BRITISH JOURNAL OF (2007), 190, 135^141. doi: 10.1192/bjp.bp.106.023911

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Phenomenology of 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 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 had either perceptual more detailed phenomenological study of ConsentConsent disturbances or but not both. delirium. The Cognitive Test for Delirium The procedures and rationale for the study Neither delusions nor 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 . 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. 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. (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

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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 et aletal, 2001,2001aa). 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 552on2on 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 et aletal, 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- younger (younger(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) and0.001)and unable to speak or write. It assesses 5 cance was determined with a cut-off of more severe affective lability (ww22¼16.1,16.1, neuropsychological domains (orientation, 0.05, except where multiple comparisons d.f.d.f.¼2,2, PP550.001).0.001). attention, memory, comprehension and were made when a Bonferroni correction Patients with psychosis tended to have vigilance), emphasising non-verbal (visual ((PP550.001) was applied. disturbance of a single psychotic compo- and auditory) modalities. Each individual nent, with only 6 of these 49 patients domain is scored 0–6 in 2-point increments, scoringscoring 552 on more than one item. For except for comprehension which is scored RESULTSRESULTS the whole cohort, DRS–R98 items 2 (per- in single-point increments. Total scores ceptual disturbance) and 3 (delusions) were range between 0 and 30, with higher scores Half of the 100 patients in the study were not significantly correlated (rr¼0.16); item 6 indicating better cognitive function. This men, and the mean age of the group was (thought disturbance) was not significantly measure reliably differentiates delirium 70.1 years (s.d.¼11.5). A mean of 3.5 correlated with item 2 (rr¼0.15) or item 3 from other neuropsychiatric conditions (s.d.(s.d.¼1.3) aetiological categories were ((rr¼0.01). Moreover, when the analysis including dementia, and noted per case, with neoplasm (67%), sys- was restricted to patients with psychosis depression (Hart et aletal, 1997).,1997). temic infection (63%), metabolic–endo- ((nn¼49), thought disturbance and percep- Performance on individual neuropsy- crine disorder (45%), organ failure (32%), tual disturbances were inversely correlated chological sub-tests (e.g. attention) can be drug intoxication (27%) and central ner- ((rr770.49,0.49, PP¼0.001) and both delusions scored on a 4-point scale (6 normal, 4 mild vous system lesions (26%) being the most ((rr¼0.59,0.59, PP¼0.001) and thought disturb- inattention, 2 moderate inattention, 0 common contributing causes. Patients had ance (ance(rr¼0.35,0.35, PP¼0.01) correlated positively severe inattention). Item severities were a mean DRS–R98 total score of 21.1 with affective lability, whereas perceptual used to compare the relationship between (s.d.(s.d.¼5.5) and severity score of 16.6 disturbance was negatively correlated with individual items of the DRS–R98 to assess (s.d.(s.d.¼5.5), and a mean CTD score of 14.5 affective lability (rr¼770.41,0.41, PP¼0.003).0.003). the relationship between cognitive and (s.d.(s.d.¼8.1). The characteristics of patients Although neither delusions nor percep- non-cognitive elements of delirium. with delirium only are compared with those tual disturbances correlated significantly of patients with comorbid dementia in with any of the cognitive items of DRS– AetiologyAetiology Table 1.Table1. R98 or CTD, thought process disturbance Attribution of aetiology based on all avail- Table 2 summarises the cognitive and correlated with impairments of attention able clinical information was made by the non-cognitive disturbances assessed with ((rr¼770.46,0.46, PP¼0.001), memory (rr770.40,0.40, palliative care physician according to a the DRS–R98. Inattention (diagnostic cri- PP550.01), orientation (rr¼770.30,0.30, PP¼0.03)0.03) standardised delirium aetiology checklist terion A of DSM–IV) was present in 97% and comprehension (rr¼770.28,0.28, PP¼0.05)0.05)

