTR criteria to confirm the diagnosis. Those with a diagnosis of delirium were evaluated on the DRS-R-98 to study the phenomenology and on the amended Delirium Motor Symptom Scale (DMSS) to study the motor sub-types.Results: Eighty-one patients were found to have delirium. Commonly seen symptoms of delirium included: disturbances in sleep–wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long–term memory. Very few patients had delusions. More than half of the participants were categorized as having hyperactive (n = 46; 56.8%) followed by hypoactive sub-type (n = 21; 26%) and mixed sub-type (n = 9; 11.1%) of delirium. There were minor differences in the frequency and severity of symptoms of delirium between incidence and prevalence cases of delirium and those with different motoric sub-types.Conclusion: Delirium in CCU set-up is characterized by the symptoms of disturbances in sleep–wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Hyperactive delirium is more common than hypoactive delirium.

Effect of delirium motoric subtypes on administrative documentation of delirium in the surgical intensive care unit.

This study compares the proportions of surgical intensive care unit (ICU) patients with delirium detected using the Confusion Assessment Method for the ICU (CAM-ICU) who received administrative documentation for delirium using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, stratified by delirium motoric subtypes. This retrospective cohort study was conducted at a surgical ICU from 06/2012 to 05/2013. Delirium was assessed twice daily and was defined as having ≥1 positive CAM-ICU rating. Delirious patients were categorized into hyperactive/mixed and hypoactive subtypes using corresponding Richmond Agitation Sedation Scales. Administrative documentation of delirium was defined as having ≥1 of 32 unique ICD-9-CM codes. Proportions were compared using Pearson's Chi-square test. Of included patients, 40% (423/1055) were diagnosed with delirium, and 17% (183/1055) had an ICD-9-CM code for delirium. The sensitivity and specificity of ICD-9-CM codes for delirium were 36 and 95%. ICD-9-CM codes for delirium were available for 42% (95% CI 35-48%; 105/253) of patients with hyperactive/mixed delirium and 27% (95% CI 20-34%; 46/170) of patients with hypoactive delirium (relative risk=1.5; 95% CI 1.2-2.0; p=0.002). ICD-9-CM codes yielded a low sensitivity for identifying patients with CAM-ICU positive delirium and were more likely to identify hyperactive/mixed delirium compared with hypoactive delirium.

Evaluation of psychomotor/motor disturbances in elderly medical inpatients

IntroductionTraditionally psychomotor subtypes have been investigated in patients with delirium in different settings and it has been found that those with hypoactive type is the largest proportion, often missed and with the worst outcomes.Aims and objectivesWe examined the psychomotor subtypes in an older age inpatients population, the effects that observed clinical variables have on psychomotor subtypes and their association with one year mortality.MethodsProspective study. Participants were assessed using the scales CAM, APACHE II, MoCA, Barthel Index and DRS-R98. Pre-existing dementia was diagnosed according to DSM-IV criteria. Psychomotor subtypes were evaluated using the two relevant items of DRS-R98. Mortality rates were investigated one year after admission day.ResultsThe sample consisted of 200 participants [mean age 81.1 ± 6.5; 50% female; pre-existing cognitive impairment in 126 (63%)]. Thirty-four (17%) were identified with delirium (CAM+). Motor subtypes of the entire sample was: none: 119 (59.5%), hypo: 37 (18.5%), mixed: 15 (7.5%) and hyper: 29 (14.5%). Hypoactive and mixed subtype were significantly more frequent to delirious patients than to those without delirium, and none subtype more often to those without delirium. There was no difference in the hyperactive subtype between those with and without delirium. Hypoactive subtype was significant associated with delirium and lower scores in MoCA (cognition), while mixed was associated mainly with delirium. Predictors for one-year mortality were lower MoCA scores and severity of illness.ConclusionsPsychomotor disturbances are not unique to delirium. Hypoactivity, this “silent epidemic” is also part of a deteriorated cognition.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Etiologic and Cognitive Differences in Hyperactive and Hypoactive Delirium.

