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Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies

  • Sarah Richardson (a1), Andrew Teodorczuk (a2), Giuseppe Bellelli (a3), Daniel H. J. Davis (a4), Karin J. Neufeld (a5), Barbara A. Kamholz (a6), Marco Trabucchi (a7), Alasdair M. J. MacLullich (a8) and Alessandro Morandi (a9)...

Abstract

Background:

Despite advances in delirium knowledge and the publication of best practice guidelines, uncertainties exist regarding assessment of Delirium Superimposed on Dementia (DSD). An international survey of delirium specialists was undertaken to evaluate current practice.

Methods:

Invitations to participate in an online survey were distributed by email among members of four international delirium associations with additional publication on their websites. The survey covered the assessment and diagnosis of DSD in clinical practice and research studies. Questions were structured around current practice and attitudes.

Results:

The 205 responders were mostly confident that they could detect DSD with 60% rating their confidence at 7 or above on a likert scale of 0 (none) to 10 (excellent). Seventy-six percent felt that Dementia with Lewy Bodies (DLB) was the most challenging dementia subtype in which to diagnose DSD. Several scales were used to assess for the presence of DSD including the Confusion Assessment Method (CAM) (54%), DSM-5 criteria (25%) and CAM-ICU (15%). Responders stated that attention (71%), fluctuation in cognitive status (65%), and arousability (41%) were the most clinically useful features to assess when diagnosing DSD. Motor fluctuations were also deemed important but 61% had no specific test to monitor these.

Conclusions:

The largest survey of DSD practice to date demonstrates that despite good levels of confidence in recognizing DSD, there exists a lack of consensus concerning assessment and diagnosis globally. These findings suggest the need for the development of more research leading to precise diagnostic criteria and comprehensive guidelines regarding the assessment and diagnosis of DSD.

Copyright

Corresponding author

Correspondence should be addressed to: Sarah Richardson, 3rd floor Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, NE4 5 PL, UK. Phone: 0191 2081314. Email: Sarah.Richardson1@newcastle.ac.uk.

