Skip to main content Accessibility help
  • Print publication year: 2013
  • Online publication date: March 2013

26 - Delirium and confusional state in stroke patients

from Section VI - Behavioral and mood disorders


1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn text revision. Washington, DC: American Psychiatric Association, 2000.
2. World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders, 10th edn. Geneva: World Health Organization, 1992.
3. AdamsRD, ViktorM, RopperAH. Principles of Neurology, 6th edn. New York: McGraw-Hill, 1997: 405–16.
4. CamusV, GonthierR, DubosG, SchwedP, Simeone, I. Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J Geriatr Psychiatry Neurol 2000; 13: 38–42.
5. YoungJ, InouyeSK. Delirium in older people. BMJ 2007; 334: 842–6.
6. SiddiqiN, HouseAO, HolmesJD. Occurrence and outcome of delirium in medical in-patients. Age Ageing 2006; 35: 350–64.
7. McCuskerJ, ColeM, DendukuriN, BelzileE, PrimeauF. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 2001; 165: 575–83.
8. WitloxJ, EurelingsLS, de JongheJF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010; 28: 443–51.
9. LipowskiZJ. Delirium in the elderly patient. N Engl J Med 1989; 320: 578–82.
10. RahkonenT, Luukkainen-MarkkulaR, PaanilaS, SiveniusJ, SulkavaR. Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: a 2 year follow up study. J Neurol Neurosurg Psychiatry 2000; 69: 519–21.
11. HanL, McCuskerJ, ColeM, et al. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Intern Med 2001; 161: 1099–105.
12. CaeiroL, FerroJM, ClaroMI, et al. Delirium in acute stroke: a preliminary study of the role of anticholinergic medications. Eur J Neurol 2004; 11: 699–704.
13. EdlundA, LundströmM, KarlssonS, et al. Delirium in older patients admitted to general internal medicine. J Geriatr Psychiatry Neurol 2006; 19: 83–90.
14. NaughtonBJ, MoranM, GhalyY, MichalakesC. Computed tomography scanning and delirium in elder patients. Acad Emerg Med 1997; 4: 1107–10.
15. FerroJM, CaeiroL, VerdelhoA. Delirium in acute stroke. Curr Opin Neurol 2002; 15: 51–5.
16. MaclullichAM, FergusonKJ, MillerT, de RooijSE, CunninghamC. Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses. J Psychosom Res 2008; 65: 229–38.
17. TrzepaczPT. Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999; 10: 330–4.
18. OlssonT. Activity in the hypothalamic-pituitary-adrenal axis and delirium. Dement Geriatr Cogn Disord 1999; 10: 345–9.
19. GustafsonY, OlssonT, AsplundK, HäggE. Acute confusional state (delirium) soon after stroke is associated with hypercortisolism. Cerebrovasc Dis 1993; 3: 33–8.
20. FassbenderK, SchmidtR, MossnerR, DaffertshoferM, HennericiM. 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 1994; 25: 1105–8.
21. InouyeSK. Delirium in older persons. N Engl J Med 2006; 16: 1157–65.
22. HshiehTT, FongTG, MarcantonioER, InouyeSK. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci 2008; 63: 764–72.
23. TuneLR and EgeliS. Acetylcholine and delirium. Dement Geriatr Cogn Disord 1999; 10: 342–4.
24. WengelSP, RoccaforteWH, BurkeWJ. Donezepil improves symptoms of delirium in dementia: implications for future research. J Geriatr Psychiatr Neurol 1998; 11: 159–61.
25. FisherP. Successful treatment of nonanticholinergic delirium with a cholinesterase inhibitor. J Clin Pharmacol 2001; 21: 118.
26. MussiC, FerrariR, AscariS, SalvioliG. Importance of serum anticholinergic activity in the assessment of elderly patients with delirium. J Geriatr Psychiatr Neurol 1999; 12: 82–6.
27. AlsopDC, FearingMA, JohnsonK, et al. The role of neuroimaging in elucidating delirium pathophysiology. J Gerontol A Biol Sci Med Sci 2006; 61: 1287–93.
28. FongTG, BogardusST, Jr., DaftaryA, et al. Cerebral perfusion changes in older delirious patients using 99mTc HMPAO SPECT. J Gerontol A Biol Sci Med Sci 2006; 61: 1294–99.
29. Reyes-OrtizCA. Delirium, dementia and brain reserve. J Am Geriatr Soc 1997; 45: 778–9.
30. FlackerJM, WeiJY. Endogenous anticholinergic substances may exist during acute illness in elderly medical patients. J Gerontol A Biol Sci Med Sci 2001; 56: M353–5.