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Ta b l e 11Tab Characteristics of patients with delirium v. patients with comorbid delirium and dementia significance levels were corrected for multi- ple comparisons, the degree of inattention Delirium only Delirium and dementia was associated with the level of impairment of other cognitive disturbances (rated on ((nn¼83)83) ((nn¼17) both CTD and DRS–R98) but not the Mean (s.d.) Mean (s.d.) non-cognitive DRS–R98 items, except for 22 Age, years** 68.7 (11.6) 77.2 (7.8)(7.8)77.2 language (language(ww ¼19.5, d.f.19.5,d.f.¼6,6, PP¼0.001).0.001). Aetiology: number of categories** 3.3 (1.2) 4.5 (1.3) We further examined whether impair- ment on the other CTD items related to CTD score* 15.3 (8.1) 10.4 (7.1) scores on DRS–R98 items as strongly as DRS^R98 severity score* 15.6 (5.6) 18.2 (4.4) did CTD attention, to ascertain whether at- CTD,CognitiveTestforCTD,CognitiveTest for Delirium; DRS^R98, Dementia Rating Scale^Revised^98. tention had a unique role. After corrections **PP550.05; **PP550.01.0.01. for multiple comparisons, the severity of Ta b l e 22Tab Frequency of delirium symptoms rated with the Dementia Rating Score^Revised^98 and recorded if vigilance impairment was closely related present at different levels of severity (nn¼100)100) to all other aspects of cognition but not to non-cognitive items (except for language) and thus mirrored the findings with the DRS^R98 item Present at any severity Moderate or severe severity CTD attention item. Orientation, memory %% %% and comprehension were less strongly asso- ciated with DRS–R98 cognitive items Neuropsychiatric and behavioural (Table 5). In contrast to attention, severity Sleep^wake cycle disturbance 97 73 of comprehension disturbance was asso- Perceptual disturbances and hallucinations50 2626 ciated with the most non-cognitive DRS– Delusions 31 9 R98 symptoms, including sleep–wake cycle Lability of affect 53 1818 disturbance, psychomotor retardation and Language 57 25 language difficulties. These patterns suggest Thought process abnormalities 54 22 two different domains of delirium symptoms. Motor agitation 62 27 Seventeen patients had documented Motor retardation 62 37 evidence of pre-existing cognitive deficits, Cognitive suggesting their delirium co-occurred with OrientationOrientation 76 42 chronic cognitive impairment. These patients were significantly older, had a Attention 97 73 greater aetiological burden of underlying Short-term memory 88 53 diseases, and had more severe disturbances Long-term memory 89 6464 on the DRS–R98 and CTD than patients Visuospatial ability 87 64 with delirium only (see Table 1). This dif- DRS^R98, Delirium Rating Scale^Revised^98. ference in severity of DRS–R98 scores was accounted for by greater disturbance on the five DRS–R98 cognitive items (tt¼772.8,2.8, items on the CTD, and with attention assessed in the CTD. Corresponding items PP550.01) rather than the eight DRS–R98 ((rr¼0.59,0.59, PP550.001), orientation (rr¼0.33,0.33, on the CTD and the DRS–R98 correlated neuropsychiatric and behavioural items. PP¼0.03) and long-term memory (rr¼0.34,0.34, highly: DRS–R98 orientation and CTD Out of concern that the inclusion of PP¼0.03) items – but not short-term mem- orientation (rr¼770.75), DRS–R98 attention patients (patients(nn¼17) with comorbid pre-existing ory or visuospatial function items – on the and CTD attention (rr¼770.73), DRS–R98 cognitive impairment might have influ- DRS–R98.DRS–R98. attention and CTD vigilance (rr¼770.60),0.60), enced findings, analyses were repeated