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Annals of Delirium
Editorial

This edition of the Annals coincides with the 5th Annual Scientific the over 50s you will find reference to Ebola virus, but there is no
Congress on Delirium in Amsterdam, which has an excellent page on delirium. Also, consider that the UK has recently produced
programme of lectures and workshops. Apart from the educational national best practice guidelines (guidance.nice.org.uk/CG103).
side, the opportunity to network with like-minded colleagues and These guidelines provide the most comprehensive survey of the
discuss new initiatives and ideas for research is priceless. delirium research literature currently available but the ““large
It is worth pointing out that it was in the Netherlands just over 4 lacunae in knowledge”” are clearly evident and acknowledged as
years ago that 50 delegates met and from that gathering the such by the authors throughout the document.
European Delirium Association was launched. The meetings have
gone from strength to strength always with high quality lectures but In this edition there is the experience of a daughter who has
with an increasing number of original research presentations and experienced her mother having several bouts of delirium alongside
posters. Apart from organising the annual meeting, however, it was an abstract of a project on relatives experiences. Increasingly
recognised the EDA should campaign on behalf of our patients and patients and relatives are speaking out about delirium and maybe it
relatives. is their stories as much as our efforts in education and research that
will make the difference. There is also an interesting contribution by
As no doubt we all will realise on our return there is no room for David Meagher, our Vice President, on pharmacotherapy (‘‘sceptics
complacency. Delirium has a long way to go before it get the vs. neuroleptics’’), a neuropsychologically-orientated perspective on
attention it deserves, before it is present in the public the assessment of inattention in delirium research and practice from
consciousness in the way cancer is, or even HIV. Bearing in mind Edinburgh, an account of the experience of implementing universal
the prevalence of delirium and the impact it has on patients and delirium screening in acute medical admissions from Fife, Scotland,
families we may believe it is only a matter of time, but I believe that an update on the American Delirium Society, the usual ““Did you
the process is going far too slowly. Some countries are doing better see?”” and the results of our latest poll.
than others and some areas of medicine are making greater
inroads, which can only benefit us all in the long run. In the UK, If you would like to contribute to the Annals, articles, opinions,
however, if you search for delirium on the BBC website you are letters or news all welcome, please e-mail me at
directed to the music page and the group Delirium Tremens. On the valerie.page@whht.nhs.uk.
BBC health page if you look up the index of possible concerns for

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A Personal Experience familiar routines that she fights and struggles as she tries to make
sense of what is happening to her. She refuses all food liquids and
Mum was asleep in the chair by her bed. The other five beds were treatment, people are trying to kill her. Then she is sedated with
filled by skeletal women waiting to be moved to nursing homes, Lorazepam and Haloperidol, knocked out for a few days, and
occasionally moaning or calling out. I stroked mums arm and called sometimes her mind comes back quickly and sometimes she goes
her. Nothing. Called harder- still nothing. Panic. Fourth try and in and out for weeks.
she opened her eyes and looked at me for several minutes as I
spoke to her. Then she smiled, recognising me and saying how It comes on insidiously, a series of blips and ‘‘is she isn’’t she’’
pleased she was to see me. Then she began, urgently and episodes where she is perfectly lucid in between but that gradually
distressed –– she had done something terrible. Or not done become more frequent. Confusion, muddled thinking, worsening
something. There would be world wide strikes and poverty dual incontinence, changes in her sleep pattern, occasional slurring
marches. And she knew where the body was buried. And on and on of words, looses the ability to read and spell, becomes suspicious
and on. and paranoid, sees coloured dots over surfaces and then come the
falls and hallucinations and another emergency admission. In the
I made soothing noises and tried to talk about something else. What interim the GP and Community Matron try to treat the suspected
had she had for lunch? She grabbed at me ““We can’’t speak of that cause at home, and I arrange for masses of homecare to keep an
–– I‘‘ll tell you later”” she whispered. She was so tiny and thin, clothes eye on her. There is no underlying dementia, at last discharge her
hanging off her and food stained, hair unbrushed, and huge bruises MMSE was 29, and in-between episodes (which usually last from
covering both arms from the fight she had had with the nurses a the blips starting for 4-6 weeks before admission, although on a
week ago. couple of occasions it hasn’’t cleared for months) mum needs no
help with daily living and rebuilds her confidence and social
This was mum’’s seventh emergency admission for an episode of contacts.
delirium. When well, mum is a self caring, fiercely independent,
smart and sociable lady of 83. Her network of friends far exceeds It breaks my heart. Mum has very little recollection of events during
mine, and until 18 months ago mum was very active in the local these periods. She has occasional flashbacks, and is mortified at
church, a hospice volunteer, and just ceased caring for her sister –– what she remembers. The benign episodes she refers to as vivid
in ––law who had recently died from cancer. dreams. Each time I am terrified that her mind won’’t come back. It
has taken vast amounts of time trying to find out what is the matter
The most frequent trigger is a urinary tract infection, but with her via the web, educating primary care staff and arguing with
constipation or ‘‘no clear cause’’ have also resulted in this horrible doctors in emergency departments and ward staff , getting the
condition. Each time it is different. One time she ranted for 48 basics onto her hospital notes , no she doesn’’t have dementia, she
hours, religion and the bible mixed up with family history. Another does have delirium, please don’’t put her through A&E and
time she spent two days accusing my brother of trying to take her Admissions and etc it will make her worse ... I don’’t know what else
money for drugs. It is like Jekyll and Hyde, a sweet mild woman to do.
becomes angry, violent and cruel. Most times she is so frightened 
at being in hospital, away from her home of 55 years and the

