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  • Print publication year: 2007
  • Online publication date: October 2009

24 - Delirium and confusional state in stroke patients


Main characteristics of delirium and confusional state

Delirium or acute confusional state (ACS) is a mental disorder characterized by acute onset, altered level of consciousness, fluctuating course, and disturbances in orientation, memory, thought, and behavior (Lipowski, 1990). This condition is frequent in stroke patients, although stroke is a rare cause of ACS. Many predisposing factors have been identified. Stroke per se may, however, induce ACS. The occurrence of this behavioral disturbance adversely influences outcome in stroke patients. However, no specific treatment is available.

ACS is an acute, transient disorder of consciousness and cognition with fluctuating intensity. The symptoms of delirium are wide ranging, and although they are non-specific, their abrupt or rapid onset and their fluctuating nature is highly characteristic and is a valuable diagnostic tool. The main feature of delirium is disordered attention with difficulties in focusing and sustaining attention on one stimulus and difficulties in shifting attention to new external stimuli: attention wanders, perseverations may be observed. Attention disturbances are not isolated and examination will reveal abnormalities of thinking, perception, and memory. The change in cognition includes impaired memory, language (anomia, incoherent speech, aphasia, agraphia), disorientation to time and place and visuospatial dysfunction. Perception disturbances may also be present with illusions, hallucinations, or delusions. Sleep–wake abnormalities are frequent with daytime sleepiness and reduced and fragmented sleep during the night with nocturnal agitation, shouting, and aggressivity. Many individuals are restless and hyperactive while others are lethargic.

Adams, R. D., Viktor, M. and Ropper, A. H. (1997). Principles of Neurology, 6th edn. New York: McGraw-Hill, pp. 405–16.
Albert, M. S., Levkoff, S. E., Reilly, C., et al. (1992). The delirium symptom interview: An interview for the detection of delirium symptoms in hospitalized patients. J. Geriatr. Psychiatry Neurol., 5, 14–21.
Alexander, G. E. and DeLong, M. R. (1985). Microstimulation of the primate neo-striatum, I: Physiological properties of striatal microexcitable zones. J. Neurophysiol., 53, 1417–32.
Alexander, G. E., DeLong, M. R. and Strick, P. L. (1986). Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Ann. Rev. Neurosci., 9, 357–81.
American Psychiatric Association (1999). Practice guidelines for the treatment of delirium. Am. J. Psychiatry., 156, 1–20.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. DSM-IV-Washington, D.C., American Psychiatric Association, 143. Copyright 2000, American Psychiatric Association.
Amyes, E. W. and Nielsen, J. M. (1955). Clinicopathological study of vascular lesions of the anterior cingulated region. Bull. Los Angeles Neurol. Soc., 20, 112–30.
Beuzen, J. N., Taylor, N., Wesnes, K. and Wood, A. (1999). A comparison of the effects of olanzapine, haloperidol and placebo on cognitive and psychomotor functions in healthy elderly volunteers. J. Psychopharmacol., 13, 152–8.
Bogousslavsky, J. and Regli, F. (1990). Anterior cerebral artery territory infarction in the Lausanne Stroke Registry: Clinical and etiologic patterns. Arch. Neurol., 47, 144–50.
Breitbart, W., Marotta, R., Platt, M. M., et al. (1996). A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am. J. Psychiatry, 153, 231–7.
Breitbart, W., Rosenfeld, B., Roth, A., et al. (1997). The Memorial Delirium Assessment Scale. Pain Symptom Manage., 13, 128–37.
Brodaty, H., Ames, D., Snowden, J., et al. (2003). A randomized placebo controlled trial of risperidone for the treatment of aggression, agitation, and psychosis in dementia. J. Clin. Psychiatry, 64, 134–43.
Burke, W. J., Roccaforte, W. H. and Wengel, S. P. (1999). Treating visual hallucinations with donepezil. Am. J. Psychiatry, 156, 1117–18.
Caeiro, L., Ferro, J. M., Claro, M. I., et al. (2004a). Delirium in acute stroke: A preliminary study of the role of anticholinergic medications. Eur. J. Neurol., 11, 699–704.