31. InouyeSK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97: 278–88.
32. RobertssonB. Assessment scales in delirium. Dement Geriatr Cogn Disord 1999; 10: 368–79.
33. InouyeSK, van DyckCH, AlessiCA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: 941–8.
34. MonetteJ, Galbaud du FortG, et al. Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen Hosp Psychiatry 2001; 23: 2025.
35. JensenE, DehlinO, GustafsonL. A comparison between three psychogeriatric rating scales. Int J Geriatr Psychiatry 1993; 8: 215–29.
36. AlbertMS, LevkoffSE, ReillyC, et al. The delirium symptom interview: an interview for the detection of delirium symptoms in hospitalized patients. J Geriatr Psychiatry Neurol 1992; 5: 14–21.
37. TrzepaczPT, BakerRW, GreenhouseJ. A symptom rating scale for delirium. Psychiatry Res. 1988; 23: 89–97.
38. TrzepaczPT, MittalD, TorresR, et al. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001; 13: 229–42.
39. BreitbartW, RosenfeldB, RothA, et al. The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997; 13: 128–37.
40. O'KeeffeST. Rating the severity of delirium: the delirium Assessment Scale. Int J Geriatr Psychiatry 1994; 9: 551–6.
41. RobertssonB, KarlssonI, StyrudE, GottfriesCG. Confusional State Evaluation (CSE): an instrument for measuring severity of delirium in the elderly. Br J Psychiatry 1997; 170: 565–70.
42. McCuskerJ, ColeM, BellavanceF, PrimeauF. Reliability and validity of a new measure of severity of delirium. Int Psychogeriatr 1998; 10: 421–33.
43. GustafsonY, OlssonT, ErikssonS, AsplundK, BuchtG. Acute confusional states (delirium) in stroke patients. Cerebrovasc Dis 1991; 1: 257–64.
44. HénonH, LebertF, DurieuI, et al. Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome. Stroke 1999; 30: 773–9.
45. SandbergO, FranklinKA, BuchtG, GustafsonY. Sleep apnea, delirium, depressed mood, cognition, and ADL ability after stroke. J Am Geriatr Soc 2001; 49: 391–7.
46. CaeiroL, FerroJM, AlbuquerqueR, FigueiraML. Delirium in the first days of acute stroke. J Neurol 2004; 251: 171–8.
47. CaeiroL, MengerC, FerroJM, AlbuquerqueR, FigueiraML. Delirium in acute subarachnoid haemorrhage. Cerebrovasc Dis 2005; 19: 31–8.
48. McManusJ, PathansaliR, HassanH, et al. The course of delirium in acute stroke. Age Ageing 2009; 38: 385–9.
49. ShengAZ, ShenQ, CordatoD, ZhangYY, Yin ChanDK. Delirium within three days of stroke in a cohort of elderly patients. J Am Geriatr Soc 2006; 54: 1192–8.
50. DahlMH, RønningOM, ThommessenB. Delirium in acute stroke–prevalence and risk factors. Acta Neurol Scand Suppl 2010; 190: 39–43.
51. OldenbeuvingAW, de KortPL, JansenBP, et al. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology 2011; 15: 993–9.
52. DostovićZ, SmajlovićD, SinanovićO, VidovićM. Duration of delirium in the acute stage of stroke. Acta Clin Croat 2009; 48: 13–17.
53. GodefroyO, RousseauxM, PruvoJP, CabaretM, LeysD. Neuropsychological changes related to unilateral laterostriatal infarcts. J Neurol Neurosurg Psychiatry 1994; 57: 480–5.
54. KumralE, KocaerT, ErtubeyNO, KumralK. Thalamic hemorrhage. A prospective study of 100 patients. Stroke 1995; 26: 964–70.
55. Graff-RadfordNR, EslingerPJ, DamasioAR, YamadaT. Nonhemorrhagic infarction of the thalamus: behavioral, anatomic, and physiologic correlates. Neurology 1984; 34: 14–23.
56. CastaigneP, LhermitteF, BugeA, et al. Paramedian thalamic and midbrain infarct: clinical and neuropathological study. Ann Neurol 1981; 10: 127–48.
57. GaudreauJD, GagnonP. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypoth 2005; 64: 471–5.
58. DevinskyO, Bea, RD, VolpeBT. Confusional states following posterior cerebral artery infarction. Arch Neurol 1988; 45: 160–3.
59. MilandreL, BrossetC, BottiG, KhalilR. A study of 82 cerebral infarctions in the area of posterior cerebral arteries. Rev Neurol (Paris) 1994; 150: 133–41.