for Cognitive dysfunction rated with the and CTD memory with DRS–R98 short- the study population with delirium only CTD is shown in Table 3. This shows wide- term memory (rr¼770.47) and long-term ((nn¼83). The findings regarding DRS–R98 spread impairment of neuropsychological memory (memory(rr¼770.61). Interestingly, CTD item frequencies, patterns of psychosis and function, with the most frequent (94%) comprehension correlated with the DRS– interrelationship of cognitive items on and severest impairments in attention and R98 item for language (rr¼770.42,0.42, CTD and DRS–R98 phenomenology were vigilance. This parallels the DRS–R98 im- PP¼0.001) but not with thought process ab- essentially unaltered. pairments, of which attention was most normalities (rr770.09).0.09). often impaired and orientation least im- In view of the central role given to dis- paired, even though these scales were rated turbed attention in current delirium de- DISCUSSION independently of one another and for scriptions, patients were divided into three different time frames– DRS–R98 for the categories according to the severity of This work investigates a more comprehen- previous 24 h and CTD for current per- attentional deficit measured using the sive range and specificity of symptoms than formance. The DRS–R98 attention item CTD: score 4–6, (nn¼32), score 2 (nn¼34)34) previous studies of delirium. We assessed includes distractibility and therefore en- and score 0 (nn¼34). These groups differed 100 consecutive cases of DSM–IV delirium compasses both attention and vigilance as for many items (Table 4); however, when using valid, sensitive and standardised

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Ta b l e 3 Frequency of different severity levels of cognitive dysfunction and mean item scores assessed with instruments designed for detailed phenom- the CognitiveTest for Delirium (nn¼100)100) enological and neuropsychological evalua- tion of delirium. We confirmed that delirium is a complex neuropsychiatric syn- Frequency, % drome that includes a combination of cog- CTD item Score 5^6Score 3^4Score 1^2Score 0CTD score11 nitive, behavioural and psychopathological Mean (s.d.) features. We assessed the frequency and severity of less studied symptoms includ- OrientationOrientation 2721 30 2222 3.1 (2.2)(2.2)3.1 ing visuospatial impairment, disorganised Attention 6266 2634 34 2.1 (1.8)(1.8)2.1 thinking, language impairment and differ- Memory 1634 19 31 2.7 (2.2)(2.2)2.7 ent components of attention, memory, and Comprehension 3517 39 9 4.4 (1.8) motoric presentations, as well as more detailed evaluation of characteristics of Vigilance 1427 262633 2.4 (2.1) sleep–wake cycle abnormality, perceptual CTD, CognitiveTest for Delirium. disturbances and thought process abnorm- 1. Range 0^6; lower scores indicate poorer performance. ality. Previous phenomenological work has generally classed symptoms as present or ab- sent without proportioning severity. This can result in more minor disturbances (e.g. of Ta b l e 4 Item scores for the two delirium scales according to degree of inattention on the CognitiveTestfor sleep) that are common in all hospitalised DeliriumDelirium patients being rated as equivalent to more significant major disturbances (e.g. sleep– wake cycle reversal) that occur in delirium. ItemItem Item score: mean (s.d.)11 PP22 Our findings support the concept of CTD CTDCTD CTDCTD delirium as primarily a disorder of cogni- attentionattention attentionattention attentionattention tion with prominent disturbance of atten- score4or6score 4 or 6 score 22score score 00score tion consistent with DSM–IV, but also ((nn¼32) ((nn¼34)34) ((nn¼34)34) highlight the frequency of non-cognitive disturbances. Notably, the frequency of DRS^R98 sleep and motoric disturbances were higher 1 Sleep-wake cycle disturbance 1.5(0.6)1.5 (0.6) 1.6(0.7)1.6(0.7)2.1 2.1(0.5) (0.5) 550.010.01 than previously described using the original Delirium Rating Scale (Meagher & 2 Perceptual disturbances and