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Delirium in the general hospital: exploring the needs of elderly
patients and their relatives and consequences for nursing care They lack details on information and nursing care that are needed
from the perspectives of patients and relatives.
B. van der Velde, MANP. Dept of Geriatrics, Slingeland Hospital
Doetinchem. The Netherlands. Bertine van der Velde
b.van.der.velde@slingeland.nl
Background 10-40% of elderly patients become delirious during
hospitalization. Delirium has a huge impact on patients and their
relatives. A better understanding of their needs and tailored care Impact of an educational workshop upon attitudes towards
will probably increase the quality of care and satisfaction. pharmacotherapy for delirium
Information on this topic is scarce.
Setting Surgical wards of a general hospital. David J. Meagher, Department of Psychiatry, University of Limerick,
Objectives To obtain information on the needs of patients and their Limerick, Ireland
relatives during and after a delirium. Relating this information to
established criteria for treatment and care planning. Full report published : International Psychogeriatrics September
Participants 7 Patients aged •70 years, diagnosed with delirium 2010; 22:6, 938-46.
during hospitalization, and 10 close relatives.
Method Exploratory study using in-depth interviews. This report details the format and immediate outcome of a workshop
Findings Both patients and relatives expressed their need for focusing on pharmacotherapy for delirium conducted at the 4th Annual
written and verbal information on causes, symptoms, clinical meeting in Leeds last year. The workshop was designed firstly, to
presentation, treatment (medical, nursing) and consequences of the explore pre-existing attitudes and practice towards use of medications
delirium. Relatives needed advice on coping strategies. Patients to manage delirious patients, secondly, to expose participants to a
needed support and safety. This can be provided by a structured highly interactive educational event designed around a common
and reassuring approach and by reality orientation and validation television quiz show format with two teams (sceptics vs neuroleptics)
techniques. Relatives wanted to be involved in the care. They presented with a series of statements relating to delirium
needed emotional and practical support on how to deal with pharmacotherapy, and finally, through using a post workshop
aggressive behavior, disorientation, agitation and hallucinations. questionnaire, to explore for changes in attitudes as a result of
After discharge there is a need to discuss the recent experiences, participation in the workshop. Given the nature of the workshop as
feelings and unresolved questions. part of a specialist international conference on delirium, it is
reasonable to suggest that these findings represent a valuable
Interpretation Tailored individualized care during and after delirium snapshot of current expert opinion regarding delirium
is warranted for patients as well as close relatives. After delirium it pharmacotherapy.
is important to offer opportunities to discuss experiences, and
provide additional information and explanation. Many delirium- Information from the pre-workshop survey highlighted the variability in
related needs fit within established quality criteria. However, these attitudes and stated practice in this area and also explored the
criteria mainly describe organizational aspects of the provided care. relationship with differing perspectives on the probable mechanism of
therapeutic action of pharmacotherapies. This produced some