60. ShihHT, HuangWS, LiuCH, et al. Confusion or delirium in patients with posterior cerebral arterial infarction. Acta Neurol Taiwan 2007; 16: 136–42.
61. CaplanLR.Posterior Circulation Disease: Clinical Findings, Diagnosis and Management. Boston, MA: Butterworth-Heinemann, 1996.
62. KumralE, BayulkemG, EvyapanD, YuntenN. Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings. Eur J Neurol 2002; 9: 615–24.
63. CaplanLR, SchmahmannJD, KaseCS, et al. Caudate infarcts. Arch Neurol 1990; 47: 133–43.
64. KumralE, EvyapanD, BalkirK. Acute caudate vascular lesions. Stroke 1999; 30: 100–8.
65. AlexanderGE, DeLongMR, StrickPL. Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Ann Rev Neurosci 1986; 9: 357–81.
66. TatemichiTK, DesmondDW, ProhovnikI, et al. Confusion and memory loss from capsular genu infarction: a thalamocortical disconnection syndrome?Neurology 1992; 42: 1966–79.
67. MesulamMM, WaxmanSG, GeschwindN, SabinTD. Acute confusional states with right middle cerebral artery infarctions. J Neurol Neurosurg Psychiatry 1976; 39: 84–9.
68. MoriE, YamadoriA. Acute confusional state and acute agitated delirium. Occurrence after infarction in the right middle cerebral artery territory. Arch Neurol 1987; 44: 1139–43.
69. MullalyW, RonthalM, HuffK, GeschwindN. Chronic confusional state. N J Med 1989; 86: 541–4.
70. MobbsRJ, ChandranKN, NewcombeRL. Psychiatric presentation of aneurysmal subarachnoid haemorrhage. Aust N Z J Surg 2001; 71: 69–70.
71. ReijneveldJC, WermerM, BoonmanZ, van GijnJ, RinkelGJ. Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics. J Neurol 2000; 247: 112–16.
72. BourneRS, TahirTA, BorthwickM, SampsonEL. Drug treatment of delirium: past, present and future. Psychosom Res 2008; 65: 273–82.
73. ColeMG. Delirium: effectiveness of systematic interventions. Dement Geriatr Cogn Disord 1999; 10: 406–11.
74. SimonL, JewellN, BrokelJ. Management of acute delirium in hospitalized elderly: a process improvement project. Geriatr Nurs 1997; 18: 150–4.
75. InouyeSK, BogardusST, Jr., CharpentierPA., et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76.
76. MeagherDJ. Delirium: optimising management. BMJ 2001; 322: 144–9.
77. American Psychiatric Association. Practice guidelines for the treatment of delirium. Am J Psychiatry 1999; 156: 1–20.
78. BreitbartW, MarottaR, PlattMM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153: 231–7.
79. SipahimalaniA, MasandPS. Olanzapine in the treatment of delirium. Psychosomatics 1998; 39: 422–30.
80. SipahimalaniA, MasandPS. Use of risperidone in delirium: case reports. Ann Clin Psychiatry 1997; 9: 105–7.
81. BeuzenJN, TaylorN, WesnesK, WoodA. A comparison of the effects of olanzapine, haloperidol and placebo on cognitive and psychomotor functions in healthy elderly volunteers. J Psychopharmacol 1999; 13: 152–8.
82. BrodatyH, AmesD, SnowdonJ, et al. A randomized placebo controlled trial of risperidone for the treatment of aggression, agitation, and psychosis in dementia. J Clin Psychiatry 2003; 64: 134–43.
83. WooltortonE. Olanzapine (Zyprexa): increased incidence of cerebrovascular events in dementia trials. CMAJ 2004; 170: 1395.
84. GillSS, RochonPA, HerrmannN, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ 2005; 330: 445.
85. LonerganE, BrittonAM, LuxenbergJ, WyllerT. Antipsychotics for delirium. Cochrane Database Syst Rev 2007; (2): CD005594.
86. LonerganE, LuxenbergJ, AreosaSastre A. Benzodiazepines for delirium. Cochrane Database Syst Rev 2009; (4): CD006379.
87. BurkeWJ, RoccaforteWH, WengelSP. Treating visual hallucinations with donepezil. Am J Psychiatry 1999; 156: 1117–18.
88. KobayashiK, HigashimaM, MutouK, et al. Severe delirium due to basal forebrain vascular lesion and efficacy of donepezil. Prog Neuropsychopharmacol Biol Psychiatry 2004; 28: 1189–94.
89. OldenbeuvingAW, de KortPL, JansenBP, KappelleLJ, RoksG. A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative. BMC Neurol 2008; 8: 34.
90. van EijkMM, RoesKC, HoningML, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010; 376: 1829–37.