hallucinations1.0 (1.0)0.6 (0.9)1.0 (1.1)NS Trzepacz, 1998). This may be related to 3 Delusions3Delusions 0.4 (0.9)0.5 (0.8)0.4 (0.6) NSNS sampling bias in the current study in the 4 Lability of affect 0.6 (0.7)0.7 (0.8)0.8 (0.8)NS hospice setting or to methodological differ- 33 55Language Language 0.4 (0.6)0.9(0.8) 0.9 (0.8) 1.3 1.3(1.0) (1.0) 550.001 ences between the original scale and its re- 6 Thought process abnormalities 0.4 (0.6)0.9 (0.8)1.0 (1.0) 550.01 vised version, or both. 7 Motor agitation 0.7 (0.8)0.9(0.8) 0.9 (0.8) 1.0 1.0(0.9) (0.9)NS Delirium symptoms can be divided into 8 Motor retardation 0.9(0.8)0.9 (0.8) 0.9(0.9)0.9(0.9)1.4 1.4(1.1) (1.1)0.01 0.01 ‘core’ features that are almost invariably 99Orientation Orientation 0.7 (0.7)1.2 (0.9)1.9 (0.7) 550.00133 present (disturbances of attention, memory, 10 Attention 1.2 (0.6)2.0 (0.5) 2.6 (0.5)(0.5)2.6 550.00133 orientation, language, thought processes 11 Short-term memory 1.3 (1.0)1.5 (0.7)2.1 (1.0)0.0011 0.00 33 and sleep–wake cycle) and ‘associated’ fea- 12 Long-term memory 1.4 (1.0)(1.0)1.4 1.9 (0.9)2.4 (0.9)0.0011 0.00 33 tures that are more variable in presentation (e.g. psychotic symptoms, affective distur- 13 Visuospatial ability 1.2 (1.0)1.7 (0.8) 2.3 (0.7)(0.7)2.3 550.00133 bances, different motoric profiles) (Ameri- can Psychiatric Association, 1999; Severity score 12.0 (4.2) 15.5 (4.3)(4.3)15.5 20.4 (4.5) 550.00133 Trzepacz, 1999). Disturbance of attention Severity score minus attention item 10.8 (3.9) 13.5 (4.2)(4.2)13.5 17.8 (4.3) 550.00133 is a cardinal symptom of delirium and in our analysis associated strongly with all CTD other cognitive deficits and language, but Orientation 4.6 (1.6) 2.9 (2.2)(2.2)2.9 1.7 (1.8) 550.00133 not with most of the non-cognitive features. Comprehension 5.5 (0.8)(0.8)5.5 4.7 (1.2)(1.2)4.7 3.1 (2.1) 550.00133 Some neurologists have viewed delirium as Memory 4.5 (1.5)2.5 (1.9)1.1 (1.7) 550.00133 a disorder of attention. However, the fre- Vigilance 4.0 (1.8) 2.7 (1.6)(1.6)2.7 0.6 (1.4) 550.00133 quency of non-cognitive symptoms and their lack of association with the severity Total minus attention item 18.1 (4.5)12.6 (4.5)6.6 (5.4) 550.00133 of objectively measured attentional impair- ment strongly support the view of delirium CTD,CTD,CognitiveTestfor CognitiveTest for Delirium; DRSDRS^R98, ^R98, Delirium Rating ScaleScale^Revised^98. ^Revised ^98. being a broader neuropsychiatric disorder. 1. Lower scores are worse on CTD; higher scores are worse on DRS^R98. 2.2. ww22-test for item comparisons and one-way analysis of variance for total scale scores. Unfortunately, DSM–IV criteria do not 3. Values after Bonferroni correction. adequately reflect the importance of these

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Ta b l e 55Tab Significance values for relationship between DRS^R98 items and severity levels for individual CTD DRS–R98 items than the other CTD items items (other than attention) and may denote a different domain of delir- ium symptoms than does attention. The combination of disturbed attention and DRS^R98 item CTD item comprehension may best represent the OrientationOrientation Memory Comprehension Vigilance underlying disturbances central to overall PP 11 PP PP PP delirium phenomenology. Visuospatial abnormalities are not 1 Sleep^wake cycle disturbance 0.04 0.020.02 550.00122 0.02 usually measured in delirium assessments 2 Perceptual disturbances and hallucinationsNS NS NSNS NSNS even though they may underlie problems 3 Delusions NSNS 0.02 NS of wandering and poor environmental in- 4 Lability of affect 0.020.05 NS NSNS teractions. Mean visuospatial ability scores were almost as impaired as attention, and 5Language5 Language 0.05 550.00122 550.00122 550.00122 CTD attention is measured in a visuospatial 6 Thought process abnormalities NSNS 0.05 0.030.03 modality. This overlap may reflect the 7 Motor agitation NSNS NSNS NSNS shared role of the non-dominant posterior 22 22 8 Motor retardation NSNS0.003 550.001 0.02 parietal cortex in both attention and visuo- 22 22 22 22 9Orientation 550.001 550.001 550.001 550.001 spatial functions (Trzepacz, 1999). 