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revealing insights in the enigma that is delirium, whereby the recommended televisual experience for any uninitiated readers! This
frequency of antipsychotic use was inversely related to perception of allowed for a nice mix of harmless humour with an earnest
the strength of supporting evidence (p=0.02) –– perhaps the old adage inquisitorial structure. It proved highly interactive and as facilitator it
‘‘must do is a hard task master’’ applies here!. Moreover, the was much more challenging to keep the process focused for the
uncertainty as to possible mechanisms of action was highlighted by second day after the busy scientific and social schedule of day one!
the finding that respondents rated sedative (38%) and antipsychotic
(33%) effects as the principal mechanism of action rather than a The post workshop survey indicated considerable changes in some
specific neurochemical anti-delirium effect (21%). This probe determinants of clinical practice including attitudes towards side effect
produced some interesting responses including that use of propensity and use of medications for various delirium presentations.
medications was to alleviate carer stress rather than that of the Interestingly, use of pharmacotherapy for hypoactive presentations
delirious patient, emphasising a influential but perhaps and prophylactically in high risk patients were two practices that were
underacknowledged therapeutic triangle that commonly impacts upon deemed more likely to be applied in future practice by 61% and 56%
(even drives?) pharmacotherapy for delirious patients. This author, an of respondents respectively. The extent to which these changed
acknowledged subscriber to the ‘‘neuroleptic team’’, has sometimes attitudes convert to actual clinical practice is uncertain.
mused that patients sometimes get the right treatment but often for
the wrong reasons. The importance of perceived adverse effect An additional benefit of the workshop was the identification of expert
potential was highlighted by the strong relationship between stated clinician attitudes (i.e. EDA attendees) towards optimal choice of
practice and concerns regarding likelihood of extrapyramidal, agent and duration of pharmacotherapy. Haloperidol emerged as still
sedative, metabolic and cerebrovascular effects. This brought to mind the most commonly chosen agent of first choice but with many
the excellent presentation by Irene Schofield at EDA 2009, which caveats where alternate agents were considered more appropriate
through analysis of documentation relating to the care of delirious (e.g. where extrapyramidal side effect propensity might be elevated
patients highlighted the dominance of risk management over effective etc). The median duration of treatment continuation was 3 days with
therapeutic intervention in management of problematic delirious a range of immediate cessation once symptoms resolve to as much
patients. as two weeks of continuation therapy.

The actual quiz-show activity was designed to be fun but also Overall, this work highlights the opportunities presented by the EDA
challenging. Based on stated leanings, six participants were divided to explore key issues around the science of delirium management
into two teams (‘‘sceptics’’ –– relatively cautious regarding and to use the all too little time available at the annual conference to
pharmacotherapy vs ‘‘neuroleptics’’ –– more convinced as to evidence develop our knowledge and collate this into meaningful information
to support effectiveness in everyday practice). The true/ false that can inform our day to day practices. As a final comment, the
statements were deliberately contentious in content and provoked turnaround time with International Psychogeriatrics (less than one
much debate. Moreover, given the emergence of important new data calendar month including revisions) was remarkable and highlights
around drug treatment of delirium episodes with differing clinical the speed with which new information can be disseminated. I
presentations, pharmacological prophylaxis and side effect frequency, recommend the full article to all delirium enthusiasts but have
this aspect of the workshop highlighted varying levels of awareness attached the key findings as outlined in Tables for ease of access.
and allowed for participants to learn about recent developments,
including some unpublished work. The format was essentially
University Challenge meets Shooting Stars, the latter a highly

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Table 1. Workshops 1-3: true / false questions

6. Benzodiazepines have Gaudreau et al False False True


Consensus opinion at a useful role in delirium (2005),
workshop NOT related to substance Pandharipande
Question Reference 1 2 3 withdrawal or seizures et al (2006),
material used in Lonergan et al
discussion (2009)
1. Drug treatment of 7. Studies indicate that Platt et al True True False
delirium is supported by Meagher and False False False drug-treatment response (1994), Breitbart
quality prospective Leonard differs according to clinical et al (2002),
research studies (2008) subtype (e.g. hypoactive Boettger et al
vs hyperactive (2007a),
2. Placebo controlled
Breitbart et al True True True presentations) Boettger et al
studies of delirium
(1996), (2007b),
treatment are lacking
8. Patients with delirium Meagher and False False False
Hu et al (2006) are especially prone to Leonard (2008)
extrapyramidal symptoms
3. Placebo controlled
9. The treatment of Breitbart et al False True False
studies of antipsychotics Kalisvaart et al False False False
delirium is similar (2002), Van der
in delirium prevention are (2005),
regardless of whether it Cammen et al
lacking Prakanrattana
involves comorbid (2006)
and
dementia
Prapaitrakool
10. Excess sedation is Meagher and False False False
(2007), Larsen
commonly reported in Leonard (2008)
et al (2007)
studies of delirium
4. Studies support the role False False treatment
of procholinergic agents in Liptzin et al False
delirium prevention (2005),
Sampson et al
(2006),
Gamberini et
al (2009)
5. The effectiveness of Meagher et al False True False
drug treatment mostly (1996), Breitbart
reflects sedation and / or et al (1996)
psychosis reduction

