Current Treatment Options in Neurology

, Volume 10, Issue 5, pp 386–395 | Cite as

Delirium: Underrecognized and undertreated

  • Chi-Un Pae
  • David M. Marks
  • Changsu Han
  • Ashwin A. Patkar
  • Prakash Masand
Article

Opinion statement

Delirium is a complex neuropsychiatric syndrome presenting primarily with disturbances of cognition, perception and sensorium, alertness, sleep/wake cycle, and psychomotor behavior in the context of a medical etiology. The presentation can be quite variable among patients and even within a given patient because of its waxing and waning course. This variability and overlap with other psychiatric syndromes has led to substantial underrecognition and undertreatment in clinical settings. Considering the significant morbidity and mortality associated with delirium and its tremendous economic burden, the failure to diagnose, refer, and treat such patients represents a critically important public health care issue. Clinicians should be systematically educated about delirium symptoms. Also, caregivers and family members of medically compromised patients should be educated about recognizing delirium. The use of structured diagnostic instruments and scales to follow the severity of symptoms has been an improvement in the field. However, much more research is needed into the use of such instruments and how they can be applied to clinical situations to improve the detection and treatment of delirium. Similarly, research is warranted that focuses on preventing delirium, potentially by identifying susceptible patients and intervening early. It is particularly challenging to devise cost-effective interventions for preventing and identifying delirium early in its course, given the rapid pace and resource limitations in inpatient and intensive care settings, and current data do not clearly indicate that such systems have proven benefit. Still, the indisputable health and financial costs of delirium indicate that prevention and identification should be a high priority.

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References and Recommended Reading

