Journal of Neurology

, Volume 259, Issue 8, pp 1590–1599 | Cite as

Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review

  • G. Carin-LevyEmail author
  • G. E. Mead
  • K. Nicol
  • R. Rush
  • F. van Wijck
Original Communication


Delirium is a common complication in acute stroke yet there is uncertainty regarding how best to screen for and diagnose delirium after stroke. We sought to establish how delirium after stroke is identified, its incidence rates and factors predicting its development. We conducted a systematic review of studies investigating delirium in acute stroke. We searched The Cochrane Collaboration, MEDLINE, EMBASE, CINHAL, PsychINFO, Web of Science, British Nursing Index, PEDro and OT Seeker in October 2010. A total of 3,127 citations were screened, full text of 60 titles and abstracts were read, of which 20 studies published between 1984 and 2010 were included in this review. The methods most commonly used to identify delirium were generic assessment tools such as the Delirium Rating Scale (n = 5) or the Confusion Assessment Method (n = 2) or both (n = 2). The incidence of delirium in acute stroke ranged from 2.3–66%, with our meta-analysis random effects approach placing the rate at 26% (95% CI 19–33%). Of the 11 studies reporting risk factors for delirium, increased age, aphasia, neglect or dysphagia, visual disturbance and elevated cortisol levels were associated with the development of delirium in at least one study. The outcomes associated with the condition are increased morbidity and mortality. Delirium is found in around 26% of stroke patients. Difference in diagnostic and screening procedures could explain the wide variation in frequency of delirium. There are a number of factors that may predict the development of the condition.


Delirium Acute stroke Diagnosis and screening 



Ms Carin-Levy is a part time PhD student funded by Queen Margaret University, Edinburgh. No other funding has been received for this study. We are grateful to Prof. Marie Donaghy for her contribution during the development of this project and for her comments on manuscript drafts.

Conflicts of interest

There are no conflicts of interest to disclose.