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Table 2. Suggested first and second line agents with dose Table 3. Impact of the workshop upon proposed use of
ranges
pharmacological strategies in future delirium management
N Suggested dose range
(mg / day) More likely to About the Less likely to
First Line 61 use in the same use in the
Haloperidol 40 0.5 - 15 future future
Risperidone 9 0.25 - 5 Delirium treatment in 55% 5%
40%
Quetiapine 6 6.25 –– 100 general
Lorazepam 4 0.5 –– 4 Hypoactive 26% 13%
61%
Olanzapine 2 2.5 –– 15 presentations
Second Line 61 Hyperactive 67% 3%
30%
Lorazepam 19 0.5 –– 4 presentations
Olanzapine 11 1.25 - 20 Comorbid delirium- 73% 13%
14%
Haloperidol 10 0.5 –– 20 dementia
Risperidone 8 0.25 –– 6 Older medico-surgical 68% 5%
37%
Quetiapine 8 12.5 –– 400 patients
Rivastigmine 2 1.5 –– 3 ICU 47% 50% 3%
Melatonin 1 3 Palliative Care 47% 51% 2%
Clozapine 1 6.25 upwards Prophylaxis in high- 36% 8%
56%
Amisulpiride 1 50 - 100 risk patients

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Screening for delirium in the general hospital setting: the 
experience from NHS Fife, Scotland 
CGADomain Assessmentused
Prof. Emma Reynish ͳǤ Š›•‹…ƒŽ ‡ƒŽ–Š ‘—–‹‡ …Ž‡”‹‰ ‹…Ž—†‹‰
Consultant Geriatrician Š‹•–‘”› ‘ˆ •‡•‘”›
Victoria Hospital, Kirkcaldy, Fife, Scotland ‹’ƒ‹”‡–Ǥ
ʹǤ —…–‹‘ƒŽ„‹Ž‹–› ƒ–œ  …ƒŽ‡ ȋͶȌ ȋ„‡•– ‹
Delirium in the inpatient hospital setting has been shown to result in
poor outcomes namely increased mortality, prolonged length of stay ’”‡˜‹‘—• ͵ ‘–Š• ƒ†
and need for institutionalization. Despite its serious nature it is …—””‡–Ȍ
generally poorly recognized by healthcare professionals.(1-3). ƒŽŽ•Š‹•–‘”›
•—ƒŽƒ†…—””‡–‘„‹Ž‹–›
As part of ongoing audit work within the department of Geriatric ͵Ǥ ‘‰‹–‹˜‡ ƒ† ‡–ƒŽ ‡‡–‹ƒŠ‹•–‘”›
Medicine in NHS Fife, Scotland it was shown that routine cognitive ‡ƒŽ–Š ‘‰‹–‹˜‡…‘”‡ȋͷȌ
testing was infrequently performed when older people were •…”‡‡ˆ‘”‡Ž‹”‹—ȋ͸Ȍ
admitted acutely to hospital. In order to ameliorate this situation a
ͶǤ ‘…‹‘Ǧ‡˜‹”‘‡–ƒŽ ‡‹Ǧ•–”—…–—”‡‹–‡”˜‹‡™
pilot project was funded to develop a standardized tool for routine
Comprehensive Geriatric Assessment within the acute setting. 
(Acute-CGA) and establish its use in routine clinical practice. 
The choice of screening tool for delirium was debated (7). The
The Acute-CGA tool development was carried out by a decision to adopt the Confusion assessment method (CAM)
multidisciplinary team which included a geriatrician, and old age screening tool was based on well published validation and clinical
psychiatrist, an occupational therapist, a physiotherapist, a mental utility of the instrument along with local familiarity with its use within
health liaison officer; a charge nurse specialized in geriatric the mental health team.
medicine and a clinical nurse manager. The remit of the team was
to develop a standardized tool encompassing the 4 salient domains The pilot Acute-CGA project has been running for the last one year.
of CGA using well validated internationally recognized instruments Positive feedback from patients, carers and staff (health and social
in addition to a semi-structured interview with patients and carers. care professionals) in addition to improved recognition of cognitive
Feasibility was crucial; it had to result in an assessment that impairment and delirium have resulted in adoption of the process
allowed up to 15 full assessments to be carried out each day, it had across the health board.
to be used by trained staff nurses, it had to be applicable to the
population 65 years and over and finally it had to be understood by The implementation of the routine use of the CAM has resulted in
all general hospital healthcare professionals. improved recognition of delirium. The process involving one-off
 screening using the CAM has raised a number of points which are
worth considering when looking at the practicalities of widespread

screening by nurses in this setting.