10 Attention 550.00122 550.00122 550.00122 550.00122 Despite an enduring emphasis on the 11 Short-term memory 550.010.01 550.010.01 550.050.05 550.00122 characteristic fluctuating nature of delir- 12 Long-term memory 550.00122 550.00122 NS 550.00122 ium, this has not been directly studied. 13 Visuospatial ability 550.050.05 550.010.01 550.00122 550.00122 Ratings of equivalent cognitive items on the DRS–R98 and CTD were highly corre- 55 22 55 55 Severity score 0.001 0.010.01 0.010.01NSNS lated (inversely as expected), despite one CTD,CognitiveTestforCTD,CognitiveTest for Delirium; DRS^R98, Delirium Rating Scale^Revised^98. being a symptom rating scale evaluating a 1. Values ofof1.Values PP refer to ww22 test for item comparisons and one way analysis of variance for total scores. 24 h period and the other a cognitive test 2. Values after Bonferroni correction. measuring current status. This suggests that certain delirium symptoms– cognition and language – are not as fluctuant as pre- other symptoms, for example, sleep–wake al, 1975), which are heavily weighted to- viously described, although this requires cycle disturbance, altered motoric behav- wards orientation, to detect or monitor delir- further scrutiny with serial measurement iours, and thought content and process ab- ium is therefore not supported by these over relatively short periods. normalities. Sleep–wake cycle disturbance findings. may underlie the fluctuating nature of delir- The cognitive impairment of delirium ium severity over a 24 h period (Balan et aletal,, may represent a single construct or a con- Psychotic symptoms 2003).2003). stellation of elements with differing under- The significance of psychotic symptoms in pinnings. Poor performance on CTD delirium remains unclear. It is not known attention and vigilance items was signifi- whether patients develop these features Pattern of cognitive disruption in cantly related to the degree of disturbance due to specific physiological causes, cogni- deliriumdelirium on all other cognitive items on both the tive impairment with misunderstanding of This study confirms delirium as a disorder CTD and DRS–R98, but much less so for the external environment, misperceptions, of global cognition characterised by a non-cognitive items. Because intact atten- as part of mood disturbances, or through prominent disturbance of attention and tion is required to recall new information, some other aspect of individual patient vul- vigilance. Disorientation was the least it is unclear whether the short-term mem- nerability (Francis, 1992). We found that frequent cognitive symptom, even though ory deficits measured on the DRS–R98 thought process abnormalities – but not many non-psychiatric physicians rely on (tested in verbal modality) and the visual delusions or perceptual disturbances – cor- bedside tests of orientation to time, place memory deficits measured on the CTD are related with overall cognitive impairment. and person as their principal mental status truly primary memory dysfunctions or sec- Both delusions and thought disorder corre- evaluation. Almost a quarter of our delir- ondary to attentional deficits. The DRS– lated with affective lability, although ious patients had no evidence of disorienta- R98 long-term memory impairments may perceptual disturbance was inversely tion on the DRS–R98 and only 52% had be more related to retrieval problems and correlated to both thought disorder and af- evidence of greater than mild disturbance perhaps less affected by inattention than fective lability. Previous work comparing of orientation on the CTD. The use of dis- short-term memory for new material. the psychosis of delirium with that of orientation as a key indicator of delirium Performance on CTD orientation, schizophrenia found that in delirium is thus fraught with the likelihood of missed memory and comprehension items was sig- thought content