Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-22T05:33:36.576Z Has data issue: false hasContentIssue false
  • English
  • Français

A longitudinal study of delirium phenomenology indicates widespread neural dysfunction

Published online by Cambridge University Press:  04 November 2013

Maeve Leonard ,
Dimitrios Adamis ,
Jean Saunders ,
Paula Trzepacz  and
David Meagher
Maeve Leonard
Affiliation:
Department of Adult Psychiatry, University Hospital Limerick, Limerick, Ireland Milford Hospice Palliative Care Centre, Limerick, Ireland University of Limerick Medical School, Limerick, Ireland
Dimitrios Adamis*
Affiliation:
University of Limerick Medical School, Limerick, Ireland Research and Academic Institute of Athens, Athens, Greece Sligo Mental Health Services, Sligo, Ireland
Jean Saunders
Affiliation:
Statistical Consulting Unit, University of Limerick, Limerick, Ireland
Paula Trzepacz
Affiliation:
Tufts University School of Medicine, Medford, Massachusetts Indiana University School of Medicine, Indianapolis, Indiana Lilly Research Laboratories, Indianapolis, Indiana
David Meagher
Affiliation:
Department of Adult Psychiatry, University Hospital Limerick, Limerick, Ireland Milford Hospice Palliative Care Centre, Limerick, Ireland University of Limerick Medical School, Limerick, Ireland
*
Address correspondence and reprint requests to: Dimitrios Adamis, University of Limerick Medical School, Limerick, Ireland. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives:

Delirium affects all higher cortical functions supporting complex information processing consistent with widespread neural network impairment. We evaluated the relative prominence of delirium symptoms throughout episodes to assess whether impaired consciousness is selectively affecting certain brain functions at different timepoints.

Methods:

Twice-weekly assessments of 100 consecutive patients with DSM-IV delirium in a palliative care unit used the Delirium Rating Scale Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). A mixed-effects model was employed to estimate changes in severity of individual symptoms over time.

Results:

Mean age = 7 0.2 ± 10.5 years, 51% were male, and 27 had a comorbid dementia. A total of 323 assessments (range 2–9 per case) were conducted, but up to 6 are reported herein. Frequency and severity of individual DRS-R98 symptoms was very consistent over time even though the majority of patients (80%) experienced fluctuation in symptom severity over the course of hours or minutes. Over time, DRS-R98 items for attention (88–100%), sleep–wake cycle disturbance (90–100%), and any motor disturbance (87–100%), and CTD attention and vigilance were most frequently and consistently impaired. Mixed-effects regression modeling identified only very small magnitudes of change in individual symptoms over time, including the three core domains.

Significance of results:

Attention is disproportionately impaired during the entire episode of delirium, consistent with thalamic dysfunction underlying both an impaired state of consciousness and well-known EEG slowing. All individual symptoms and three core domains remain relatively stable despite small fluctuations in symptom severity for a given day, which supports a consistent state of impaired higher cortical functions throughout an episode of delirium.

Keywords

DeliriumPhenomenologyLongitudinal assessmentCourseCore domains
Type
Original Articles
Information
Palliative & Supportive Care , Volume 13 , Issue 2 , April 2015 , pp. 187 - 196
Copyright
Copyright © Cambridge University Press 2013 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