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recognized within the specialist setting of acute
1. Training geriatric medicine but may not be recognized within
The routine assessment of all patients 65 years and over is other medical specialties.
being carried out by staff nurses from geriatric medicine who
attend the medical admissions unit (MAU) on a daily basis. c. Time constraint to screen 100% patients
Training in the use of the CAM initially involved one to one The number of admissions aged 65 years and over
sessions with the mental health liaison officer prior to the fluctuates on a daily basis resulting in fluctuations in
start of the project. This was repeated at 3 months into the the workload for the nurses performing the
project as inconsistencies between the 5 trained nurses assessments. On days of highest admission
were apparent with differing confidence in diagnosing a numbers not all admissions will be screened.
patient as CAM +ve.
4. Translating improved recognition into improved outcomes
2. Confidence surrounding delirium in general hospital staff Routine hospital data does confirm the poorer outcomes of
Routine screening has changed the vocabulary used in those recognized as having delirium. Improving
those patients admitted with ““confusion””. The terms CAM management of these patients and therefore their outcomes
+ve and delirium have needed repeated explanation and an is the ultimate goal. Current activity is focusing on the
ongoing programme of education for junior medical staff and development of a ““Delirium Care Pathway”” and with the
other general hospital staff has attracted positive feedback input of the Scottish Patient Safety Programme using
as to its utility. improvement methodologies to bring about meaningful
change in clinical practice.

3. Under-recognition

a. Reduced conscious level These findings are due to be presented at the European Delirium
In those patients with drowsiness or reduced Association meeting in Amsterdam Nov 2010 will open this forum
conscious level the diagnosis of delirium appears to for discussion at an international level. Our endeavor is to in set the
be more difficult. This has resulted in the discussion scene for meaningful and enduring improvement in outcomes for
as to whether the two questions ““Does the patient those at risk of delirium.
appear drowsy?”” and ““Is this different from normal?””
should be part of the semi-structured assessment
prior to the application of the CAM.

b. Development later in hospital stay


The Acute-CGA assessment is generally being
performed within the first 24 hours of admission to
hospital. In a number of cases delirium develops
within the course of the hospital stay. This is

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References Objective testing of attention in delirium: room for
1. Gustafson Y, Brännström B, Norberg A et al. Underdiagnosis improvement?
and poor documentation of acute confusional states in elderly
hip fracture patients. J Am Geriatr Soc 1991;39:760––765. Zoë Tieges, Edinburgh Delirium Research Group, The University of
2. Inouye SK, Foreman MD, Mion LC et al. Nurses’’ recognition of Edinburgh, Edinburgh, Scotland
delirium and its symptoms. Arch Intern Med 2001;161:2467––
2473. Laura Brown, Institute for Ageing and Health, Newcastle University,
3. Milisen K, Foreman MD, Wouters B et al. Documentation of Newcastle, England
delirium in elderly patients with hip fracture. J Gerontol Nurs
2002;28:23––29. Alasdair MacLullich, Edinburgh Delirium Research Group, The
4. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW: University of Edinburgh, Edinburgh, Scotland
Studies of illness in the aged. The Index of ADL: a standardized
measure of biological and psychosocial function. JAMA 1963; A major contributing factor to the problem of under-recognition of
185: 914––919. delirium is that many of the commonly used delirium assessment
5. Hodkinson HM. "Evaluation of a mental test score for methods (e.g., DRS-R-98) rely on subjective clinical judgments and
assessment of mental impairment in the elderly." Age and are only suitable for use by experienced clinicians or trained
Ageing 1972;1:233-8. researchers (Kean & Ryan, 2008). Another factor impeding
6. Clarifying confusion: the confusion assessment method. A new accurate diagnosis is the overlap of delirium symptoms with those
method for detection of delirium. Inouye SK et al. Ann Intern seen in dementia. Inattention is a core feature of delirium, and so
Med. (1990) 113:941-948 the accurate assessment of attentional functioning is central to
7. Wong CL, Holroyd-Leduc, J, Simel, DL et al. Does This Patient diagnosis. Moreover, inattention may have diagnostic value in
Have Delirium?: Value of Bedside instruments. JAMA, discriminating delirium from dementia (Meagher et al., 2010).
2010;304(7):779-786. However, there is a lack of consensus over how attention is
assessed in patients who may have delirium, with many different
methods being used in clinical practice and research. The
uncertainty over how this core diagnostic feature should be
assessed likely contributes to the low rates of detection of delirium
------------------------------------------------------------------------ in mainstream healthcare settings (Davis & MacLullich, 2009). From
this it follows that there is a clear need for more objective
assessments of attention in delirium.

In this article we discuss the construct of attention in the context of


delirium diagnosis, summarise the available literature, and go on to
make suggestions for future research.