Caeiro, L., Ferro, J. M., Albuquerque, R. and Figueira, M. L. (2004b). Delirium in the first days of acute stroke. J. Neurol., 251, 171–8.
Caeiro, L., Menger, C., Ferro, J. M., Albuquerque, R. and Figueira, M. L. (2004c). Delirium in Acute Subarachnoid Haemorrhage. Cerebrovasc. Dis., 3; (19), 31–8.
Camus, V., Gonthier, R., Dubos, G., Schwed, P. and Simeone, I. (2000). Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J. Geriatr. Psychiatry Neurol., 13, 38–42.
Caplan, L. R. (1980). Top of the basilar syndrome: Selected clinical aspects. Neurology, 30, 72–9.
Caplan, L. R. (1996). Posterior Circulation Disease: Clinical findings, Diagnosis and Management, Boston: Butterworth-Heinemann.
Caplan, L. R. (2000). Acute confusional states and delirium. In Behavior and Mood Disorders in Focal Brain Lesions, ed. Bogousslavsky, J. and Cummings, J. L.. Cambridge: Cambridge University Press.
Caplan, L. R., Kelly, M., Kase, C. S., et al. (1986). Infarcts of the inferior division of the right middle cerebral artery: Mirror image of Wernicke's aphasia. Neurology, 36, 1015–20.
Caplan, L. R., Schmahmann, J. D., Kase, C. S., et al. (1990). Caudate infarcts. Arch. Neurol., 47, 133–43.
Castaigne, P., Lhermitte, F., Buge, A., et al. (1981). Paramedian thalamic and midbrain infarct: Clinical and neuropathological study. Ann. Neurol., 10, 127–48.
Curyto, K. J., Johnson, J., TenHave, T., et al. (2001). Survival of hospitalized elderly patients with delirium: A prospective study. Am. J. Geriatr. Psychiatry, 9, 141–7.
Cole, M. G. (1999). Delirium: Effectiveness of systematic interventions. Dement. Geriatr. Cogn. Disord., 10, 406–11.
Damasio, A. R., Damasio, H., Rizzo, M., Varney, N. and Gersh, F. (1982). Aphasia with nonhemorrhagic lesions in the basal ganglia and internal capsule. Arch. Neurol., 39, 2–14.
Devinsky, O., Bear, D. and Volpe, B. T. (1988). Confusional states following posterior cerebral artery infarction. Arch. Neurol., 45, 160–3.
Erkinjuntti, T., Wikstrom, J., Palo, J. and Autio, L. (1986). Dementia among medical inpatients. Evaluation of 2000 consecutive admissions. Arch. Intern. Med., 146, 1923–6.
Fassbender, K., Schmidt, R., Mossner, R., Daffertshofer, M. and Hennerici, M. (1994). Pattern of activation of the hypothalamic–pituitary–adrenal axis in acute stroke. Relation to acute confusional state, extent of brain damage, and clinical outcome. Stroke, 25, 1105–8.
Ferro, M. (2001). Hyperacute cognitive stroke syndromes. J. Neurol., 248, 841–9.
Ferro, J. M., Caeiro, L. and Verdelho, A. (2002). Delirium in acute stroke. Curr. Opin. Neurol., 15, 51–5.
Fisher, C. M. (1975). Clinical syndromes in cerebral thrombosis, hypertensive haemorrhage and ruptures saccular aneurysm. Clin. Neurosurg., 22, 117–47.
Fisher, C. M. (1983). Honored guest presentation: Abulia minor vs agitated behavior. Clinical Neurosurgery, Baltimore: Williams & Wilkins, pp. 9–31.
Fisher, P. (2001). Successful treatment of nonanticholinergic delirium with a cholinesterase inhibitor. J. Clin. Pharmacol., 21, 118.
Flacker, J. M., Lipsitz, L. A. (1999). Neural mechanisms of delirium: Current hypotheses and evolving concepts. J. Gerontol. A. Biol. Sci. Med. Sci., 5, B239–46.
Flacker, J. M. and Wei, J. Y. (2001). Endogenous anticholinergic substances may exist during acute illness in elderly medical patients. J. Gerontol. A. Biol. Sci. Med. Sci., 56, M353–5.
