Skip to main content

Advertisement

SpringerLink
Log in

Delirium: Where do we stand?

  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Clinicians are likely to encounter delirium frequently, particularly in inpatient and intensive care settings. However, delirium is underrecognized and undertreated because of its heterogeneous and fluctuating presentation and due to the limitations in resources and training in contemporary clinical settings. Translation of current knowledge about delirium into clinical practice may improve patient care and benefit public health economics. Hence, this review comprehensively discusses the phenomenology and pathophysiology of delirium and its presenting features, risk factors, differential diagnoses, assessment, prognosis, and treatment with antipsychotics; the goal is to facilitate better prevention, recognition, and treatment of delirium. Available research is reviewed, limitations of the research are discussed, and future directions for further delirium research are identified.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 4. Washington, DC: American Psychiatric Association; 1994.

    Google Scholar 

  2. Ely EW, Shintani A, Truman B, et al.: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004, 291:1753–1762.

    Article  PubMed  CAS  Google Scholar 

  3. Pandharipande P, Jackson J, Ely EW: Delirium: acute cognitive dysfunction in the critically ill. Curr Opin Crit Care 2005, 11:360–368.

    PubMed  Google Scholar 

  4. Franco K, Litaker D, Locala J, Bronson D: The cost of delirium in the surgical patient. Psychosomatics 2001, 42:68–73.

    Article  PubMed  CAS  Google Scholar 

  5. Iseli RK, Brand C, Telford M, LoGiudice D: Delirium in elderly general medical inpatients: a prospective study. Intern Med J 2007, 37:806–811.

    Article  PubMed  CAS  Google Scholar 

  6. Tabet N, Howard R: Prevention, diagnosis and treatment of delirium: staff educational approaches. Expert Rev Neurother 2006, 6:741–751.

    Article  PubMed  Google Scholar 

  7. Pun BT, Ely EW: The importance of diagnosing and managing ICU delirium. Chest 2007, 132:624–636.

    Article  PubMed  Google Scholar 

  8. Ely EW, Stephens RK, Jackson JC, et al.: Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 health-care professionals. Crit Care Med 2004, 32:106–112.

    Article  PubMed  Google Scholar 

  9. Gleason OC: Delirium. Am Fam Physician 2003, 67:1027–1034.

    PubMed  Google Scholar 

  10. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, et al.: Risk factors for intensive care delirium: a systematic review. Intensive Crit Care Nurs 2008, 24:98–107.

    Article  PubMed  Google Scholar 

  11. Inouye SK, Zhang Y, Jones RN, et al.: Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med 2007, 167:1406–1413.

    Article  PubMed  Google Scholar 

  12. Kalisvaart KJ, Vreeswijk R, de Jonghe JF, et al.: Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model. J Am Geriatr Soc 2006, 54:817–822.

    Article  PubMed  Google Scholar 

  13. Inouye SK, Charpentier PA: Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996, 275:852–857.

    Article  PubMed  CAS  Google Scholar 

  14. Leslie DL, Zhang Y, Bogardus ST, et al.: Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc 2005, 53:405–409.

    Article  PubMed  Google Scholar 

  15. Rabinowitz T, Murphy K, Nagle K, et al.: Delirium: pathophysiology, recognition, prevention and treatment. Expert Rev Neurother 2003, 3:343–355.

    Article  PubMed  Google Scholar 

  16. Trzepacz PT: Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry 2000, 5:132–148.

    PubMed  CAS  Google Scholar 

  17. Trzepacz PT: Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999, 10:330–334.

    Article  PubMed  CAS  Google Scholar 

  18. Kales HC, Kamholz BA, Visnic SG, Blow FC: Recorded delirium in a national sample of elderly inpatients: potential implications for recognition. J Geriatr Psychiatry Neurol 2003, 16:32–38.

    Article  PubMed  Google Scholar 

  19. Edlund A, Lundstrom M, Karlsson S, et al.: Delirium in older patients admitted to general internal medicine. J Geriatr Psychiatry Neurol 2006, 19:83–90.