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The construct of attention Review of studies
The term ‘‘attention’’ actually refers to a range of different processes Recently we have reviewed the literature on objective attention
including the ability to focus, sustain, or shift the spotlight of assessment in delirium. Thirteen studies were identified that met
attention. However, within the large psychology literature on the inclusion criteria of using validated methods for diagnosing
attention there is ongoing debate over many issues such as the delirium as defined in DSM or ICD. Studies on delirium tremens
nature of the underlying systems giving rise to the observable were excluded. Where cognitive test batteries consisting of one or
behavioural product of attention, the degree to which different more subtests of attention were used, these were included only if
aspects of attention can be studied separately, and the data from the individual attention subtest(s) were provided.
measurement of attention. One key issue highly relevant to the
detection of delirium and its discrimination from dementia is that Patients and cognitively unimpaired control participants were mostly
most so-called tests of attention actually measure a constellation of aged over 60, and were recruited from the community, acute
cognitive functions, rather than just attention. These cognitive hospital wards and nursing homes. Sample sizes for delirium
functions may include working memory, executive function, groups ranged from 9 to 100, amounting to a total of 298 delirium
arithmetic abilities and psychomotor speed. Thus, performance patients who were tested in these studies.
deficits on ‘‘attention tests’’ may reflect impairments in one or more
of these other aspects of cognition rather than, or in addition to, The selected studies report several categories of objective, paper
deficits in attentional functioning. Indeed whether the tests are and pencil neuropsychological tests of attention (see Figure 1).
labelled as tests of attention or other psychological constructs often These were defined as: 1) tests that do not require stimulus
relates to the theoretical focus of the paper rather than the test material (e.g. months of the year backwards), 2) measures of
itself. For example, though digit span is sometimes used as a test attention span (e.g., digit span), 3) vigilance tests, and 4) other pen
of attention in delirium, it is also used clinically and in research and paper tests such as the trailmaking test and Stroop task. In
studies to measure IQ, working memory and executive functioning. addition, three studies employed computerised tests of attention,
This has implications for understanding attentional deficits in including a test for assessing sustained attention through counting
delirium. In particular, because patients with dementia frequently of slowly-presented visual stimuli (Brown et al., 2010).
show deficits in tests such as digit span, many such tests will not be
able to discriminate between dementia and delirium. Nearly half of the studies reported pre- to post-operative declines in
attention in delirium patients (e.g., Bettin et al., 1998). Interestingly,
It is not yet clear which particular aspects of attention are affected in attention was also compromised post-operatively in patients without
delirium. The DSM-IV criteria state that patients must demonstrate delirium, demonstrating a more general impact of surgery on
‘‘reduced ability to focus, sustain, or shift attention’’. This criterion is attentional processes. In addition, almost half of the studies
largely based on psychiatric observation during interview, (perhaps included data from control groups of patients with dementia (e.g.,
supported by brief cognitive testing) rather than formal studies of O’’Keeffe & Gosney, 1997). These studies revealed that cancellation
these aspects of attentional deficits in delirium, which are lacking. tests, visual span tests and computerised tests may offer utility in
Also, currently it remains unclear to what extent poor performance discriminating delirium from dementia. More research in larger
on tests of attention in delirium groups reflects a fairly specific groups of patients, and in different subtypes of dementia, is needed
deficit of attention in these patients, rather than more general though to determine reliability of findings.
cognitive deficits, such as an inability to understand or remember
task instructions, or even to stay fully awake during testing.