disturbances tended to in- cases, and the use of other, more consistent nificantly related to fewer cognitive items volve themes from the immediate environ- symptoms (such as inattention) would be a compared with CTD attention. The CTD ment and circumstances, hallucinations more reliable way of screening for suspected comprehension item (comprising a combi- were frequently visual rather than auditory, delirium. The use of instruments such as the nation of language and executive function) and formal thought disorder typically com- Mini-Mental State Examination (Folstein et was associated with more non-cognitive prised poverty of thinking and illogicality

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(Cutting, 1987). We found little relation- sleep–wake cycle (Fann et aletal, 2005), and and the influence of clinical variables. International Journal ship among the three elements of psychosis that orientation difficulties, inattention, of Geriatric Psychiatry,, 20,531^536., 531^536. in delirium, as suggested by previous work poor memory, emotional lability and sleep American Psychiatric Association (1994) Diagnostic (Trzepacz & Dew, 1995). This contrasts disturbances are more persistent symptoms and Statistical Manual of Mental Disorders (4th edn)edn)(4th (DSM^IV).Washington, DC: APA. with functional psychotic illness, in which (Levkoff(Levkoff et aletal, 1994; McCusker et aletal,, closer relationships have been identified 2003).2003). American Psychiatric Association (1999) Practice Guidelines for thetheTreatment Treatment of Patients with Delirium.. (O’Leary(O’Leary et aletal, 2000; Meagher et aletal,, Second, the inclusion of patients with Washington, DC: American Psychiatric Publishing. 2004). The psychosis of delirium also dif- dementia might affect the clinical profile Balan, S., Leibowitz, A., Zila, S. O., et aletal (2003)(2003) TheThe fers from dementia, in which psychotic but there was little discernible effect when relation between the clinical subtypes of delirium and symptoms are less common despite the our study analyses were repeated for the the urinary level of 66-SMT. -SMT. Journal of Neuropsychiatry shared generalised nature of brain impair- pure-delirium study population. It appears and Clinical Neurosciences,, 1515, 363^366.,363^366. ment, and psychosis is associated with that delirium phenomenology is altered Centeno, C., Sanz, A. & Bruera, E. (2004) DeliriumDelirium degree and rate of decline in cognition little by the presence of dementia (Trzepacz in advanced cancer patients. Palliative Medicine,, 1818,, 184^194. (Levy(Levy et aletal, 1996; Aalten et aletal, 2005). These et aletal, 1998), such that delirium symptoms Cole, M. G., Dendukuri, N., McCusker, J., et aletal (2003)(2003) differences may have important implica- tend to overshadow dementia when they An empirical study of different diagnostic criteria for tions for delirium neuropathophysiology. co-exist although these symptoms do occur delirium among elderly medical inpatients. Journal ofofJournal Psychotic symptoms are considered par- in the context of greater overall cognitive Neuropsychiatry and Clinical Neurosciences,, 1515, 200^207.,200^207. ticularly common in hyperactive delirium, impairment. Equally, it should be recog- Cutting, J. (1987) The phenomenology of acute organic such as delirium tremens, but also occur nised that in order to be truly representative psychosis. Comparison with acute schizophrenia. BritishBritish in hypoactive presentations. We did not of delirium, studies need to include patients Journal of Psychiatry,, 151,,324^332. 324^332. find a relationship between psychosis and who also have dementia, in recognition of Fann, J. R., Alfano, C. M., Burington, B., et aletal (2005)(2005) Clinical presentation of delirium in patients undergoing motoric items, highlighting the fact that pa- the substantial comorbidity between the hamatopoietic stem cell transplantation. Cancer,, 103103,, tients with quieter presentations also ex- two conditions. 810^820.