Francis, J. (1996). Drug-induced delirium: Diagnosis and treatment. CNS Drugs, 5, 102–14.
Francis, J., Martin, D. and Kapoor, W. N. (1990). A prospective study of delirium in hospitalized elderly. JAMA, 263, 1097–101.
Garcia-Albea, E. (1989). Confusional state and cerebral infarcts. Postgrad. Med. J., 65, 286–90.
Gaudreau, J. D. and Gagnon, P. (2005). Psychotogenic drugs and delirium pathogenesis: The central role of the thalamus. Med. Hypotheses, 64, 471–5.
George, J., Bleasdale, S. and Singleton, S. J. (1997). Causes and prognosis of delirium in elderly patients admitted to a district general hospital. Age Ageing, 26, 423–7.
Ghika-Schmid, F. and Bogousslavsky, J. (2000). The acute behavioral syndrome of anterior thalamic infarction: A prospective study of 12 cases. Ann. Neurol., 48, 220–7.
Gill, S. S., Rochon, P. A., Herrmann, N., et al. (2005). Atypical antipsychotic drugs and risk of ischaemic stroke: Population based retrospective cohort study. BMJ, 330, 445.
Godefroy, O., Rousseaux, M., Pruvo, J. P., Cabaret, M. and Leys, D. (1994). Neuropsychological changes related to unilateral laterostriatal infarcts. J. Neurol. Neurosurg. Psychiatry, 57, 480–5.
Graff-Radford, N. R., Eslinger, P. J., Damasio, A. R. and Yamada, T. (1984). Nonhemorrhagic infarction of the thalamus: Behavioral, anatomic, and physiologic correlates. Neurology, 34, 14–23.
Gustafson, Y., Olsson, T., Asplund, K. and Hägg, E. (1993). Acute confusional state (delirium) soon after stroke is associated with hypercortisolism. Cerebrovasc. Dis., 3, 33–8.
Gustafson, Y., Olsson, T., Eriksson, S., Asplund, K. and Bucht, G. (1991). Acute confusional states (Delirium) in stroke patients. Cerebrovasc. Dis., 1, 257–64.
Han, L., McCusker, J., Cole, M., et al. (2001). Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch. Intern. Med., 161, 1099–105.
Hassan, E., Fontaine, D. K. and Nearman, H. S. (1998). Therapeutic considerations in the management of agitated or delirious critically ill patients. Pharmacotherapy, 18, 113–29.
Hénon, H., Lebert, F., Durieu, I., et al. (1999). Confusional state in stroke: Relation to preexisting dementia, patient characteristics, and outcome. Stroke, 30, 773–9.
Inouye, S. K. (1994). The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am. J. Med., 97, 278–88.
Inouye, S. K., Bogardus, S. T. Jr, Charpentier, P. A., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. N. Engl. J. Med., 340, 669–76.
Inouye, S. K., Dyck, C. H., Alessi, C. A., et al. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann. Intern. Med., 113, 941–8.
Jensen, E., Dehlin, O. and Gustafson, L. (1993). A comparison between three psychogeriatric rating scales. Int. J. Geriatr. Psychiatry, 8, 215–29.
Jitapunkul, S., Pillay, I. and Ebrahim, S. (1992). Delirium in newly admitted elderly patients: A prospective study. Q. J. Med., 83, 307–14.
Karlsson, I. (1999). Drugs that induce delirium. Dement. Geriatr. Cogn. Disord., 10, 412–15.
Kaufer, D. I., Catt, K. E., Lopez, O. L. and DeKosky, S. T. (1998). Dementia with Lewy bodies: Response of delirium-like features to donepezil. Neurology, 51, 1512.
Kobayashi, K., Higashima, M., Mutou, K., et al. (2004). Severe delirium due to basal forebrain vascular lesion and efficacy of donepezil. Prog. Neuropsychopharmacol. Biol. Psychiatry, 28, 1189–94.
Koponen, H. J. and Riekkinen, P. J. (1993). A prospective study of delirium in elderly patients admitted to a psychiatric hospital. Psychol. Med., 23, 103–9.