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Only two of the studies reviewed here provided any reliability or Suggestions for development of future tests
validity data, despite the usefulness of such information for 1) An increased use of tests that make minimal demands on other
evaluating neuropsychological tests. However, four studies did aspects of cognitive function would be useful in delirium as this
address the relationship between objective measures of attention would allow specific aspects of attentional functioning to be more
and subjective observations by expert raters, which may provide a precisely examined. Tests should also employ simple task
standard against which objective measures of attention can be instructions, so that comprehension problems are less likely to
meaningfully compared. These studies (Bettin et al., 1998, Meagher influence patients’’ performance.
et al., 2010) have demonstrated that cognitive tests of attention and
observer-rated scales may, to some extent, tap into the same type 2) Computerised testing offers the advantage of controlled
of attentional deficits in delirium. This was particularly true for presentation of stimuli and automated scoring, and may therefore
vigilance tests. constitute a suitable technique for objective testing of attention.
Development of automated tests should take into account some
Finally, none of the studies have examined if, and to what extent, practical considerations, including the ease-of-use as bedside
the degree of attentional impairments in delirious patients is instruments, hygiene (in case of button pressing) and brief duration
predictive of clinical outcome in these patients. We argue that this of the test.
would be an interesting avenue of future research, as such findings
could be useful in identifying high risk patients and may also 3) Assessment tools may be particularly useful in tracking disease
provide insights into the pathophysiological mechanisms associated progress over time and monitoring drug effects, which require
with delirium. frequent reassessment. Hence, tests should ideally be resistant to
practice effects, to rule out the possibility that performance
Conclusions improvements are the result of repeated testing rather than
The existing evidence base is very small. Studies which have aimed recovery from delirium symptoms.
to characterise attentional deficits in delirium, fundamental to
development of valid tests, are rare. One domain of attention that 4) Studying attentional deficits alongside formal measures of
may be particularly vulnerable in delirium is the ability to maintain arousal will also help to understand the extent to which reduced
attention to stimuli over time (sustained attention). This could alertness affects the nature and extent of attentional deficits in
explain the broad pattern of performance deficits seen in delirium delirium. Currently it is unknown if drowsy patients always show
across a variety of cognitive tests, since many tests require impaired attention or if they can have normal attention despite a
participants to stay alert and sustain attention to the stimulus reduced level of arousal.
material. Accordingly it is recommended that, where possible, tests
examining other aspects of cognitive functioning should minimise
the demands on sustained attention by, for instance, allowing long
exposure times to stimulus materials, and repeated prompting when
necessary.

Taken together, objective testing of attention is underdeveloped but


holds considerable promise in clinical practice and research.

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References
Bettin, K. M., et al. (1998). Measuring delirium severity in older
general hospital inpatients without dementia. The Delirium Severity
Scale. The American Journal of Geriatric Psychiatry, 6, 296-307.

Brown, L. J., Fordyce, C., Zaghdani, H., Starr, J. M., & MacLullich,
A. M. (2010). Detecting deficits of sustained visual attention in
delirium. Journal of Neurology, Neurosurgery, and Psychiatry.

Davis, D., & MacLullich A.M.J. (2009). Understanding barriers to


delirium care: a multicentre survey of knowledge and attitudes
amongst UK junior doctors. Age Ageing, 38, 559-63.

Kean, J, & Ryan, K. (2008). Delirium detection in clinical practice


and research: critique of current tools and suggestions for future
development. Journal of Psychosomatic Research, 65, 255-259

O’’Keeffe, S. T., & Gosney, M. A. (1997). Assessing attentiveness in


older hospital patients: global assessment versus tests of attention.
Journal of the American Geriatrics Society, 45, 470-473.

Mathias, J. L., & Wheaton, P. (2007). Changes in attention and


information-processing speed following severe traumatic brain
injury: a meta-analytic review. Neuropsychology, 21, 212-23.
Figure 1. Objective, paper and pencil neuropsychological tests
Meagher, D. J., Leonard, M., Donnelly, S., Conroy, M., Saunders,
J., & Trzepacz, P. T. (2010). A comparison of neuropsychiatric and used for measuring attention in delirium.
cognitive profiles in delirium, dementia, comorbid delirium-dementia
and cognitively intact controls. Journal of Neurology, Neurosurgery,
and Psychiatry, 81, 876-881.

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Editors Choice: Did you see?
Long-term Cognitive Impairment and Functional Disability
Single Question in Delirium (SqiD): testing its efficacy against among Survivors of Severe Sepsis. TJ Iwashyna, EW Ely, DM
psychiatrist interview, the Confusion Assessment Method and Smith and KM Langa.
the Memorial Delirium Assessment Scale.
JAMA 2010; 304: 1787-94
MB Sands, BP Dantoc, A Hartshorn, CJ Ryan and S Lujic. Septic encephalopathy gets the attention of intensive care
clinicians. It is important to establish the concept of monitoring and
Palliative Medicine 2010; 24: 561-65. managing ““brain failure”” (delirium) in ICU clinicians minds and this
paper goes some way to doing it. This is a large cohort study using
““Do you think (name of patient) has been more confused lately?”” the Health and Retirement study database begun in 1992. The
This was asked of a friend or member of the family of 21 patients subjects are reinterviewed every 2 years. These 516 survivors had
and the result compared to a psychiatric interview and two other been hospitalized for severe sepsis. Incident severe sepsis was
delirium-screening tools. All the patients had solid tumours and associated with a clinically and statistically significant increase in
were inpatients. While there are some issues over blinding, this moderate to severe cognitive impairment as well as a greater risk of
study is not only interesting because of the result (which you will additional functional limitations.
have to find out for yourself!) but because it outlines the difficulties
in obtaining consent in delirium studies and how these authors Delirious Deficiency. RQ Olsen and JT Regis.
managed them. An exquisite paper from Australia.
Lancet 2010; 376: 1362
A case report and a reminder that even in well developed countries
Infant Delirium in Pediatric Critical Care settings. GH Silver, we still have the opportunity to diagnose wet beriberi in the
JA Kearney, MC Kutko, AS Bartell. emergency department.
American Journal of Psychiatry 2010; 167: 1172-77
This is a review paper which focuses on the treatment of delirium in
critically ill patients which has only relatively recently been
appreciated as being important in this patient population. The main
emphasis is, interestingly, on pharmacological treatment and it
illustrates this point with a case report of the use of haloperidol in a
7.5-month infant receiving treatment for a neuroblastoma.

