Hypoactive Symptoms Research Articles

Factors Associated with Improvement in Activities of Daily Living during Hospitalization: A Retrospective Study of Older Patients with Hip Fractures.

In this study, we aimed to examine the changes in delirium during hospitalization of patients and its association with behavioral and psychological symptoms of dementia (BPSD), as well as improvements in activities of daily living (ADL). A longitudinal, retrospective cohort study was conducted involving 83 older adults (≥65 years) with hip fractures. We collected Mini-Mental State Examination (MMSE) and Functional Independence Measure-motor domain (m-FIM) assessment results from the medical charts at two time points: baseline (first week of hospitalization) and pre-discharge (final week before discharge). Additionally, we collected data on delirium and BPSD at three points: baseline, week 2 post-admission, and pre-discharge. We performed univariate logistic regression analysis using changes in m-FIM scores as the dependent variable and MMSE and m-FIM scores at baseline and pre-discharge, along with delirium and BPSD subtypes at baseline, week 2 post-admission, and pre-discharge, as the explanatory variables. Finally, we performed a multivariate logistic regression analysis incorporating the significant variables from the univariate analysis to identify factors associated with ADL improvement during hospitalization. We observed significant correlations between ADL improvement during hospitalization and baseline m-FIM and MMSE scores, hypoactive delirium state, and BPSD subtype pre-discharge. Notably, all participants with hypoactive symptoms before discharge exhibited some subtype of delirium and BPSD at baseline. Besides ADL ability and cognitive function at admission, the presence of hypoactive delirium and BPSD subtype before discharge may hinder ADL improvement during hospitalization.

Suffering in silence – Cardiac surgery patients recalling hypoactive delirium a qualitative descriptive study

ObjectivesPostoperative delirium affects up to 50% of patients undergoing cardiac surgery. Delirium phenotypes are commonly divided into hyperactive and hypoactive, with hypoactive symptoms (reduced motor activity and withdrawal) often being overlooked due to their discreet character. Although the consequences of hypoactive delirium are severe, studies focusing on patients’ experiences of hypoactive delirium are scarce. The aim of the study was to describe cardiac surgery patients’ experiences of hypoactive delirium. Research Methodology/DesignWe used qualitative descriptive semi-structured interviews with an inductive, latent approach. Twelve patients with hypoactive symptoms of delirium after cardiac surgery were purposefully selected. Interview data were analysed by qualitative content analysis. FindingsTwo themes based on eight sub-themes emerged. “Dream or reality in parallel worlds” included disturbing experiences of existing in parallel realities with cognitive effects, residual nightmares, and illusions that occasionally persisted after hospital discharge. “Managing the state of hypoactive delirium” included experiences of intellectually dealing with hypoactive delirium with assumptions of causes and cures, and through interactions like communicating with others. ConclusionParticipants experienced hypoactive delirium as extensive and long-lasting with perceptions of existing in parallel realities. The findings emphasize the need for healthcare professionals to have expertise in hypoactive delirium and its fluctuating course, as the delirium of many patients may be undetected and undiagnosed. Improving the use of screening tools for clinical practice is essential for the detection of hypoactive delirium, and a person-centred approach is needed to properly care for this group of patients. Implications for clinical practiceThe challenges in the recognition of hypoactive delirium need to be emphasized because the syndrome is still overlooked. The use of screening tools in clinical practice is essential. A person-centred approach supports relationships between delirious patients and healthcare professionals.

The Motoric Types of Delirium and Estimated Blood Loss during Perioperative Period in Orthopedic Elderly Patients.

Background Delirium is a common and serious syndrome in elderly patients. The hypoactive type of delirium is known to have different characteristics, but further studies are needed to define the specificities of these characteristics. Our study aims at finding specific risk factors, especially estimated blood loss during operations of hyper- and hypoactive delirium in orthopedic elderly patients. Methods One hundred and seventy-five elderly patients were evaluated using the Confusion Assessment Method (CAM) and the 4th edition text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Trained psychiatrists interviewed the subjects directly at pre- and postoperative time points. We reviewed medical records after the patients were discharged. Results Thirty-nine patients (22.3%) were diagnosed with multiple types of delirium, which included 17 hyperactive types (65.9%), 13 hypoactive types (33.3%), and 9 mixed types (23.1%). Although the mean estimated blood loss in patients with either hyper- or hypoactive symptoms was larger than in patients lacking these symptoms, the odds ratio was only significant in patients with hyperactive symptoms. In addition, age, preoperative daily function, and preoperative hyponatremia were found to be risk factors for hyperactive but not hypoactive symptoms. Conclusion Patients with hypoactive symptoms had different risk factors than patients with hyperactive symptoms of delirium. The estimated blood loss, well-known risk factors for delirium, might be risk factors for only hyperactive delirium. The acute precipitating factors seemed to show stronger correlation with the hyperactive type of delirium than with the hypoactive type.