To assess the differing patterns of cognitive impairment in the hyperactive and hypoactive subtypes of delirium and test the hypothesis that cognitive disturbances are high in patients with hypoactive delirium. The study was conducted in a general hospital in Pune, India from 2007 to 2009 and included 80 patients with delirium (DSM-IV-TR criteria). A detailed sociodemographic profile was obtained for each patient, and their cognitive function was assessed with the Mini-Mental State Examination (MMSE) and Memorial Delirium Assessment Scale (MDAS). Patients were classified as hyperactive or hypoactive using the MDAS. Of the 80 patients, 70% (n = 56) were identified as hyperactive, with a mean ± SD age of 33.42 ± 7.37 years, and 30% (n = 24) as hypoactive, with a mean ± SD age of 34.62 ± 6.64 years. Alcohol and other substance use disorders were the most frequent diagnosis associated with the hyperactive subtype, whereas other psychiatric disorders such as schizophrenia and mood disorders, infection, and chronic medical conditions were associated with the hypoactive subtype. Cognitive impairments were significantly high in the hypoactive subtype, as found in various cognitive domains of the MMSE and MDAS (P = .000). The hyperactive and hypoactive subtypes of delirium appear to be etiologically associated with a different diagnostic group. Severe cognitive impairment was associated with the hypoactive subtype.

Cognitive, Emotional, and Psychological

Introduction: Delirium is a serious medical complication, which can have adverse effects on patients. Identifying delirium following a stroke can be challenging due to the complexity of cognitive screening. This study explored how multidisciplinary team (MDT) members understand delirium following a stroke and what actions are taken when working with a patient exhibiting delirium symptoms. Method: A grounded theory exploration utilising two online focus groups and email exchanges with nurses, physiotherapists, speech and language and occupational therapists working in acute stroke across Scotland. 2 case vignettes were used to elicit responses: 1 described a stroke patient with hypoactive delirium, the other, a hyperactive delirium. Results: 15 participants from various professional groups were recruited. A minority of participants who received delirium training in the past were able to identify symptoms and suggest relevant screening tools. Most participants struggled to identify a hypoactive delirium, mistaking it for dementia or depression and using more tentative language to discuss delirium symptoms. Participants placed an emphasis on the roles of MDT members as instrumental in working out the clinical picture: nurses saw their role as identifying the biomarkers as well as using a delirium screening tool. Allied health staff tended to defer to nurses and medical staff to take these actions. Discussion: MDT members can struggle to identify delirium in acute stroke, particularly the hypoactive subtype. Education and raising awareness of all MDT members working in stroke units has the potential to increase identification rates and possibly lead to more favourable outcomes for these patients.

Differential Associations Between Delirium and Mortality According to Delirium Subtype and Age: A Prospective Cohort Study.

This study investigated the differential associations between delirium and mortality in terminally ill patients according to delirium subtype and age. This was a prospective cohort study of terminally ill patients. Delirium was diagnosed using the confusion assessment method. Delirium subtypes were defined based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria and the Delirium Rating Scale-98-R. A multivariate Cox proportional hazards regression analysis was used to examine predictors of mortality. Of the 322 cases, 98 patients (30.4%) were diagnosed as having delirium. The median (interquartile range) number of survival days after admission was 17.0 (10.0-36.0) days for patients with delirium and 28.0 (16.0-57.0) days for patients without delirium (p = .002). A multivariate analysis revealed that patients with hypoactive and mixed subtypes of delirium survived for shorter periods compared with patients without delirium (hazard ratio [HR] = 1.65 [95% confidence interval {CI} = 1.05-2.59, p = .029] and HR = 2.30 [95% CI = 1.44-3.69, p = .001], respectively). The hypoactive and mixed delirium subtypes exhibited significant interactions with age: younger age was associated with shorter periods of survival in patients with hypoactive and mixed subtype delirium (HR = 0.95 [95% CI = 0.93-0.98, p < .001] and HR = 0.97 [95% CI = 0.93-1.00, p = .038], respectively). The hypoactive and mixed subtypes of delirium were associated with shorter survival periods in terminally ill patients, and these associations interacted significantly with age. These findings support the clinical and academic value of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition specifiers that differentiate the diagnoses of delirium subtypes.