perience disturbing psychotic symptoms. This study describes delirium phenom- Folstein, M. F., Folstein, S. E. & McHugh, P.R. (1975) enology in a palliative care population, ‘Mini-Mental State’: a practical method for grading the Advancing the concept of delirium which may restrict its generalisability to cognitive state of patients for the clinician. Journal of Psychiatric Research,, 12,189^198.,189^198. other groups with this condition. Delirium The concept of delirium has evolved con- is considered a unitary syndrome with a Francis, J. (1992) Delusions, delirium, and cognitive siderably over the past 25 years. This is impairment: the challenge of clinical heterogeneity. stereotyped constellation of symptoms reflected in recent studies comparing diag- Journal of the American Geriatric Society,, 40,,848^849. 848^849. thought to reflect disturbance of a final nostic frequency when DSM–III, DSM– Hart, R. P., Levenson, J. L., Sessler,C. N., et aletal (19 9 6)6)(19 common neural pathway (Trzepacz, III–R, DSM–IV and ICD–10 criteria are ap- Validation of a cognitive test for delirium in medical ICU 1999). Moreover, the term has subsumed patients.patients. Psychosomatics,, 3737,533^546. plied to single populations (Laurila et aletal,, the many synonyms that have been used 2003; Cole2003;Cole et aletal, 2003). Future descriptions Hart,Hart,R.P.,Best,A.M.,Sessler,C.N., R. P., Best, A. M., Sessler,C. N., et aletal (19 9 7)7)(19 to denote acute generalised cognitive distur- Abbreviated CognitiveTestCognitive Test for delirium. Journal of will allow further refinement of the syn- bances in various settings but were not Psychosomatic Research,, 43,417^423., 417^423. drome in keeping with emerging evidence based on scientific evidence. Nonetheless, Inouye, S. K., van Dyck, C. H., Alessi, C. A., et al and need to account for key phenomenolo- clinical profile may be influenced by factors (19 9 0) Clarifying confusion: the confusion assessment gical issues, including the following: method, a new method for the detection of delirium. that characterise different aetiological or Annals of Internal Medicine,, 113,941^948., 941^948. (a)(a)deliriumdelirium detection and diagnosis are treatment settings, but single studies have confounded by inadequate appreciation Laurila, J.V., Pitkala, K. H., Strandberg, et aletal (2003).(2003). not compared symptom profiles across The impact of different diagnostic criteria on prevalence of variations in presentation and patient groups. Delirium occurring in can- rates for delirium. Dementia and Geriatric Cognitive breadth of symptoms; cer patients tends to be particularly multi- DisordersDisorders,, 1616,156^162.,156^162. (b)(b)corecore features used to define delirium factorial in causation, with hypoactive Levkoff, S. E., Liptzin, B., Evans, D., et aletal (19 94) should be readily detectable and occur motoric presentations especially common Progression and resolution of delirium in elderly patients hospitalised for acute care. American Journal of Geriatric with consistency; over-reliance on less (Morita(Morita et aletal, 2001; Centeno et aletal, 2004;,2004; PsychiatryPsychiatry,, 22, 230^238.,230^238. common symptoms contributes to Spiller & Keen, 2006). Our sample in- Levy, M. L., Cummings, J. L., Fairbanks, L. A., et aletal non-detection, which in turn hampers cluded patients with a broad range of rele- (19 9 6) Longitudinal assessment of symptoms of clinical and research efforts; vant aetiologies and medications, many depression, agitation, and psychosis in 181 patients with with significant psychotropic effects that Alzheimer’s disease. American Journal of Psychiatry,, 153,, (c)(c)corecore defining features should differ- 1438^14 43.43.1438^14 entiate delirium from other neuropsy- could alter clinical presentation. Further chiatric disorders, especially dementia. studies are needed to explore the impact McCusker, J., Cole, M., Dendukuri, N., et al (2003) The course of delirium in older medical inpatients: a of aetiological, treatment and other individ- prospective study. Journal of General Internal