  1. 1.
    Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LMJ (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676PubMedCrossRefGoogle Scholar
  2. 2.
    Henon H, Lebert F, Durieu I, Godefroy O, Lucas C, Pasquier F, Leys D (1999) Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome. Stroke: J Cereb Circ 30:773–779CrossRefGoogle Scholar
  3. 3.
    Siddiqi N, House AO, Holmes JD (2006) Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 35:350–364PubMedCrossRefGoogle Scholar
  4. 4.
    McCusker J, Cole MG, Dendukuri N, Belzile E (2003) Does delirium increase hospital stay? J Am Geriatr Soc 51:1539–1546PubMedCrossRefGoogle Scholar
  5. 5.
    Young J, Inouye SK (2007) Delirium in older people. BMJ (Clinical Research Ed) 334:842–846CrossRefGoogle Scholar
  6. 6.
    Carson A, Zeman A, Brown T, Sharpe M (2004) Organic disorders. In: Johnstone E, Cunningham Owens D, Lawrie S, Sharpe M, Freeman C (eds) Companion to psychiatric studies, 7 ed. edn. Churchill Livingstone, Edinburgh, pp 341–344Google Scholar
  7. 7.
    Scottish Intercollegiate Guidelines Network (2010) Management of Patients with Stroke: Rehabilitation, prevention and management of complications, and discharge planning. A National Clinical Guideline. NHS Quality Improvement ScotlandGoogle Scholar
  8. 8.
    National Institute for Health and Clinical Excellence (2008) Stroke: National Clinical Guidelines for treatment and initial management of acute stroke and transient ischaemic attack (TIA). London, Royal College of PhysiciansGoogle Scholar
  9. 9.
    National Institute for Clinical Excellence (2010) Delirium: Diagnosis prevention and management. NICEGoogle Scholar
  10. 10.
    McManus J, Pathansali R, Stewart R, Macdonald A, Jackson S (2007) Delirium post-stroke. Age Ageing 36:613–618PubMedCrossRefGoogle Scholar
  11. 11.
    Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52:377–384PubMedCrossRefGoogle Scholar
  12. 12.
    Hatano S (1976) Experience from a Multicentre stroke register: a preliminary report. bulletin of the World Health Organisation; 54 Available at: URL: Accessed 15 Sept 2010
  13. 13.
    Whiting P, Rutjes AWS, Reitsma JB, Bossuyt PMM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25PubMedCrossRefGoogle Scholar
  14. 14.
    Deeks J (2001) Systematic reviews of evaluations of diagnostic and screening tests. In: Egger M, Davey Smith G, Altman D (eds) Systematic reviews in health care: Meta-Analysis in Context. BMJ Publishing Group, London, pp 248–282CrossRefGoogle Scholar
  15. 15.
    American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders DSM III, 3rd edn. American Psychiatric Association, Washington, DCGoogle Scholar
  16. 16.
    American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders: DSM-III-R. American Psychiatric Association, Washington, DCGoogle Scholar
  17. 17.
    American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders: DSM IV. American Psychiatric Association, Washington, DCGoogle Scholar
  18. 18.
    American Psychiatric Association (2002) Diagnostic and statistical manual of mental disorders (DSM-IV-R), 4th edn. American Psychiatric Association Press, Washington DCGoogle Scholar
  19. 19.
    Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 13:941–948Google Scholar
  20. 20.
    Trzepacz PT, Baker RW, Greenhouse J (1988) A symptom rating scale for delirium. Psychiatry Res 23:89–97PubMedCrossRefGoogle Scholar
  21. 21.
    Gustafson L, Lindgren M, Westling B (1995) The OBS Scale—a factor analysis approach to evaluation of confusional states and other organic brain syndromes. Unpublished work available from: Accessed 1 Jun 2011
  22. 22.
    Folstein MF, Folstein SE, McHugh PR (1975) Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198PubMedCrossRefGoogle Scholar
  23. 23.
    Caeiro L, Ferro JM, Albuquerque R, Figueira ML (2004) Delirium in the first days of acute stroke. J Neurol 251:171–178PubMedCrossRefGoogle Scholar
  24. 24.
    Dostovic Z, Smajlovic D, Sinanovic O, Vidovic M (2009) Duration of delirium in the acute stage of stroke. Acta Clin Croat 48:13–17PubMedGoogle Scholar
  25. 25.
    Sandberg O, Franklin KA, Bucht G, Gustafson Y (2001) Sleep apnea, delirium, depressed mood, cognition, and ADL ability after stroke. J Am Geriatr Soc 49:391–397PubMedCrossRefGoogle Scholar
  26. 26.
    Sheng AZ, Shen Q, Cordato D, Zhang YY, Yin Chan DK (2006) Delirium within three days of stroke in a cohort of elderly patients. J Am Geriatr Soc 54:1192–1198PubMedCrossRefGoogle Scholar
  27. 27.
    Dahl MH, Ronning OM, Thommessen B (2010) Delirium in acute stroke—prevalence and risk factors. Acta Neurol Scand 122(suppl 190):39–43CrossRefGoogle Scholar
  28. 28.
    Fassbender K, Schmidt R, Mossner R, Daffertshofer M, Hennerici M (1994) Pattern of activation of the hypothalamic-pituitary-adrenal axis in acute stroke. Relation to acute confusional state, extent of brain damage, and clinical outcome. Stroke: J Cereb Circ 25:1105–1108CrossRefGoogle Scholar
  29. 29.