Determinants of the Motoric Subtypes of Delirium in Elderly

Background: Several studies have confi rmed the existence of three cl inical forms for del i r ium: hyperactive,hypoactive, and mixed, based on psychomotor behavior Aim: study the association between the psychomotor activi ty among di fferent del i rium subtypes and the admission characters in del i rious elderly patients to prove a hypothesis that hypoactive del i rium car ries worse underlying admission characters.Methods: A cross-s ec ti o nal s t udy w as c on duc te d on 4 5 ne wl y admi t te d del i ri o us el d erl y di agn os e d wi t h “C o nf us i on A s s es sm en t M et ho d ” CAM. Psychomotor activi ty was detected. Assessment of basel ine depression, function by Activi ties of dai ly l iving (ADL) , Inst rumental activi ties of dai ly l iving ( IADL), APACHE score and Erythrocyte sedimentation rate (ESR) were done.Results: Mean age was 71.2±7.9 years ( range 60.0 –91.0). 27 (60%) of patients were females. According topsychomotor characteristics, 19 (42.2%) of the participants were hypoactive, 13 (28.9%) were hyperactive and 13(28.9%) were mixed. Unl ike the hyperactive groups; the hypoac tive and mixed group have signi ficantly high ESR.There was no signi ficant association between motoric subtypes and presence of premorbid depression orfunctional dependence. There was no signi ficant di fference in basel ine comorbidi ties among the three sub types.Regarding the underlying etiology, Hypoglycemia was signi ficantly most f requent among hypoactive patients whi ledehydration was signi ficantly most f requent among patients wi th mixed type. APACHE score and the calculatedmortal i ty score were highest in hypoactive subtype and least among hyperactive, yet , this was of no statisticalsigni ficance.Conclusions: The hypoactive form of del i rium is common among older persons. Inflammation has a role in thepathology of hypoactive del i rium as indicated by hig h ESR. It is recommended to prompt ly recognize hypoactivedel i rium and to put a proper plan for ADL suppor t and functional rehabi l i tation.

Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit

Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes. Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure. Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02). A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.

Predicting outcome in older hospital patients with delirium: a systematic literature review.

Delirium is a serious neuropsychiatric syndrome common in older hospitalised adults. It is associated with poor outcomes, however not all people with delirium have poor outcomes and the risk factors for adverse outcomes within this group are not well described. The objective was to report which predictors of outcome had been reported in the literature. We performed a systematic review by an initial electronic database search of MEDLINE, Embase and PsycINFO using four key search criteria. These were: (1) participants with a diagnosis of delirium, (2) clearly defined outcome measures, (3) a clearly defined variable as predictor of outcomes and (4) participants in the general hospital, rehabilitation and care home settings, excluding intensive care. Studies were then selected in a systematic fashion using specific predetermined criteria by three reviewers. A total of 559 articles were screened, and 57 full text articles were assessed for eligibility. Twenty seven studies describing 18 different predictors of poor outcome were reported. The studies were rated by the Newcastle-Ottawa Score and were generally at low risk of bias. Four broad themes of predictor were identified; five delirium related predictors, two co-morbid psychiatric illness related predictors, eight patient related predictors and three biomarker related predictors. The most numerously described and clinically important appear to be the duration of the delirium episode, a hypoactive motor subtype, delirium severity and pre-existing psychiatric morbidity with dementia or depression. These are all associated with poorer delirium outcomes. Important predictors of poor outcomes in patients with delirium have been demonstrated. These could be used in clinical practice to focus direct management and guide discussions regarding prognosis. These results also demonstrate a number of key unknowns, where further research to explore delirium prognosis is recommended and is vital to improve understanding and management of this condition.

A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment

BackgroundStudies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear. AimTo determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment. Design and methodsThis paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication. SettingsThe study was conducted within four medical wards of an acute care university hospital in urban Switzerland. ParticipantsA total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively. ResultsEighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units. ConclusionsThe DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.

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.

A Longitudinal Study of Delirium Motor Subtypes in Elderly Hip Surgery Patients: Frequency and Determinants.