References

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Albert, S. M., Costa, R., Merchant, C., Small, S., Jenders, R. A. and Stern, Y. (1999). Hospitalization and Alzheimer's disease: results from a community-based study. Journals of Gerontology: Series A Biological Sciences and Medical Sciences, 54, M267M271. doi:10.1093/gerona/54.5.M267.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn, (DSM-5). Washington, DC: American Psychiatric Association.
Ballard, C., Corbett, A. and Howard, R. (2014). Prescription of antipsychotics in people with dementia. British Journal Psychiatry, 205, 45. doi:10.1192/bjp.bp.113.128710.
Ballard, C. et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews. Neurology, 5, 245255. doi:10.1038/nrneurol.2009.39.
Bellelli, G., Frisoni, G. B., Turco, R., Lucchi, E., Magnifico, F. and Trabucchi, M. (2007). Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 62, 13061309. doi:10.1093/gerona/62.11.1306.
Bellelli, G., Speciale, S., Morghen, S., Torpilliesi, T., Turco, R. and Trabucchi, M. (2011). Are fluctuations in motor performance a diagnostic sign of delirium? Journal of the American Medical Directors Association, 12, 578583. doi:10.1016/j.jamda.2010.04.010.
Bergeron, N., Dubois, M. J., Dumont, M., Dial, S. and Skrobik, Y. (2001). Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Medicine, 27, 859864.
Brown, L. J., Fordyce, C., Zaghdani, H., Starr, J. M. and MacLullich, A. M. (2011). Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery and Psychiatry, 82, 13341340. doi:10.1136/jnnp.2010.208827.
Collins, N., Blanchard, M. R., Tookman, A. and Sampson, E. L. (2010). Detection of delirium in the acute hospital. Age and Ageing, 39, 131135.
Davis, D. H. et al. (2012). Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain, 135, 28092816.
Ely, E. W. et al. (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association, 286, 27032710.
Fick, D. M., Agostini, J. V. and Inouye, S. K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatric Society, 50, 17231732. doi:10.1046/j.1532–5415.2002.50468.x.
Fick, D. M., Hodo, D. M., Lawrence, F. and Inouye, S. K. (2007). Recognizing delirium superimposed on dementia: assessing nurses’ knowledge using case vignettes. Journal of Gerontological Nursing, 33, 4049.
Fick, D. M., Steis, M. R., Waller, J. L. and Inouye, S. K. (2013). Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. Journal of Hospital Medicine, 8, 500505. doi:10.1002/jhm.2077.
Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A. and Inouye, S. K. (2015). The interface between delirium and dementia in elderly adults. The Lancet, 14, 823832. doi:10.1016/S1474-4422(15)00101-5.
Fong, T. G. et al. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology, 72, 15701575.
Givens, J. L., Sanft, T. B. and Marcantonio, E. R. (2008). Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium. Journal of the American Geriatrics Society, 56, 10751079. doi:10.1111/j.1532-5415.2008.01711.x.
Han, J. H. et al. (2014). Impaired arousal at initial presentation predicts 6-month mortality: an analysis of 1084 acutely ill older patients. Journal of Hospital Medicine, 9, 772778.
Hasegawa, N. et al. (2013). Prevalence of delirium among outpatients with dementia. International Psychogeriatrics, 25, 1877–1833. doi:10.1017/S1041610213001191.
Holmes, J. and House, A. (2000). Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine, 30, 921929.
Inouye, S. K. et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, 669676.
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P. and Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941948.
Jackson, T. A., Wilson, D., Richardson, S. and Lord, J. M. (2015). Predicting outcome in older hospital patients with delirium: a systematic literature review. International Journal of Geriatric Psychiatry, doi:10.1002/gps.4344.
Landreville, P., Voyer, P. and Carmichael, P.-H. (2013). Relationship between delirium and behavioural symptoms of dementia. International Psychogeriatrics, 25, 635643. doi:10.1017/S1041610212002232.
MacKnight, C. and Rockwood, K. (1995). A hierarchical assessment of balance and mobility. Age and Ageing, 24, 126130.
MacLullich, A. M., Meagher, D. J., Laurila, J. V. and Kalisvaart, K. J. (2007). The European delirium association. Journal of Psychosomatic Research, 62, 397398.
Meagher, D. J., Leonard, M., Donnelly, S., Conroy, M., Saunders, J. and Trzepacz, P. T. (2010). A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Journal of Neurology, Neurosurgery and Psychiatry, 81, 876881. doi:10.1136/jnnp.2009.200956.
Morandi, A. et al. (2012). Tools to detect delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 60, 20052013. doi:10.1111/j.1532-5415.2012.04199.x.
Morandi, A. et al. (2013). Consensus and variations in opinions on delirium care: a survey of European delirium specialists. International Psychogeriatriatrics, 25, 20672075. doi:10.1017/S1041610213001415.
Morandi, A. et al. (2014). Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. Journal of the American Medical Directors Association, 15, 349354. doi:10.1016/j.jamda.2013.12.084.
National Institute for Health and Clinical Excellence (2010). Delirium: diagnosis, prevention and managment. Available at: http://www.nice.org.uk/CG103; last accessed 14 August 2015.
Neef, D. and Walling, A. D. (2006). Dementia with Lewy bodies: an emerging disease. American Family Physician, 73, 12231229.
Partridge, J. S. L., Martin, F. C., Harari, D. and Dhesi, J. K. (2013). The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? International Journal of Geriatric Psychiatry, 28, 804812. doi:10.1002/gps.3900.
Robinson, L., Tang, E. and Taylor, J.-P. (2015). Dementia: timely diagnosis and early intervention. British Medical Journal, 350, h3029. doi:http://dx.doi.org/10.1136/bmj.h3029.
Ryan, D. J. et al. (2013). Delirium in an adult acute hospital population: predictors, prevalence and detection. British Medical Journal Open, 3, e001772. doi:10.1136/bmjopen-2012-001772.
Sampson, E. L., Blanchard, M. R., Jones, L., Tookman, A. and King, M. (2009). Dementia in the acute hospital: prospective cohort study of prevalence and mortality. British Journal of Psychiatry, 195, 6166. doi:10.1192/bjp.bp.108.055335.
Savva, G. M. and Arthur, A. (2015). Who has undiagnosed dementia? A cross-sectional analysis of participants of the aging, demographics and memory study. Age and Ageing, 44, 642647. doi:10.1093/ageing/afv020.
Sessler, C. N. et al. (2002). The richmond agitation–sedation scale. American Journal of Respiratory and Critical Care Medicine, 166, 13381344.
Teasdale, G. and Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2, 8184.
Tieges, Z., Brown, L. J. E. and MacLullich, A. M. J. (2014). Objective assessment of attention in delirium: a narrative review. International Journal of Geriatric Psychiatry, 29, 11851197. doi:10.1002/gps.4131.
Tieges, Z., McGrath, A., Hall, R. J. and Maclullich, A. M. (2013). Abnormal level of arousal as a predictor of delirium and inattention: an exploratory study. American Journal of Geriatric Psychiatry, 21, 12441253.
Trzepacz, P. T., Mittal, D., Torres, R., Kanary, K., Norton, J. and Jimerson, N. (2001). Validation of the delirium rating scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. The Journal of Neuropsychiatry & Clinical Neurosciences, 13, 229242.
Vardy, E., Holt, R., Gerhard, A., Richardson, A., Snowden, J. and Neary, D. (2014). History of a suspected delirium is more common in dementia with Lewy bodies than Alzheimer's disease: a retrospective study. International Journal of Geriatric Psychiatry, 29, 178181. doi:10.1002/gps.3986.
Voyer, P., Cole, M. G., McCusker, J. and Belzile, E. (2006). Prevalence and symptoms of delirium superimposed on dementia. Clinical Nursing Research, 15, 4666.
Voyer, P., Richard, S., Doucet, L., Danjou, C. and Carmichael, P.-H. (2008). Detection of delirium by nurses among long-term care residents with dementia. BioMedCentral Nursing, 7, 44.
Witlox, J., Eurelings, L. S., de Jonghe, J. F., Kalisvaart, K. J., Eikelenboom, P. and van Gool, W. A. (2010). Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. Journal of the American Medical Association, 304, 443451. doi:10.1001/jama.2010.1013.
Yevchak, A. M. et al. (2015). Impaired arousal in older adults is associated with prolonged hospital stay and discharge to skilled nursing facility. Journal of the American Medical Directors Association, 16, 586589.

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