    Article  PubMed  Google Scholar 

  20. Rigney TS: Delirium in the hospitalized elder and recommendations for practice. Geriatr Nurs 2006, 27:151–157.

    Article  PubMed  Google Scholar 

  21. Thomas C, Hestermann U, Walther S, et al.: Prolonged activation EEG differentiates dementia with and without delirium in frail elderly. J Neurol Neurosurg Psychiatry 2008, 79:119–125.

    Article  PubMed  CAS  Google Scholar 

  22. McCusker J, Cole M, Dendukuri N, et al.: The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med 2003, 18:696–704.

    Article  PubMed  Google Scholar 

  23. Manos PJ, Wu R: The duration of delirium in medical and postoperative patients referred for psychiatric consultation. Ann Clin Psychiatry 1997, 9:219–226.

    PubMed  CAS  Google Scholar 

  24. McCusker J, Cole M, Dendukuri N, et al.: Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 2001, 165:575–583.

    PubMed  CAS  Google Scholar 

  25. McAvay GJ, Van Ness PH, Bogardus ST Jr, et al.: Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc 2006, 54:1245–1250.

    Article  PubMed  Google Scholar 

  26. Leslie DL, Zhang Y, Holford TR, et al.: Premature death associated with delirium at 1-year follow-up. Arch Intern Med 2005, 165:1657–1662.

    Article  PubMed  Google Scholar 

  27. Cole MG, McCusker J, Bellavance F, et al.: Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 2002, 167:753–759.

    PubMed  Google Scholar 

  28. Young LJ, George J: Do guidelines improve the process and outcomes of care in delirium? Age Ageing 2003, 32:525–528.

    Article  PubMed  CAS  Google Scholar 

  29. Inouye SK, Bogardus ST Jr, Charpentier PA, et al.: A multi-component intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999, 340:669–676.

    Article  PubMed  CAS  Google Scholar 

  30. Tabet N, Hudson S, Sweeney V, et al.: An educational intervention can prevent delirium on acute medical wards. Age Ageing 2005, 34:152–156.

    Article  PubMed  Google Scholar 

  31. Rockwood K, Cosway S, Stolee P, et al.: Increasing the recognition of delirium in elderly patients. J Am Geriatr Soc 1994, 42:252–256.

    PubMed  CAS  Google Scholar 

  32. Lundstrom M, Edlund A, Karlsson S, et al.: A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005, 53:622–628.

    Article  PubMed  Google Scholar 

  33. Folstein MF, Folstein SE, McHugh PR: “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975, 12:189–198.

    Article  PubMed  CAS  Google Scholar 

  34. Sunderland T, Hill JL, Mellow AM, et al.: Clock drawing in Alzheimer’s disease. A novel measure of dementia severity. J Am Geriatr Soc 1989, 37:725–729.

    PubMed  CAS  Google Scholar 

  35. Inouye SK, van Dyck CH, Alessi CA, et al.: Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990, 113:941–948.

    PubMed  CAS  Google Scholar 

  36. Trzepacz PT, Baker RW, Greenhouse J: A symptom rating scale for delirium. Psychiatry Res 1988, 23:89–97.

    Article  PubMed  CAS  Google Scholar 

  37. Trzepacz PT, Mittal D, Torres R, et al.: Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001, 13:229–242.

    PubMed  CAS  Google Scholar 

  38. Pfeiffer E: A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975, 23:433–441.

    PubMed  CAS  Google Scholar 

  39. Schuurmans MJ, Shortridge-Baggett LM, Duursma SA: The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract 2003, 17:31–50.

    Article  PubMed  Google Scholar 

  40. Breitbart W, Rosenfeld B, Roth A, et al.: The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997, 13:128–137.

    Article  PubMed  CAS  Google Scholar 

  41. Jacobs JW, Bernhard MR, Delgado A, Strain JJ: Screening for organic mental syndromes in the medically ill. Ann Intern Med 1977, 86:40–46.

    PubMed  CAS  Google Scholar 

  42. Neelon VJ, Champagne MT, Carlson JR, Funk SG: The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res 1996, 45:324–330.