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News

American Delirium Society

To further address awareness of and knowledge about delirium in Until the website is operative (within the next month), the Society
the United States, the American Delirium Society (““ADS””) is in the can be reached by emailing our secretary, Marianne Shaughnessy,
process of development and incorporation at this time. This society RN, PhD, our president, James Rudolph, MD, or our treasurer,
grew out of a national group dedicated to the development of Barbara Kamholz MD.
expertise in delirium from with the United States’’ Veterans
Administration (““VA””). The ““National VA Delirium Working Group””,
which has had monthly phone calls for 5 years, will continue to have
a role within VA. The Working Group has been quite successful so
far, having sponsored (with assistance from national VA educational
development funds), two national delirium conferences in June,
2009, and June 2010. In conjunction with the June, 2010 VA
conference, the new ADS board convened to launch the Society.

The Society has already received grant support from the Hartford
Foundation (Hartford, Connecticut, US) and has received further
significant support from Malaz Boustani, MD, MPH, Indiana
University and the Regenstrief Institute in Indianapolis. The
Regenstrief Institute is a free standing geriatrics research institute.
Dr Boustani has offered resources to develop the ADS website and
will sponsor next year’’s ADS meeting in Indianapolis in June, 2011
(details to follow). We are also indebted to the leadership of
Kenneth Shay, DDS, MS, Director of Geriatric Programs, Central
Office, VA Washington, DC. The ADS plans to have yearly
meetings to enhance the awareness of the dire clinical outcomes of
delirium, to educate both the public as well as healthcare providers,
and to advocate for further research. We are authoring a
supplement to the Journal of the American Geriatrics Society, which
will be published in mid-2011. We eagerly anticipate collaborations
with the EDA and are already grateful for the kind extensions of
offers to help from members of the EDA.

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Books Radio interview

There are 2 clinical books on delirium to look out for For your interest and perhaps to pass to others for educational
February/March next year: purposes here is a BBC radio interview (in English) with a patient
who had delirium whilst in the ICU. The interview runs in the first 10
minutes of a 24 minute programme.
Delirium: Acute confusional states in palliative medicine by Augusto http://www.bbc.co.uk/programmes/b00ts58d
Caraceni and Luigi Grassi 2nd edition. Oxford University press.
Around £50UK
OUP say: Delirium: Acute confusional states in palliative medicine, NICEly does it – UK guidelines launched
Second Edition demonstrates that only an interdisciplinary
treatment of delirium between neurology, psychiatry and palliative The UK National Institute for Health and Clinical Excellence has just
medicine can develop knowledge of the syndrome and improve published its guidelines ““based on best available evidence”” on
patient and family care. This book has been written for palliative delirium. The full document has 662 pages but there is a summary
care physicians and specialist nurses, neurologists, psychiatrists, as well as guidance for patients and carers. Regarding
and other health professionals treating terminally ill patients, pharmacological intervention, depending on your practice, you will
offering them a clear account of how to recognize and deal with the either agree with the conclusion or be disappointed.
syndrome. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=13060

EDA ballot
Delirium in the Critically Ill by Valerie Page and Wes Ely.
Cambridge University Press. Around £20UK Question: With regard to outcomes, the cause of delirium is more
CUP say: This clinical handbook explains why delirium goes important
unrecognised in most ICUs and describes simple tools the bedside than severity
clinician can use to detect it, even in the ventilated patient. It is in an Total votes: 50
easy-to-read format and illustrated with figures, case reports and * Answer: Yes Votes: 33 (66%)
patient testimony. This book contains all you need to know in order * Answer: No Votes: 17 (34%)
to prevent, diagnose and manage delirium in your patients. Delirium
in Critical Care is essential reading for all members of the intensive
care multidisciplinary team, including senior and junior physicians,
and nurses.

Both available for preorder!

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