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      Detecting delirium in elderly outpatients with cognitive impairment

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          ABSTRACT

          Background:

          Delirium may be more prevalent in elderly outpatients than has long been assumed. However, it may be easily missed due to overlap with dementia. Our aim was to study delirium symptoms and underlying somatic disorders in psycho-geriatric outpatients.

          Methods:

          We performed a case-control study among outpatients that were referred to a psychiatric institution between January 1st and July 1st 2010 for cognitive evaluation. We compared 44 cases with DSM-IV delirium (24 with and 20 without dementia) to 44 controls with dementia only. All participants were aged 70 years or older. We extracted from the medical files (1) referral characteristics including demographics, medical history, medication use, and referral reasons, (2) delirium symptoms, scored with the Delirium Rating Scale-Revised-98, and (3) underlying disorders categorized as: drugs/intoxication, infection, metabolic/endocrine disturbances, cardiovascular disorders, central nervous system disorders, and other health problems.

          Results:

          At referral, delirium patients had significantly higher numbers of chronic diseases and medications, and more often a history of delirium and a recent hospital admission than controls. Most study participants, including those with delirium, were referred for evaluation of (suspected) dementia. The symptoms that occurred more frequently in cases were: sleep disturbances, perceptual abnormalities, delusions, affect lability, agitation, attention deficits, acute onset, and fluctuations. Drug related (68%), infectious (61%), and metabolic-endocrine (50%) disturbances were often involved.

          Conclusions:

          Detection of delirium and distinction from dementia in older outpatients was feasible but required detailed caregiver information about the presence, onset, and course of symptoms. Most underlying disorders could be managed at home.

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          Most cited references 19

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          Validation of the Delirium Rating Scale-Revised-98

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            Phenomenology of delirium. Assessment of 100 adult cases using standardised measures.

            Delirium phenomenology is understudied. To investigate the relationship between cognitive and non-cognitive delirium symptoms and test the primacy of inattention in delirium. People with delirium (n=100) were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). Sleep-wake cycle abnormalities and inattention were most frequent, while disorientation was the least frequent cognitive deficit. Patients with psychosis had either perceptual disturbances or delusions but not both. Neither delusions nor hallucinations were associated with cognitive impairments. Inattention was associated with severity of other cognitive disturbances but not with non-cognitive items. CTD comprehension correlated most closely with non-cognitive features of delirium. Delirium phenomenology is consistent with broad dysfunction of higher cortical centres, characterised in particular by inattention and sleep-wake cycle disturbance. Attention and comprehension together are the cognitive items that best account for the syndrome of delirium. Psychosis in delirium differs from that in functional psychoses.
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              Prognostic Significance of Delirium in Frail Older People

              Our aim was to investigate the long-term prognosis of delirium in the frailest elderly, and to clarify whether delirium is just a marker of the underlying severe disease. We used logistic regression analysis to determine the independent prognostic significance of delirium. A representative sample of 425 patients (≥70 years) in acute geriatric wards and nursing homes were assessed at baseline and followed up for 2 years. DSM-IV was used for classification. The prevalence of delirium at baseline was 24.9% (106/425). The prognosis of delirium was poor: mortality at 1 year was 34.9 vs. 21.6% in nondelirious subjects (p = 0.006), and at 2 years 58.5 vs. 42.6% (p = 0.005). Among home-dwelling people at baseline, 54.4% of the delirious vs. 27.9% of others were permanently institutionalized within 2 years (p < 0.001). In logistic regression analysis, delirium was an independent predictor for mortality at 1 year (OR 1.86, 95% CI 1.1–3.1), at 2 years (OR 1.76, 95% CI 1.1–2.8), and for permanent institutionalization (OR 2.45, 95% CI 1.2–4.9). Delirious patients with prior dementia tended to have a better prognosis than those without.
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                Author and article information

                Journal
                International Psychogeriatrics
                Int. Psychogeriatr.
                Cambridge University Press (CUP)
                1041-6102
                1741-203X
                August 2016
                April 15 2016
                August 2016
                : 28
                : 8
                : 1303-1311
                Article
                10.1017/S1041610216000600
                © 2016

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