  1. 1.
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 4. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  2. 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.PubMedCrossRefGoogle Scholar
  3. 3.
    Pandharipande P, Jackson J, Ely EW: Delirium: acute cognitive dysfunction in the critically ill. Curr Opin Crit Care 2005, 11: 360–368.PubMedGoogle Scholar
  4. 4.
    Franco K, Litaker D, Locala J, Bronson D: The cost of delirium in the surgical patient. Psychosomatics 2001, 42: 68–73.PubMedCrossRefGoogle Scholar
  5. 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.PubMedCrossRefGoogle Scholar
  6. 6.
    Tabet N, Howard R: Prevention, diagnosis and treatment of delirium: staff educational approaches. Expert Rev Neurother 2006, 6: 741–751.PubMedCrossRefGoogle Scholar
  7. 7.
    Pun BT, Ely EW: The importance of diagnosing and managing ICU delirium. Chest 2007, 132: 624–636.PubMedCrossRefGoogle Scholar
  8. 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 healthcare professionals. Crit Care Med 2004, 32: 106–112.PubMedCrossRefGoogle Scholar
  9. 9.
    Gleason OC: Delirium. Am Fam Physician 2003, 67: 1027–1034.PubMedGoogle Scholar
  10. 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.PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 15.
    Rabinowitz T, Murphy K, Nagle K, et al.: Delirium: pathophysiology, recognition, prevention and treatment. Expert Rev Neurother 2003, 3: 343–355.CrossRefPubMedGoogle Scholar
  16. 16.
    Trzepacz PT: Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry 2000, 5: 132–148.PubMedGoogle Scholar
  17. 17.
    Trzepacz PT: Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999, 10: 330–334.PubMedCrossRefGoogle Scholar
  18. 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.PubMedCrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 20.
    Rigney TS: Delirium in the hospitalized elder and recommendations for practice. Geriatr Nurs 2006, 27: 151–157.PubMedCrossRefGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 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.PubMedGoogle Scholar
  24. 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.PubMedGoogle Scholar
  25. 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.PubMedCrossRefGoogle Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 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.PubMedGoogle Scholar
  28. 28.
    Young LJ, George J: Do guidelines improve the process and outcomes of care in delirium? Age Ageing 2003, 32: 525–528.PubMedCrossRefGoogle Scholar
  29. 29.
    Inouye SK, Bogardus ST Jr, Charpentier PA, et al.: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999, 340: 669–676.PubMedCrossRefGoogle Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. 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.PubMedGoogle Scholar
  32. 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.PubMedCrossRefGoogle Scholar
  33. 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.PubMedCrossRefGoogle Scholar
  34. 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.PubMedGoogle Scholar
  35. 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.PubMedGoogle Scholar
  36. 36.
    Trzepacz PT, Baker RW, Greenhouse J: A symptom rating scale for delirium. Psychiatry Res 1988, 23: 89–97.PubMedCrossRefGoogle Scholar
  37. 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.PubMedGoogle Scholar
  38. 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.PubMedGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 40.
    Breitbart W, Rosenfeld B, Roth A, et al.: The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997, 13: 128–137.PubMedCrossRefGoogle Scholar
  41. 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.PubMedGoogle Scholar
  42. 42.
    Neelon VJ, Champagne MT, Carlson JR, Funk SG: The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res 1996, 45: 324–330.PubMedCrossRefGoogle Scholar
  43. 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.PubMedCrossRefGoogle Scholar
  44. 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.PubMedGoogle Scholar
  45. 45.
    Hart RP, Best AM, Sessler CN, Levenson JL: Abbreviated cognitive test for delirium. J Psychosom Res 1997, 43: 417–423.PubMedCrossRefGoogle Scholar
  46. 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.PubMedCrossRefGoogle Scholar
  47. 47.
    Devlin JW, Fong JJ, Fraser GL, Riker RR: Delirium assessment in the critically ill. Intensive Care Med 2007, 33: 929–940.PubMedCrossRefGoogle Scholar
  48. 48.
    Schuurmans MJ, Deschamps PI, Markham SW, et al.: The measurement of delirium: review of scales. Res Theory Nurs Pract 2003, 17: 207–224.PubMedCrossRefGoogle Scholar
  49. 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.PubMedCrossRefGoogle Scholar
  50. 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.PubMedCrossRefGoogle Scholar
  51. 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.PubMedCrossRefGoogle Scholar
  52. 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.PubMedCrossRefGoogle Scholar
  53. 53.
    Britton A, Russell R: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. Cochrane Database Syst Rev 2004, 2: CD000395.PubMedGoogle Scholar
  54. 54.
    Lonergan E, Britton AM, Luxenberg J, Wyller T: Antipsychotics for delirium. Cochrane Database Syst Rev 2007, 2: CD005594.PubMedGoogle Scholar
  55. 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.PubMedCrossRefGoogle Scholar
  56. 56.
    Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry 1999, 156(5 Suppl): 1–20.Google Scholar
  57. 57.
    Leentjens AF, Diefenbacher A: A survey of delirium guidelines in Europe. J Psychosom Res 2006, 61: 123–128.PubMedCrossRefGoogle Scholar
  58. 58.
    Trzepacz P, Meagher D: Delirium. In Textbook of Psychosomatic Medicine. Arlington, VA: American Psychiatric Publishing; 2005.Google Scholar
  59. 59.
    FDA Public Health Advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. US Food and Drug Administration website. Available at http://www.fda.gov/cder/drug/advisory/antipsychotics.htm. Updated April 11, 2005. Accessed February 22, 2008.
  60. 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.PubMedCrossRefGoogle Scholar
  61. 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.PubMedCrossRefGoogle Scholar
  62. 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.PubMedCrossRefGoogle Scholar
  63. 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.PubMedGoogle Scholar
  64. 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.PubMedGoogle Scholar
  65. 65.
    Schwartz TL, Masand PS: Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry 2000, 2: 10–12.PubMedGoogle Scholar
  66. 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.PubMedCrossRefGoogle Scholar
  67. 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.PubMedCrossRefGoogle Scholar
  68. 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.PubMedCrossRefGoogle Scholar
  69. 69.
    Alao AO, Moskowitz L: Aripiprazole and delirium. Ann Clin Psychiatry 2006, 18: 267–269.PubMedCrossRefGoogle Scholar
  70. 70.
    Straker DA, Shapiro PA, Muskin PR: Aripiprazole in the treatment of delirium. Psychosomatics 2006, 47: 385–391.PubMedCrossRefGoogle Scholar
  71. 71.
    Leso L, Schwartz TL: Ziprasidone treatment of delirium. Psychosomatics 2002, 43: 61–62.PubMedCrossRefGoogle Scholar
  72. 72.
    Young CC, Lujan E: Intravenous ziprasidone for treatment of delirium in the intensive care unit. Anesthesiology 2004, 101: 794–795.PubMedCrossRefGoogle Scholar
  73. 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.PubMedCrossRefGoogle Scholar
  74. 74.
    Takeuchi T, Furuta K, Hirasawa T, et al.: Perospirone in the treatment of patients with delirium. Psychiatry Clin Neurosci 2007, 61: 67–70.PubMedCrossRefGoogle Scholar
  75. 75.
    Akechi T, Uchitomi Y, Okamura H, et al.: Usage of haloperidol for delirium in cancer patients. Support Care Cancer 1996, 4: 390–392.PubMedCrossRefGoogle Scholar
  76. 76.
    Han CS, Kim YK: A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004, 45: 297–301.PubMedGoogle Scholar
  77. 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.PubMedCrossRefGoogle Scholar
  78. 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.PubMedCrossRefGoogle Scholar
  79. 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. 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.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Chi-Un Pae
    • 1
    • 2
  • David M. Marks
  • Changsu Han
  • Ashwin A. Patkar
  • Prakash Masand
  1. 1.Department of PsychiatryThe Catholic University of Korea College of MedicineSeoulSouth Korea
  2. 2.Department of Psychiatry and Behavioral MedicineDuke University Medical CenterDurhamUSA

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