Adamis, D. (2009). Statistical methods for analysing longitudinal data in delirium studies. International Review of Psychiatry, 21(1), 74–85.CrossRefGoogle ScholarPubMed
American Psychiatric Association (APA) (1987). Diagnostic and statistics manual of mental disorders (DSM-III-R), 3rd rev. ed.Washington, DC: American Psychiatric Association.Google Scholar
American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders (DSM-IV), 4th ed.Washington, DC: American Psychiatric Association.Google Scholar
Barnes, J., Kite, S. & Kumar, M. (2010). The recognition and documentation of delirium in hospital palliative care inpatients. Palliative & Supportive Care, 8(2), 133–136.CrossRefGoogle ScholarPubMed
Boettger, S., Passik, S. & Breitbart, W. (2009). Delirium superimposed on dementia versus delirium in the absence of dementia: Phenomenological differences. Palliative & Supportive Care, 7(4), 495–500.CrossRefGoogle ScholarPubMed
Boettger, S., Passik, S. & Breitbart, W. (2011). Treatment characteristics of delirium superimposed on dementia. International Psychogeriatrics, 23(10):1671–1676.CrossRefGoogle ScholarPubMed
Breitbart, W. & Alici, Y. (2008). Agitation and delirium at the end of life: “We couldn't manage him.” The Journal of the American Medical Association, 300(24), 2898–910.Google Scholar
Breitbart, W. & Alici, Y. (2012). Evidence-based treatment of delirium in patients with cancer. Journal of Clinical Oncology, 30(11), 1206–1214.CrossRefGoogle ScholarPubMed
Breitbart, W., Rosenfeld, B., Roth, A., et al. (1997). The Memorial Delirium Assessment Scale. Journal of Pain and Symptom Management, 13(3), 128–137.CrossRefGoogle ScholarPubMed
de Jonghe, J.F., Kalisvaart, K.J., Dijkstra, M., et al. (2007). Early symptoms in the prodromal phase of delirium: A prospective cohort study in elderly patients undergoing hip surgery. The American Journal of Geriatric Psychiatry, 15(2), 112–121.CrossRefGoogle ScholarPubMed
Ely, E.W., Shintani, A., Truman, B., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. The Journal of the American Medical Association, 291(14), 1753–1762.CrossRefGoogle ScholarPubMed
Fann, J.R., Alfano, C.M., Burington, B.E., et al. (2005). Clinical presentation of delirium in patients undergoing hematopoietic stem cell transplantation. Cancer, 103(4), 810–820.CrossRefGoogle ScholarPubMed
Franco, J.G., Trzepacz, P.T., Mejia, M.A., et al. (2009). Factor analysis of the Colombian translation of the Delirium Rating Scale (DRS), Revised–98. Psychosomatics, 50(3), 255–262.CrossRefGoogle ScholarPubMed
Franco, J.G., Valencia, C., Bernal, C., et al. (2010). Relationship between cognitive status at admission and incident delirium in older medical inpatients. The Journal of Neuropsychiatry and Clinical Neurosciences, 22(3), 329–337.CrossRefGoogle ScholarPubMed
Franco, J.G., Trzepacz, P.T., Meagher, D.J., et al. (2013). Three core domains of delirium validated using exploratory and confirmatory factor analyses. Psychosomatics, 54, 227–238.CrossRefGoogle ScholarPubMed
Gaudreau, J.D., Gagnon, P., Harel, F., et al. (2005). Psychoactive medications and risk of delirium in hospitalized cancer patients. Journal of Clinical Oncology, 23(27), 6712–6718.CrossRefGoogle ScholarPubMed
Greicius, M.D., Supekar, K., Menon, V., et al. (2009). Resting-state functional connectivity reflects structural connectivity in the default mode network. Cerebral Cortex, 19(1), 72–78.CrossRefGoogle ScholarPubMed
Hart, R.P., Levenson, J.L., Sessler, C.N., et al. (1996). Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics, 37(6), 533–546.CrossRefGoogle ScholarPubMed
Hedeker, D.R. & Gibbons, R.D. (2006). Longitudinal data analysis. Hoboken, NJ: Wiley-Interscience.Google Scholar
Inouye, S.K., van Dyck, C.H., Alessi, C.A., et al. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941–948.CrossRefGoogle Scholar
Irwin, S.A., Rao, S., Bower, K.A., et al. (2008). Psychiatric issues in palliative care: Recognition of delirium in patients enrolled in hospice care. Palliative & Supportive Care, 6(2), 159–164.CrossRefGoogle ScholarPubMed
Jabbar, F., Leonard, M., Meehan, K., et al. (2011). Neuropsychiatric and cognitive profile of patients with DSM-IV delirium referred to an old age psychiatry consultation–liaison service. International Psychogeriatrics, 23(7), 1167–1174.CrossRefGoogle Scholar
Jorm, A.F. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation. Psychological Medicine, 24(1), 145–153.CrossRefGoogle Scholar
Katz, I.R., Curyto, K.J., TenHave, T., et al. (2001). Validating the diagnosis of delirium and evaluating its association with deterioration over a one-year period. The American Journal of Geriatric Psychiatry, 9(2), 148–159.CrossRefGoogle ScholarPubMed