Medicine,, ual patient factors on the clinical presenta- 1818, 696^704. Study limitations tion of delirium. Meagher, D. J. & Trzepacz, P.T. (1998) Delirium Studies with cross-sectional designs do not phenomenology illuminates pathophysiology, examine symptom evolution or whether management, and course. Journal of Geriatric Psychiatry and Neurology,, 11,150^156.,150^156. domains of symptoms vary as overall sever- REFERENCES ity changes. Longitudinal studies suggest Meagher, D. J.,Quinn, J. F., Bourke, S., et aletal (2004) Aalten,P.,deVugt,M.E.,Jaspers,N.,Aalten, P., de Vugt, M. E., Jaspers, N., et aletal (2005)(2005) Longitudinal assessment of psychopathological domains that early delirium is characterised by psy- The course of neuropsychiatric symptoms in dementia. over late-stage schizophrenia in relation to duration of chomotor disturbances and a disrupted Part II: relationships among behavioural sub-syndromes initially untreated psychosis: 3-year prospective study in

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AUTHOR’ S P ROOF

a long-term inpatient population. Psychiatry Research,, 126126,217^227., 217^227. DAVID J. MEAGHER, MARIA MORAN, BANGARU RAJU, DYMPNA GIBBONS,GIBBONS,DepartmentofAdult Department of Adult Psychiatry,Midwestern Regional Hospital, Limerick;SINEAD DONNELLY,DONNELLY, Milford Hospice Palliative Care Morita,Morita,T., T., Tei,Y., Tsunoda, J., et aletal (2001)(2001) Underlying pathologies and their associations with clinical features in Centre, Limerick;JEAN SAUNDERS,SAUNDERS, Statistical Consulting Unit,University of Limerick, Limerick, Ireland; terminal delirium of cancer patients. Journal of Pain and PAULAT.TRZEPACZ,PAUL A T. TR ZEPACZ, Lilly Research Laboratories, Indianapolis, Indiana,University of Mississippi Medical Symptom Management,, 2222,997^1006. School, Jackson, Mississippi,Tufts University School of Medicine, Boston, Massachusetts and Indiana University School of Medicine, Indianapolis, Indiana,USA O’Leary, D. S., Flaum, M., Kesler, M. L., et aletal (2000) Cognitive correlates of the negative, disorganized, and psychotic symptom dimensions of schizophrenia. JournalJournal Correspondence: Dr David Meagher,Department of Adult Psychiatry,Midwestern Regional Hospital, of Neuropsychiatry and Clinical Neurosciences,, 12,,4^15. 4^15. Limerick, Ireland. Email: meaghermob@@eircom.neteircom.net Spiller, J. A. & Keen, J. C. (2006) Hypoactive delirium: (First received 6 March 2006, final revision12 July 2006, accepted1September 2006) assessingassessingtheextentoftheproblemforinpatient the extent of the problem for inpatient specialist palliative care. Palliative Medicine,, 20,17^23.,17^23. Trzepacz, P.T. (1999) Update on the neuropatho- genesis of delirium. Dementia and Geriatric Cognitive DisordersDisorders,, 1010, 330^334. A study using the Delirium Rating Scale. Journal ofofJournal Scale^Revised^98 (DRS^R^98).Journal of Neuropsychiatry and Clinical Neurosciences,, 1010,199^204.,199^204. Neuropsychiatry and Clinical Neurosciences,, 13,154.,154. Trzepacz, P.T. & Dew, M. A. (1995) Further analyses of the Delirium Rating Scale. General Hospital Psychiatry,, Turkel, S. B., Trzepacz, P.T. & Tavare, C. J. (2006) Trzepacz, P.T., Mittal, D., Torres, R., et aletal (2001aa)) 17,,75^79. 75^79. Comparing symptoms of delirium in adults and children. Validation of the Delirium Rating Scale-Revised-98 Psychosomatics,, 47, 320^324.,320^324. Trzepacz, P.T., Baker, R.W. & Greenhouse, J. (1988) (DRS-R-98). Journal of Neuropsychiatry and Clinical A symptom rating scale for delirium. Psychiatry Research,, Neurosciences,, 13, 229^242.,229^242. World Medical Association (2004) Declaration of 23, 89^97.,89^97. Helsinki: Ethical Principles for Medical Research Involving Trzepacz, P.T., Mulsant, B. H., Dew, M. A., et aletal Trzepacz, P.T., Mittal, D., Torres, R., et aletal (2001bb)) Human Subjects. http://www.wma.net/e/policy/pdf/ (19 9 8) Is delirium different when it occurs in dementia? Delirium phenomenology using the Delirium Rating 17c.pdf.17c.pdf.

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