Introduction Delirium is a common neuropsychiatric syndrome with considerable heterogeneity that includes a variety of clinical (motor) subtypes. Because delirium is typically highly fluctuating, understanding the longitudinal stability of subtypes is crucial to evaluating their relevance to treatment and outcome. Aims to examine the changes (variability) in motor subtype profile in patients with delirium over serial assessment using the Delirium Motor Subtype Scale, and to investigate predictors of variability. Methods We studied motor subtype profile of patients with delirium assessed daily over a week in elderly patients undergoing hip fracture surgery. A Generalized Estimating Equations Model examined possible predictors of change in motor subtype status, including baseline variables and delirium course. Results We included 118 patients developing DSM-IV delirium after hip-surgery [mean age 87.0±6.5 years; range 65–102; 66% females]. At first assessment, hyperactive subtype was most common (49%), followed by hypoactive (31%) and mixed subtype (14%), with 6% of delirious patients not fulfilling criteria of any DMSS-defined motor subtype. Almost two-thirds (n=69) of these patients underwent at least one more assessment, and for these 45 (57%) remained stable in motor subtype over time, while the rest 34 (43%) underwent change. A range of baseline characteristics were not significant predictors of variability in subtype profile. Conclusions Motor subtype profile is typically stable for orthopaedic patients with delirium. Thus evidence from cross-sectional studies of motor subtypes can be applied to many patients with delirium. Further longitudinal studies can clarify the stability of motor subtypes across different clinical populations.

Cognitive decline in different delirium subtypes and the associated change in the biomarker S100B serum level

Objectives This study was designed to assess the cognitive decline in different delirium subtypes and the change in the level of serum S100B, with determination of the outcome of delirium. Background Delirium involves a wide range of cognitive disturbances across its different subtypes. The serum S100B level is high in delirious patients and plays a role in the process of learning and memory. The outcome of delirium differs according to delirium subtypes. Participants and methods This study enrolled 35 delirious patients (group A) and two control groups. Group B comprised 10 patients with disease but without delirium. Group C comprised 10 normal healthy individuals. All participants were subjected to the Delirium Symptom Interview scale, the Cognitive Test for Delirium, the Delirium Motor Subtype Scale, and the Trail Making Test parts A and B, and the level of serum S100B was measured. About 17 delirious patients were followed up after 1 month to assess the cognitive decline and the mortality rate. Results The level of cognitive dysfunction in delirious patients was significantly higher than that in the two control groups (group B and group C). The level of cognitive dysfunction was not significantly different among the four delirium subtypes. Attention impairment occurred in 96% of the patients, and the less affected cognitive domain was comprehension, which occurred in 77% of the patients. The level of serum S100B was significantly higher in delirious patients compared with the two control groups, but it was not significantly different among the delirium subtypes. After 1 month, the hypoactive subtype was associated with more cognitive dysfunction and a high mortality rate. Conclusion Cognitive decline occurs in delirious patients, but this decline was not significantly different among the delirium subtypes. The most affected cognitive domain was attention and the least affected one was comprehension. Delirium was associated with a high level of serum S100B, but this level was not significantly different among the delirium subtypes. The hypoactive subtype was associated with a poor outcome.

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.

A prospective observational study to investigate the association between abnormal hand movements and delirium in hospitalised older people.

to examine the relationship between carphology (aimlessly picking at bedclothes), floccillation (plucking at the air) and delirium in older patients admitted to specialist elderly care wards. daily observation for behaviours of carphology and floccillation embedded within a 'before' and 'after' study. three specialist elderly care wards in a general hospital. older people admitted to hospital as emergencies. patients recruited into a delirium prevention study were observed daily for delirium using the confusion assessment method (CAM). Occurrences of carphology and/or floccillation were also recorded. Sensitivity, specificity and positive and negative predictive values for carphology/floccillation for the diagnosis of delirium were calculated. Inpatient mortality rates were compared for patients who did, and did not exhibit features of carphology and/or floccillation. four hundred and thirty-seven patients were recruited into the study. One hundred and ten participants experienced an episode of delirium, 21 exhibited behaviours of carphology and/or floccillation. The sensitivity and specificity of carphology and/or floccillation for the diagnosis of delirium were 14 and 98%, respectively; positive likelihood ratio 6.8. Carphology and floccillation were associated with both hyper- and hypo-active delirium subtypes, and occurred early during incident delirium (67% within 2 days of delirium onset). The inpatient mortality rate in patients with carphology/floccillation was double the rate in patients without the behaviours (23.8 versus 11.2%, Fisher's exact test P = 0.16). carphology and floccillation are uncommon physical signs, but their presence is highly suggestive of delirium. The behaviours are unrelated to delirium subtype making their presence particularly useful in the diagnosis of hypo-active delirium.