    Gustafson Y, Olsson T, Asplund K, Hagg E (1993) Acute confusional state (Delirium) soon after stroke is associated with hypercortisolism. Cerebrovasc Dis 3:33–38CrossRefGoogle Scholar
  30. 30.
    Gustafson Y, Olsson T, Eriksson S, Asplund K, Bucht G (1991) Acute confusional states (Delirium) in stroke patients. Cerebrovasc Dis 1:257–264CrossRefGoogle Scholar
  31. 31.
    Caeiro L, Ferro M, Claro MI, Coelho J, Albuquerque R, Figueira ML (2004) Delirium in acute stroke: a preliminary study of the role of anticholinergic medications. Eur J Neurol 11:699–704PubMedCrossRefGoogle Scholar
  32. 32.
    Caeiro L, Menger C, Ferro JM, Albuquerque R, Figueira ML (2005) Delirium in acute subarachnoid haemorrhage. Cerebrovasc Dis 19:31–38PubMedCrossRefGoogle Scholar
  33. 33.
    Dunne JW, Leedman PJ, Edis RH (1986) Inobvious stroke: a cause of delirium and dementia. Aust N Z J Med 16:771–778PubMedGoogle Scholar
  34. 34.
    Shih HT, Huang WS, Liu CH, Tsai TC, Lu CT, Lu MK, Chen PK, Tseng CH, Jou SB, Tsai CH, Lee CC (2007) Confusion or delirium in patients with posterior cerebral arterial infarction. Acta Neurol Taiwanica 16:136–142Google Scholar
  35. 35.
    Nicolai A, Lazzarino LG (1994) Acute confusional states secondary to infarctions in the territory of the posterior cerebral artery in elderly patients. Ital J Neurol Sci 15:91–96PubMedCrossRefGoogle Scholar
  36. 36.
    Mori E, Yamadori A (1987) Acute confusional state and acute agitated delirium: occurrence after infarction in the right middle cerebral artery territory. Arch Neurol 44:1139–1143PubMedCrossRefGoogle Scholar
  37. 37.
    Marklund N, Peltonen M, Nilsson TK, Olsson T (2004) Low and high circulating cortisol levels predict mortality and cognitive dysfunction early after stroke. J Intern Med 256:15–21PubMedCrossRefGoogle Scholar
  38. 38.
    McManus J, Pathansali R, Hassan H, Ouldred E, Cooper D, Stewart R, Macdonald A, Jackson S (2009) The course of delirium in acute stroke. Age Ageing 38:385–389PubMedCrossRefGoogle Scholar
  39. 39.
    McManus J, Pathansali R, Hassan H, Ouldred E, Cooper D, Stewart R, Macdonald A, Jackson S (2009) The evaluation of delirium post-stroke. Int J Geriatr Psychiatry 24:1251–1256CrossRefGoogle Scholar
  40. 40.
    Oldenbeuving AW, de Kort PLM, Jansen BPW, Kappelle LJ, Roks G (2008) A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative. BMC Neurol 8:34PubMedCrossRefGoogle Scholar
  41. 41.
    Bjorkelund KB, Larsson S, Gustafson L, Andersson E (2006) The organic brain syndrome (OBS) scale: a systematic review. Int J Geriatr Psychiatry 21:210–222PubMedCrossRefGoogle Scholar
  42. 42.
    Sandberg O, Gustafson Y, Brannstrom B, Bucht G (1999) Clinical Profile of Delirium in Older Patients. J Am Geriatr Soc 47:1300–1306PubMedGoogle Scholar
  43. 43.
    Egger M, Davey Smith G, Schneider M (2001) Systematic reviews of observational studies. In: Egger M, Davey Smith G, Altman D (eds) Systematic reviews in health care meta analysis in context, 2nd edn. BMJ Publishing Group, London, pp 211–227CrossRefGoogle Scholar
  44. 44.
    Schmidley JW, Messing RO (1984) Agitated confusional states in patients with right hemisphere infarctions. Stroke 15:883–885PubMedCrossRefGoogle Scholar
  45. 45.
    Oldenbeuving AW, de Kort PLM, Jansen BPW, Roks G, Kappelle LJ (2007) Delirium in acute stroke: a review. Int J Stroke 2:270–275PubMedCrossRefGoogle Scholar
  46. 46.
    White S, Bayer A (2007) Delirium: a clinical overview. Rev Clin Gerontol 17:45–62CrossRefGoogle Scholar
  47. 47.
    Jensen E, Dehlin O, Gustafson L (1993) A comparison between three psychogeriatric rating scales. Int J Geriatr Psychiatry 8:215–229CrossRefGoogle Scholar
  48. 48.
    Scottish Intercollegiate Guidelines Network (2002) SIGN 64: management of patients with stroke. Rehabilitation, prevention and management of complications, and discharge planning. A national clinical guideline. 1–51. Sign, EdinburghGoogle Scholar
  49. 49.
    Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703–2710PubMedCrossRefGoogle Scholar
  50. 50.
    Oldenbeuving AW, de Kort PLM, Jansen BPW, Algra A, Kappelle LJ, Roks G (2011) Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology 76:993–999PubMedCrossRefGoogle Scholar
  51. 51.
    Tune LE, Egeli S (1999) Acetylcholine and delirium. Dement Geriatr Cogn Disord 10:342–344PubMedCrossRefGoogle Scholar
  52. 52.
    Caplan LR (2010) Delirium: a neurologist’s view—the neurology of agitation and overactivity. Rev Neurol Dis 7:111–118PubMedGoogle Scholar
  53. 53.
    Burns A, Galllagley A, Byrne J (2004) Delirium. J Neurol Neurosurg Psychiatry 75:362–367PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • G. Carin-Levy
    • 1
    Email author
  • G. E. Mead
    • 2
  • K. Nicol
    • 1
  • R. Rush
    • 1
  • F. van Wijck
    • 3
  1. 1.School of Health SciencesQueen Margaret UniversityEdinburghUK
  2. 2.Geriatric Medicine, Clinical and Surgical SciencesThe University of EdinburghEdinburghUK
  3. 3.Institute for Applied Health Research and School of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK

Personalised recommendations