Koponen, H. J., Stenbäck, U., Mattila, E., et al. (1989). Delirium among elderly persons admitted to a psychiatric hospital: Clinical course during the acute stage and one-year follow-up. Acta Psychiatr. Scand., 79, 579–85.
Kumral, E., Bayulkem, G., Evyapan, D. and Yunten, N. (2002). Spectrum of anterior cerebral artery territory infarction: Clinical and MRI findings. Eur. J. Neurol., 9, 615–24.
Kumral, E., Evyapan, D. and Balkir, K. (1999). Acute caudate vascular lesions. Stroke, 30, 100–8.
Kumral, E., Kocaer, T., Ertubey, N. O. and Kumral, K. (1995). Thalamic hemorrhage. A prospective study of 100 patients. Stroke, 26, 964–70.
Levkoff, S., Cleary, P., Litzin, B. and Evans, D. (1991). Epidemiology of delirium: An overview of research issues and findings. Int. Psychogeriatr., 3, 149–67.
Lipowski, Z. J. (1989). Delirium in the elderly patient. N. Engl. J. Med., 320, 578–82.
Lipowski, Z. (1990). Delirium in geriatric patients. In Delirium: Acute Confusional States. New York: Oxford University Press, pp. 413–41.
Lundstrom, M., Edlund, A., Bucht, G., Karlsson, S. and Gustafson, Y. (2003). Dementia after delirium in patients with femoral neck fractures. J. Am. Geriatr. Soc., 51, 1002–6.
Mach, J. R. Jr, Dysken, M. W., Kuskowski, M., et al. (1995). Serum anticholinergic activity in hospitalized older persons with delirium: A preliminary study. J. Am. Geriatr. Soc., 43, 491–5.
Madureira, S., Guerreiro, M. and Ferro, J. M. (1999). A follow-up study of cognitive impairment due to inferior capsular genu infarction. J. Neurol., 246, 764–9.
McCusker, J., Cole, M., Bellavance, F. and Primeau, F. (1998). Reliability and validity of a new measure of severity of delirium. Int. Psychogeriatr., 10, 421–33.
McCusker, J., Cole, M. G., Dendukuri, N. and Belzile, E. (2004). The delirium index, a measure of the severity of delirium: New findings on reliability, validity, and responsiveness. J. Am. Geriatr. Soc., 52, 1744–9.
McCusker, J., Cole, M., Dendukuri, N., Belzile, E. and Primeau, F. (2001). Delirium in older medical inpatients and subsequent cognitive and functional status: A prospective study. CMAJ, 165, 575–83.
McDonald, A. J. and Treloar, A. (1996). Delirium and dementia: Are they distinct?J. Am. Geriatr. Soc., 44, 1001–2.
Meagher, D. J. (2001). Delirium: Optimising management. BMJ, 322, 144–9.
Medina, J. L., Rubino, F. A. and Ross, E. (1974). Agitated delirium caused by infarctions of the hippocampal formation and fusiform and lingual gyri: A case report. Neurology, 24, 1181–3.
Mendez, M. F., Adams, N. L. and Lewandowsky, K. (1989). Neurobehavioral changes associated with caudate lesions. Neurology, 39, 349–54.
Mesulam, M. M., Waxman, S. G., Geschwind, N. and Sabin, T. D. (1976). Acute confusional states with right middle cerebral artery infarctions. J. Neurol. Neurosurg. Psychiatry, 39, 84–9.
Milandre, L., Brosset, C., Botti, G. and Khalil, R. (1994). A study of 82 cerebral infarctions in the area of posterior cerebral arteries. Rev. Neurol. (Paris), 150, 133–41.
Mobbs, R. J., Chandran, K. N. and Newcombe, R. L. (2001). Psychiatric presentation of aneurysmal subarachnoid haemorrhage. ANZ. J. Surg., 71, 69–70.
Monette, J., Galbaud du Fort, G., Fung, S. H., et al. (2001). Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen. Hosp. Psychiatry, 23, 20–5.
Mori, E., Matsunaga, K., Yokoyama, K. and Yamadori, A. (1981). The effect of bilateral thalamic infarction to human behaviour. Clin. Neurol., 21, 110–16.