    Article  PubMed  CAS  Google Scholar 

  43. Ely EW, Inouye SK, Bernard GR, et al.: Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001, 286:2703–2710.

    Article  PubMed  CAS  Google Scholar 

  44. Hart RP, Levenson JL, Sessler CN, et al.: Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 1996, 37:533–546.

    PubMed  CAS  Google Scholar 

  45. Hart RP, Best AM, Sessler CN, Levenson JL: Abbreviated cognitive test for delirium. J Psychosom Res 1997, 43:417–423.

    Article  PubMed  CAS  Google Scholar 

  46. Bergeron N, Dubois MJ, Dumont M, et al.: Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001, 27:859–864.

    Article  PubMed  CAS  Google Scholar 

  47. Devlin JW, Fong JJ, Fraser GL, Riker RR: Delirium assessment in the critically ill. Intensive Care Med 2007, 33:929–940.

    Article  PubMed  Google Scholar 

  48. Schuurmans MJ, Deschamps PI, Markham SW, et al.: The measurement of delirium: review of scales. Res Theory Nurs Pract 2003, 17:207–224.

    Article  PubMed  Google Scholar 

  49. Stagno D, Gibson C, Breitbart W: The delirium subtypes: a review of prevalence, phenomenology, pathophysiology, and treatment response. Palliat Support Care 2004, 2:171–179.

    PubMed  Google Scholar 

  50. Marcantonio E, Ta T, Duthie E, Resnick NM: Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. J Am Geriatr Soc 2002, 50:850–857.

    Article  PubMed  Google Scholar 

  51. Peterson JF, Pun BT, Dittus RS, et al.: Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 2006, 54:479–484.

    Article  PubMed  Google Scholar 

  52. Mittal D, Majithia D, Kennedy R, Rhudy J: Differences in characteristics and outcome of delirium as based on referral patterns. Psychosomatics 2006, 47:367–375.

    Article  PubMed  Google Scholar 

  53. Britton A, Russell R: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. Cochrane Database Syst Rev 2004, 2:CD000395.

  54. Lonergan E, Britton AM, Luxenberg J, Wyller T: Antipsychotics for delirium. Cochrane Database Syst Rev 2007, 2:CD005594.

  55. Carnes M, Howell T, Rosenberg M, et al.: Physicians vary in approaches to the clinical management of delirium. J Am Geriatr Soc 2003, 51:234–239.

    Article  PubMed  Google Scholar 

  56. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry 1999, 156(5 Suppl):1–20.

  57. Leentjens AF, Diefenbacher A: A survey of delirium guidelines in Europe. J Psychosom Res 2006, 61:123–128.

    Article  PubMed  Google Scholar 

  58. Trzepacz P, Meagher D: Delirium. In Textbook of Psychosomatic Medicine. Arlington, VA: American Psychiatric Publishing; 2005.

    Google Scholar 

  59. FDA Public Health Advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. US Food and Drug Administration website. http://www.fda.gov/cder/drug/advisory/antipsychotics.htm Updated April 11, 2005. Accessed February 22, 2008.

  60. Breitbart W, Tremblay A, Gibson C: An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics 2002, 43:175–182.

    Article  PubMed  CAS  Google Scholar 

  61. Kim KS, Pae CU, Chae JH, et al.: An open pilot trial of olanzapine for delirium in the Korean population. Psychiatry Clin Neurosci 2001, 55:515–519.

    Article  PubMed  CAS  Google Scholar 

  62. Horikawa N, Yamazaki T, Miyamoto K, et al.: Treatment for delirium with risperidone: results of a prospective open trial with 10 patients. Gen Hosp Psychiatry 2003, 25:289–292.

    Article  PubMed  Google Scholar 

  63. Mittal D, Jimerson NA, Neely EP, et al.: Risperidone in the treatment of delirium: results from a prospective open-label trial. J Clin Psychiatry 2004, 65:662–667.