Prognostic effects of delirium motor subtypes in hospitalized older adults: A prospective cohort study.

ObjectivesTo investigate the association between delirium motor subtypes and hospital mortality and 12-month mortality in hospitalized older adults.DesignProspective cohort study conducted from 2009 to 2015.SettingGeriatric ward of a university hospital in Sao Paulo, Brazil.ParticipantsWe included 1,409 consecutive admissions of acutely ill patients aged 60 years and over. We excluded admissions for end-of-life care, with missing data on the main variables, length of stay shorter than 48 hours, or when consent to participate was not given.Main outcomes and measuresDelirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Comprehensive geriatric assessment was performed at admission and included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses used Cox proportional hazards models adjusted for possible confounders.ResultsWe included 1,409 admissions, with a mean age of 80 years. The proportion of in-hospital deaths was 19%, with a cumulative mortality of 38% in 12 months. Delirium occurred in 47% of the admissions. Hypoactive delirium was the predominant motor subtype (53%), followed by mixed delirium (30%) and hyperactive delirium (17%). Hospital mortality rates were respectively 33%, 34% and 15%. We verified that hypoactive and mixed delirium were independently associated with hospital mortality, with respective hazard ratios of 2.43 (95%CI = 1.64–3.59) and 2.31 (95%CI = 1.53–3.50). Delirium motor subtypes were not independently predictive of 12-month mortality.ConclusionsOne in three acutely ill hospitalized older adults who suffered hypoactive or mixed delirium died in the hospital. Clinicians should be aware that hypoactive symptoms of delirium, whether shown exclusively or in alternation with hyperactive symptoms, are indicative of a worse prognosis in this population.

The hinterland of delirium

The diagnostic criteria for delirium in the fi fth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specify a disturbance in attention or change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia; development over a short period; and evidence from the history, physical examination, or laboratory fi ndings that the disturbance is caused by the direct physiological consequences of a general medical condition, is due to an intoxicating substance or medication use, or has more than one cause. Although this defi nition seems unequivocal, delirium is still commonly under-recognised. Descriptions of what we would now know as delirium date back to Classical Greece, with references found in the works of Hippocrates to hyperactive and hypoactive symptoms, which he described with the terms phrenitis (mental abnormalities caused by fever, poisoning, or head trauma) and lethargy (inertia and dulling of the senses). Celus, in the 1st century AD, is generally credited with being the fi rst to use the term delirium to describe mental illness during fever or head trauma, although much debate remains about the etymology of the word. The medical literature throughout the Middle Ages and up to the 19th century is full of descriptions of delirium, although the terminology used varied widely throughout this period, with the designations phrenitis, phrensy, phrenesis, lethargy, paraphrensy, and paraphrenesis falling in and out of favour. During the 20th century, the focus moved away from looking at delirium as only a symptom and more towards understanding of the pathophysiology of the disorder itself. Engel and Romano led the way in this respect in 1959 by showing that delirium was a disturbance in the level of consciousness manifesting as cognitive attentional disturbances and was due to disruption of brain metabolism.

Factors associated with prolonged delirium: a systematic review

Delirium frequently accompanies acute illness. With treatment of the illness, some individuals recover from delirium while for others the symptoms persist. It is not understood why some individuals improve but others do not. The purpose of this paper is to review systematically what is known about the factors associated with the persistence of delirium. A medical literature search was conducted using several bibliographic databases, supplemented by manual searches of the references. English or French studies were included if they compared two groups of delirious individuals in delirium duration or persistence up to six months after the onset of delirium, diagnosed prospectively with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (or a scale derived and validated against the DSM). Information was collected on the association between possible non-therapeutic prognostic variables and delirium persistence. Twenty-one observational studies were included, in various settings (e.g. mixed medical-surgical, medical or geriatric, surgical, psychiatric, cancer or palliative care units). Variables assessed included patient characteristics (e.g. age, dementia, medical comorbidity, functional status), delirium characteristics (e.g. presence of hypoactive symptoms, delirium severity) and illness characteristics (e.g. severity of illness, and underlying acute illness). Overall, studies suggested that delirium is often persistent at discharge or beyond. Persistence was associated with dementia, increasing numbers of medical conditions, increasing severity of delirium, hypoactive symptoms and hypoxic illnesses. Preliminary findings suggest that some factors may identify those at risk for persistent delirium; however, more research is needed.

Differing management of people with advanced cancer and delirium by four sub-specialties

Introduction: Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer. Methods: A questionnaire was designed to identify investigations and treatment used, in relation to two cases. Results: Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists. Investigations: 85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium. Treatment: Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium. Discussion: The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.