Mori, E. and Yamadori, A. (1987). Acute confusional state and acute agitated delirium. Occurrence after infarction in the right middle cerebral artery territory. Arch. Neurol., 44, 1139–43.
Muir, K. W., Holzapfel, L. and Lees, K. R. (2000). Phase II clinical trial of sipatrigine (619C89) by continuous infusion in acute stroke. Cerebrovasc. Dis., 10, 431–6.
Mullaly, W., Huff, K., Ronthal, M. and Geschwind, N. (1982). Frequency of acute confusional states with lesions of the right hemisphere. Ann. Neurol., 12, 113.
Mullaly, W., Ronthal, M., Huff, K. and Geschwind, N. (1989). Chronic confusional state. N. J. Med., 86, 541–4.
Mussi, C., Ferrari, R., Ascari, S. and Salvioli, G. (1999). Importance of serum anticholinergic activity in the assessment of elderly patients with delirium. J. Geriatr. Psychiatry Neurol., 12, 82–6.
Nakamura, J., Uchimura, N., Yamada, S. and Nakazawa, Y. (1997). Does plasma free-3-methoxy-4-hydroxyphenyl (ethylene) glycol increase in the delirious state? A comparison of the effects of mianserin and haloperidol on delirium. Int. Clin. Psychopharmacol., 12, 147–52.
Naughton, B. J., Moran, M., Ghaly, Y. and Michalakes, C. (1997). Computed tomography scanning and delirium in elder patients. Acad. Emerg. Med., 4, 1107–10.
Nicolai, A. and Lazzarino, L. G. (1994). Acute confusional states secondary to infarctions in the territory of the posterior cerebral artery in elderly patients. Ital. J. Neurol. Sci., 15, 91–6.
O'Keeffe, S. T. (1994). Rating the severity of delirium: The delirium Assessment Scale. Int. J. Geriatr. Psychiatry, 9, 551–6.
O'Keeffe, S. T. (1999). Clinical subtypes of delirium in the elderly. Dement. Geriatr. Cogn. Disord., 5, 380–5.
O'Keeffe, S. and Lavan, J. (1997). The prognostic significance of delirium in older hospital patients. J. Am. Geriatr. Soc., 45, 174–8.
Olsson, T. (1999). Activity in the hypothalamic–pituitary–adrenal axis and delirium. Dement. Geriatr. Cogn. Disord., 10, 345–9.
Pedrazzi, P., Bogousslavsky, J. and Regli, F. (1990). Hématomes limités á la tête du noyau caudé. Rev. Neurol. (Paris), 146, 726–38.
Platt, M. M., Breitbart, W., Smith, M., et al. (1994). Efficacy of neuroleptics for hypoactive delirium. J. Neuropsychiatry Clin. Neurosci., 6, 66–7.
Pompei, P., Foreman, M., Rudberg, M. A., et al. (1994). Delirium in hospitalized older persons: Outcomes and predictors. J. Am. Geriatr. Soc., 42, 809–15.
Rahkonen, T., Eloniemi-Sulkava, U., Halonen, P., et al. (2001). Delirium in the non-demented oldest old in the general population: Risk factors and prognosis. J. Geriatr. Psychiatry, 16, 415–21.
Rahkonen, T., Luukkainen-Markkula, R., Paanila, S., Sivenius, J. and Sulkava, R. (2000). Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: A 2 year follow up study. J. Neurol. Neurosurg. Psychiatry, 69, 519–21.
Reijneveld, J. C., Wermer, M., Boonman, Z., Gijn, J. and Rinkel, G. J. (2000). Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: Frequency and characteristics. J. Neurol., 247, 112–16.
Reyes-Ortiz, C. A. (1997). Delirium, dementia and brain reserve. J. Am. Geriatr. Soc., 45, 778–9.
Richfield, E. K., Twyman, R. and Berent, S. (1987). Neurological syndrome following bilateral damage to the head of the caudate nuclei. Ann. Neurol., 22, 768–71.
Robertsson, B. (1999). Assessment scales in delirium. Dement. Geriatr. Cogn. Disord., 10, 368–79.
Robertsson, B., Karlsson, I., Styrud, E. and Gottfries, C. G. (1997). Confusional State Evaluation (CSE): An instrument for measuring severity of delirium in the elderly. Br. J. Psychiatry, 170, 565–70.