Katzman, R., Brown, T., Fuld, P., et al. (1983). Validation of a short orientation-memory-concentration test of cognitive impairment. The American Journal of Psychiatry, 140(6), 734–739.Google Scholar
Kean, J., Trzepacz, P.T., Murray, L.L., et al. (2010). Initial validation of a brief provisional diagnostic scale for delirium. Brain Injury, 24(10), 1222–1230.CrossRefGoogle ScholarPubMed
Kiely, D.K., Marcantonio, E.R., Inouye, S.K., et al. (2009). Persistent delirium predicts greater mortality. Journal of the American Geriatrics Society, 57(1), 55–61.CrossRefGoogle ScholarPubMed
MacLullich, A.M., Beaglehole, A., Hall, R.J., et al. (2009). Delirium and long-term cognitive impairment. International Review of Psychiatry, 21(1), 30–42.CrossRefGoogle ScholarPubMed
Matsushima, E., Nakajima, K., Moriya, H., et al. (1997). A psychophysiological study of the development of delirium in coronary care units. Biological Psychiatry, 41(12), 1211–1217.CrossRefGoogle ScholarPubMed
Mattoo, S.K., Grover, S., Chakravarty, K., et al. (2012). Symptom profile and etiology of delirium in a referral population in northern India: Factor analysis of the DRS-R98. The Journal of Neuropsychiatry and Clinical Neurosciences, 24(1), 95–101.CrossRefGoogle Scholar
McCusker, J., Cole, M., Bellavance, F., et al. (1998). Reliability and validity of a new measure of severity of delirium. International Psychogeriatrics, 10(4), 421–433.CrossRefGoogle ScholarPubMed
Meagher, D.J. & Trzepacz, P.T. (2009). Delirium. In Oxford textbook of psychiatry, 2nd ed.Geddes, J.J. et al. (eds.), pp. 325–332. Oxford: Oxford University Press.Google Scholar
Meagher, D.J., Moran, M., Raju, B., et al. (2007). Phenomenology of delirium: Assessment of 100 adult cases using standardised measures. British Journal of Psychiatry, 190, 135–141.CrossRefGoogle ScholarPubMed
Rudberg, M.A., Pompei, P., Foreman, M.D., et al. (1997). The natural history of delirium in older hospitalized patients: A syndrome of heterogeneity. Age and Ageing, 26(3), 169–174.CrossRefGoogle ScholarPubMed
Schiff, N.D. & Plum, F. (2000). The role of arousal and “gating” systems in the neurology of impaired consciousness. Journal of Clinical Neurophysiology, 17(5), 438–452.CrossRefGoogle ScholarPubMed
Sherer, M., Yablon, S.A. & Nakase-Richardson, R. (2009). Patterns of recovery of posttraumatic confusional state in neurorehabilitation admissions after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 90(10), 1749–1754.CrossRefGoogle ScholarPubMed
Siddiqi, N., House, A.O. & Holmes, J.D. (2006). Occurrence and outcome of delirium in medical inpatients: A systematic literature review. Age and Ageing, 35(4), 350–364.CrossRefGoogle ScholarPubMed
Smith, H.A., Fuchs, D.C., Pandharipande, P.P., et al. (2009). Delirium: An emerging frontier in the management of critically ill children. Critical Care Clinics, 25(3), 593–614.CrossRefGoogle ScholarPubMed
Sylvestre, M.P., McCusker, J., Cole, M., et al. (2006). Classification of patterns of delirium severity scores over time in an elderly population. International Psychogeriatrics, 18(4), 667–680.CrossRefGoogle Scholar
Trzepacz, P.T. (1994). The neuropathogenesis of delirium. A need to focus our research. Psychosomatics, 35(4), 374–391.CrossRefGoogle ScholarPubMed
Trzepacz, P.T. (1999). Update on the neuropathogenesis of delirium. Dementia and Geriatric Cognitive Disorders, 10(5), 330–334.CrossRefGoogle ScholarPubMed
Trzepacz, P.T. & Meagher, D. (2008). Neuropsychiatric aspects of delirium. In Textbook of neuropsychiatry and behavioural neurosciences, 5th ed.Yudofsky, S. & Hales, R. (eds.), pp. 445–417. Washington, DC: American Psychiatric Publishing.Google Scholar
Trzepacz, P.T., Baker, R.W. & Greenhouse, J. (1988). A symptom rating scale for delirium. Psychiatry Research, 23(1), 89–97.CrossRefGoogle ScholarPubMed
Trzepacz, P.T., Mulsant, B.H., Dew, M.A., et al. (1998). Is delirium different when it occurs in dementia? A study using the delirium rating scale. The Journal of Neuropsychiatry and Clinical Neurosciences, 10(2), 199–204.CrossRefGoogle ScholarPubMed
Trzepacz, P.T., Mittal, D., Torres, R., et al. (2001). Validation of the Delirium Rating Scale–revised-98: Comparison with the Delirium Rating Scale and the Cognitive Test for Delirium. The Journal of Neuropsychiatry and Clinical Neurosciences, 13(2), 229–242.CrossRefGoogle ScholarPubMed
World Medical Association (2004). Declaration of Helsinki: Ethical principles for medical research involving human subjects. http://www.wma.net/e/policy/pdf/17c.pdf.Google Scholar