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Phenomenology of Delirium Assessment of 100 Adult Cases

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Phenomenology of Delirium Assessment of 100 Adult Cases BRITISH JOURNAL OF PSYCHIATRY (2007), 190, 135^141. doi: 10.1192/bjp.bp.106.023911 AUTHOR’ S P ROOF Phenomenology of delirium in-patient service. Patients assessed on daily ward rounds by the palliative care team as Assessment of 100 adult cases using standardised measures having altered mental state were screened with the Confusion Assessment Method (CAM; Inouye et aletal, 1990) – a four-item DAVID J. MEAGHER, MARIA MORAN, BANGARU RAJU, DYMPNA GIBBONS, instrument based on DSM–III–R criteria. SINEAD DONNELLY, JEAN SAUNDERSand PAULA T.T.TRZEPACZ TRZEPACZ Patients were not included if they were near death or if circumstances were too difficult to allow assessment (in the opinion of the treating medical team), which resulted in a small number (less than 10%) being ex- cluded. During the study period there were Background Delirium phenomen- Although our understanding of the clinical 434 new admissions to the unit, of which ologyis understudied. epidemiology of delirium has advanced 100 (23%) are described here. considerably over the past decade, greater Delirium according to DSM–IV criteria Aims Toinvestigate the relationship phenomenological study should allow more (American Psychiatric Association, 1994) between cognitive and non-cognitive targeted studies of underlying mechanisms was confirmed by a research physician – and therapeutic response. Delirium involves (either the principal investigator (D.J.M.) delirium symptoms and testthe primacy a constellation of symptoms reflecting or one of three specialist registrars trained of inattention in delirium. widespread disruption of higher cortical to establish acceptable interrater reliability. functions that characteristically occur with Each case was then assessed by completion MethodMethod People with delirium (nn¼100) an acute onset and fluctuating course. of the DRS–R98 followed by the CTD. The were assessed using the Delirium Rating However, the interrelationship of delirium DRS–R98 rated the preceding 24 h period, Scale^Revised^98 (DRS^R98) and symptoms and their relevance to aetiology, whereas the CTD measured cognition at CognitiveTestfor Delirium (CTD). treatment experience and outcome are the time of its administration. Responses poorly understood. Moreover, there is a to the CTD were not used to rate DRS– ResultsResults Sleep^wake cycle dearth of research using validated instru- R98 items. Both the DRS–R98 and the abnormalities andandinattention inattention were most ments designed to assess the phenomenolo- CTD are well-validated instruments, highly gical breadth and complexity of this structured and anchored for rating and frequent, while disorientation was the disorder (Turkel et aletal, 2006).,2006). scoring.scoring. leastfrequentcognitiveleast frequent cognitive deficit.Patients Two validated tools open the way for with psychosis had either perceptual more detailed phenomenological study of ConsentConsent disturbances or delusions but not both. delirium. The Cognitive Test for Delirium The procedures and rationale for the study Neither delusions nor hallucinations were (CTD; Hart et aletal, 1996) measures five cognitive domains using standard neuro- were explained to all patients, but because associated with cognitive impairments. psychological methods. The Delirium of their delirium at entry into the study it Inattention was associated with severity of Rating Scale – Revised–98 (DRS–R98; was presumed that most were not capable other cognitive disturbances but not with TrzepaczTrzepacz et aletal, 2001,2001aa,,bb) covers a broad of giving informed written consent. Because of the non-invasive nature of the study, non-cognitive items.CTD comprehension range of delirium symptoms not measured by other delirium instruments, including ethics committee approval was given to correlated most closely with non- language, thought process abnormalities, augment patient assent with proxy consent cognitive features of delirium. visuospatial ability and both short- and from next of kin (where possible) or a re- long-term memory. We report a 2-year sponsible caregiver for all participants in Conclusions Delirium phenomen- study of the frequency and severity of accordance with the Helsinki guidelines ologyis consistent with broad dysfunction symptoms in 100 cases of delirium occuring for medical research involving human sub- of higher cortical centres, characterised in in a palliative care setting using the DRS– jects (World Medical Association, 2004). particular bybyinattention inattention and sleepsleep^wake ^ wake R98 and the CTD. We explored the inter- cycle disturbance. Attention and relationship among delirium symptoms Assessments and, by measuring cognition carefully in comprehension