Rockwood, K., Cosway, S., Carver, D., et al. (1999). The risk of dementia and death after delirium. Age Ageing, 28, 551–6.
Sandberg, O., Franklin, K. A., Bucht, G. and Gustafson, Y. (2001). Sleep apnea, delirium, depressed mood, cognition, and ADL ability after stroke. J. Am. Geriatr. Soc., 49, 391–7.
Schmidley, J. W. and Messing, R. O. (1984). Agitated confusional states in patients with right hemisphere infarctions. Stroke, 15, 883–5.
Schofield, I. (1997). A small exploratory study of the reaction of older people to an episode of delirium. J. Adv. Nurs., 25, 942–52.
Schor, J. D., Levkoff, S. E., Lipstitz, L. A., et al. (1992). Risk factors for delirium in hospitalised elderly. JAMA, 267, 827–31.
Simon, L., Jewell, N. and Brokel, J. (1997). Management of acute delirium in hospitalized elderly: A process improvement project. Geriatr. Nurs., 18, 150–4.
Sipahimalani, A. and Masand, P. S. (1997). Use of risperidone in delirium: Case reports. Ann. Clin. Psychiatry., 9, 105–7.
Sipahimalani, A. and Masand, P. S. (1998). Olanzapine in the treatment of delirium. Psychosomatics, 39, 422–30.
Stein, R. W., Kase, C. S., Hier, D. B., et al. (1984). Caudate hemorrhage. Neurology, 34, 1549–54.
Sumner, A. D. and Simons, R. J. (1994). Delirium in the hospitalized elderly. Cleve. Clin. J. Med., 61, 258–62.
Symonds, C. and MacKenzie, I. (1957). Bilateral loss of vision from cerebral infarction. Brain, 80, 415–55.
Tatemichi, T. K., Desmond, D. W., Prohovnik, I., et al. (1992). Confusion and memory loss from capsular genu infarction: A thalamocortical disconnection syndrome?Neurology, 42, 1966–79.
Trzepacz, P. T. (1999a). The Delirium Rating Scale. Its use in consultation-liaison research. Psychosomatics, 40, 193–204.
Trzepacz, P. T. (1999b). Update on the neuropathogenesis of delirium. Dement. Geriatr. Cogn. Disord., 10, 330–4.
Trzepacz, P. T., Baker, R. W. and Greenhouse, J. (1988). A symptom rating scale for delirium. Psychiatry Res., 23, 89–97.
Trzepacz, P. T., Mittal, D., Torres, R., et al. (2001). Validation of the Delirium Rating Scale-revised-98, comparison with the delirium rating scale and the cognitive test for delirium. J. Neuropsychiatry Clin. Neurosci., 13, 229–42.
Tune, L., Carr, S., Hoag, E. and Cooper, T. (1992). Anticholinergic effects of drugs commonly prescribed for the elderly: Potential means for assessing risk of delirium. Am. J. Psychiatry, 149, 1393–4.
Tune, L. R. and Egeli, S. (1999). Acetylcholine and delirium. Dement. Geriatr. Cogn. Disord., 10, 342–4.
Vatsavayi, V., Malhotra, S. and Franco, K. (2003). Agitated delirium with posterior cerebral artery infarction. J. Emerg. Med., 24, 263–6.
Verslegers, W., Deyn, P. P., Saerens, J., et al. (1991). Slow progressive bilateral posterior artery infarction presenting as agitated delirium, complicated with Anton's syndrome. Eur. Neurol., 31, 216–19.
Wengel, S. P., Burke, W. J. and Roccaforte, W. H. (1999). Donepezil for postoperative delirium associated with Alzheimer's disease. J. Am. Geriatr. Soc., 47, 379–80.
Wengel, S. P., Roccaforte, W. H. and Burke, W. J. (1998). Donezepil improves symptoms of delirium in dementia: Implications for future research. J. Geriatr. Psychiatry Neurol., 11, 159–61.
Wooltorton, E. (2004). Olanzapine (Zyprexa): Increased incidence of cerebrovascular events in dementia trials. CMAJ, 170, 1395.