    Article  PubMed  CAS  Google Scholar 

  64. Parellada E, Baeza I, de Pablo J, Martinez G: Risperidone in the treatment of patients with delirium. J Clin Psychiatry 2004, 65:348–353.

    PubMed  CAS  Google Scholar 

  65. Schwartz TL, Masand PS: Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry 2000, 2:10–12.

    PubMed  Google Scholar 

  66. Kim KY, Bader GM, Kotlyar V, Gropper D: Treatment of delirium in older adults with quetiapine. J Geriatr Psychiatry Neurol 2003, 16:29–31.

    Article  PubMed  Google Scholar 

  67. Sasaki Y, Matsuyama T, Inoue S, et al.: A prospective, open-label, flexible-dose study of quetiapine in the treatment of delirium. J Clin Psychiatry 2003, 64:1316–1321.

    Article  PubMed  CAS  Google Scholar 

  68. Pae CU, Lee SJ, Lee CU, et al.: A pilot trial of quetiapine for the treatment of patients with delirium. Hum Psychopharmacol 2004, 19:125–127.

    Article  PubMed  CAS  Google Scholar 

  69. Alao AO, Moskowitz L: Aripiprazole and delirium. Ann Clin Psychiatry 2006, 18:267–269.

    Article  PubMed  Google Scholar 

  70. Straker DA, Shapiro PA, Muskin PR: Aripiprazole in the treatment of delirium. Psychosomatics 2006, 47:385–391.

    Article  PubMed  CAS  Google Scholar 

  71. Leso L, Schwartz TL: Ziprasidone treatment of delirium. Psychosomatics 2002, 43:61–62.

    Article  PubMed  Google Scholar 

  72. Young CC, Lujan E: Intravenous ziprasidone for treatment of delirium in the intensive care unit. Anesthesiology 2004, 101:794–795.

    Article  PubMed  Google Scholar 

  73. Lee KU, Won WY, Lee HK, et al.: Amisulpride versus quetiapine for the treatment of delirium: a randomized, open prospective study. Int Clin Psychopharmacol 2005, 20:311–314.

    Article  PubMed  Google Scholar 

  74. Takeuchi T, Furuta K, Hirasawa T, et al.: Perospirone in the treatment of patients with delirium. Psychiatry Clin Neurosci 2007, 61:67–70.

    Article  PubMed  CAS  Google Scholar 

  75. Akechi T, Uchitomi Y, Okamura H, et al.: Usage of haloperidol for delirium in cancer patients. Support Care Cancer 1996, 4:390–392.

    Article  PubMed  CAS  Google Scholar 

  76. Han CS, Kim YK: A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004, 45:297–301.

    PubMed  CAS  Google Scholar 

  77. Kim JY, Jung IK, Han C, et al.: Antipsychotics and dopamine transporter gene polymorphisms in delirium patients. Psychiatry Clin Neurosci 2005, 59:183–188.

    Article  PubMed  CAS  Google Scholar 

  78. Skrobik YK, Bergeron N, Dumont M, Gottfried SB: Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004, 30:444–449.

    Article  PubMed  Google Scholar 

  79. Hu X, Deng W, Yang H: A prospective random control study comparison of olanzapine and haloperidol in senile delirium. Chongging Med J 2004, 8:1234–1237.

    Google Scholar 

  80. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al.: Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005, 53:1658–1666.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry, The Catholic University of Korea College of Medicine, 505 banpo-Don, Seocho-Gu, Seoul, 137701, South Korea

    Chi-Un Pae

  2. Department of Psychiatry and Behavioral Medicine, Duke University Medical Center, 2218 Elder Street, Durham, NC, 27705, USA

    Chi-Un Pae

Authors
  1. Chi-Un Pae
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David M. Marks
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Changsu Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ashwin A. Patkar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Prakash Masand
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chi-Un Pae.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pae, CU., Marks, D.M., Han, C. et al. Delirium: Where do we stand?. Curr Psychiatry Rep 10, 240–248 (2008). https://doi.org/10.1007/s11920-008-0040-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-008-0040-3

Keywords

Search

Navigation