together are the cognitive Demographic data, psychotropic drug conjunction with the DRS–R98, tested the exposure and the possibility of underlying items that best accountforaccount for the syndrome primacy of inattention in delirium. dementia (suggested by history or investiga- of delirium. Psychosis in delirium differs tion) were collected. Nursing staff were from that in functional psychoses. interviewed to assist rating of symptoms METHOD over the previous 24 h. Declaration of interest P.T. is a nnP.T. Study design employeeofEliLilly.D.M.hasanemployee of Eli Lilly.D.M. has an We conducted a prospective cross-sectional Delirium Rating ScaleScale^Revised^98 ^ Revised ^98 unrestricted educationalgrantfrom Astra study of delirium symptoms and cognitive The original Delirium Rating Scale Zeneca Pharmaceuticals. performance in consecutive cases of DSM– (Trzepacz(Trzepacz et aletal, 1988) is widely used to IV delirium referred from a palliative care measure symptom severity in delirium, but 135 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 12:56:42, subject to the Cambridge Core terms of use. MEAGHER ET AL AUTHOR’SAUTHOR’ S PROOFP ROOF has the limitations of grouping cognitive (further information available from the of patients; other cognitive deficits were disturbances into a single item, not dis- authors upon request) with 12 categories: also common (76–89%), disorientation tinguishing motoric disturbances and not drug intoxication, drug withdrawal, meta- being the least frequent. Among the non- assessing thought process or language bolic/endocrine disturbance, traumatic brain cognitive items, sleep disturbance (97%) disorder. It has therefore been substantially injury, seizures, infection (intracranial), in- and motoric disturbance (62% each for revised to allow broad phenomenological fection (systemic), neoplasm (intracranial), hypoactive and hyperactive items, with 31 assessment and serial ratings. The DRS– neoplasm (systemic), cerebrovascular, organ patients having evidence of both) were R98 is a 16-item scale with 13 severity insufficiency, other central nervous system common, such that 94 patients had evi- items and 3 diagnostic items and it has high disorder and other systemic disorder. The dence of at least some degree of motoric interrater reliability, sensitivity and specifi- presence and suspected role of multiple disturbance (items 7 and 8 of DRS–R98). city for detecting delirium in mixed neuro- potential causes were documented for each Language and thought process abnormal- psychiatric and other hospital populations case of delirium, rated on a 5-point scale ities were each present in over half the (Trzepacz(Trzepacz etetalal,, 20012001aa). It was validated for degree of attribution to the delirium epi- group but were less common than cognitive both as a total scale (16 items) and a sever- sode, ranging from ‘ruled out/not present/ symptoms. Even when only more severe de- ity scale (13 items) for repeated measures. not relevant’ (0) to ‘definite cause’ (4). grees of impairment were considered, atten- Each item is rated 0 (absent/normal) to 3 tion and sleep–wake cycle deficits remained (severe impairment), with descriptions Statistical analyses the most common, each at 73%. anchoring each severity level. Severity scale Forty-nine patients had evidence of scores range from 0 to 39, with higher Statistical analysis was conducted using the psychosis, as defined by a score of 552o2onn scores indicating more severe delirium. Statistical Package for the Social Sciences item 2 (perceptual disturbances), item 3 Delirium typically involves scores above version 10.1. Demographic and rating scale (delusions) or item 6 (thought disturbance) 15 points (severity scale) or 18 points (total data were expressed as means plus standard on the DRS–R98. Eighteen of these patients scale). For determination of item frequen- deviation. Continuous variables were com- scored 3 on one of these three items, indi- cies in this study, any item scoring at least pared by one-way analysis of variance cating florid psychosis. The 49 patients 1 was considered present. (ANOVA). The severity of categorical with psychosis were not significantly differ- and/or quasi-continuous variables such as ent from the other 51 patients regarding the individual items of the DRS–R98 and Cognitive Test for Delirium motoric profile (DRS–R98 items 7 and 8) CTD was compared with chi-squared ana- and overall severity of cognitive disturb- The CTD (Hart etetalal, 1996) was specifically lyses. Pearson correlations were performed ance (measured by the CTD). They were designed to assess patients with delirium – between some individual items and be- youngeryounger((tt¼1.9,1.9, PP¼0.05) with higher total in particular those who are intubated or tween scale total scores. Level of signifi- DRS–R98 scores (tt¼773.8;3.8; PP550.001)0.001)andand
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