Skip to main content Accessibility help
×
Home

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

  • D. Meagher (a1), N. O'Regan (a2), D. Ryan (a2), W. Connolly (a2), E. Boland (a2), R. O'Caoimhe (a2), J. Clare (a2), J. Mcfarland (a3), S. Tighe (a3), M. Leonard (a4), D. Adamis (a5), P. T. Trzepacz (a6) and S. Timmons (a2)...

Abstract

Background

The frequency of full syndromal and subsyndromal delirium is understudied.

Aims

We conducted a point prevalence study in a general hospital.

Method

Possible delirium identified by testing for inattention was evaluated regarding delirium status (full/subsyndromal delirium) using categorical (Confusion Assessment Method (CAM), DSM-IV) and dimensional (Delirium Rating Scale-Revised-98 (DRS-R98) scores) methods.

Results

In total 162 of 311 patients (52%) screened positive for inattention. Delirium was diagnosed in 55 patients (17.7%) using DSM-IV, 52 (16.7%) using CAM and 58 (18.6%) using DRS-R98⩾12 with concordance for 38 (12.2%) individuals. Subsyndromal delirium was identified in 24 patients (7.7%) using a DRS-R98 score of 7–11 and 41 (13.2%) using 2/4 CAM criteria. Subsyndromal delirium with inattention (v. without) had greater disturbance of multiple delirium symptoms.

Conclusions

The point prevalence of delirium and subsyndromal delirium was 25%. There was modest concordance between DRS-R98, DSM-IV and CAM delirium diagnoses. Inattention should be central to subsyndromal delirium definitions.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Frequency of delirium and subsyndromal delirium in an adult acute hospital population
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Frequency of delirium and subsyndromal delirium in an adult acute hospital population
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Frequency of delirium and subsyndromal delirium in an adult acute hospital population
      Available formats
      ×

Copyright

Corresponding author

David Meagher, Graduate-entry Medical School, University of Limerick, Ireland. Email: david.meagher@ul.ie

Footnotes

Hide All

Declaration of interest

P.T.T. is a full-time employee and minor shareholder at Eli Lilly & Company. P.T.T. holds the copyright for the Delirium Rating Scale – Revised-98, but does not charge a fee for its non-for-profit use.

Footnotes

References

Hide All
1 Witlox, J, Eurelings, LS, de Jonghe, JF, Kalisvaart, KJ, Eikelenboom, P, van Gool, WA. Delirium in elderly patients and the risk of post discharge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010; 304: 443–51.
2 Marcantonio, E, Ta, T, Duthie, E, Resnick, NM. Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. J Am Geriatr Soc 2002; 50: 850–7.
3 Dosa, D, Intrator, O, McNicoll, L, Cang, Y, Teno, J. Preliminary derivation of a Nursing Home Confusion Assessment Method based on data from the minimum data set. J Am Geriatr Soc 2007; 55: 1099–105.
4 Ouimet, S, Riker, R, Bergeron, N, Cossette, M, Kavanagh, B, Skrobik, Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med 2007; 33: 1007–13.
5 Cole, MG, McCusker, J, Ciampi, A, Belzile, E. The 6- and 12-month outcomes of older medical inpatients who recover from subsyndromal delirium. J Am Geriatr Soc 2008; 56: 2093–9.
6 Martinez-Velilla, N, Alonso-Bouzon, C, Cambra-Contin, K, Ibañez-Beroiz, B, Alonso-Renedo, J. Outcome in complex patients with delirium and subsyndromal delirium one year after hospital discharge. Int Psychogeriatrics 2013; 25: 2087–8.
7 Cole, M, McCusker, J, Dendukuri, N, Han, L. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc 2003; 51: 754–60.
8 Cole, MG, McCusker, J, Voyer, P, Monette, J, Champoux, N, Ciampi, A, et al. Subsyndromal delirium in older long-term care residents: incidence, risk factors, and outcomes. J Am Geriatr Soc 2011; 59: 1829–36.
9 Bourdel-Marchasson, I, Vincent, S, Germain, C, Salles, N, Jenn, J, Rasoamanarivo, E, et al. Delirium symptoms and low dietary intake in older inpatients are independent predictors of institutionalization: a 1-year prospective population-based study. J Gerontol Biol Med Sci 2004; 59: 350–4.
10 Marcantonio, ER, Kiely, DK, Simon, SE, John Orav, E, Jones, RN, Murphy, KM, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc 2005; 53: 963–9.
11 Tan, MC, Felde, A, Kuskowski, M, Ward, H, Kelly, RF, Adabag, AS, et al. Incidence and predictors of post-cardiotomy delirium. Am J Geriatric Psychiatry 2008; 16: 575–83.
12 Leonard, M, Spiller, J, Keen, J, MacLullich, A, Kamholtz, B, Meagher, D. Symptoms of depression and delirium assessed serially in palliative-care inpatients. Psychosomatics 2009; 50: 506–14.
13 Bond, SM, Dietrich, MS, Shuster, JL Jr, Murphy, BA. Delirium in patients with head and neck cancer in the outpatient treatment setting. Support Care Cancer 2012; 20: 1023–30.
14 von Gunten, A, Mosimann, UP. Delirium upon admission to Swiss nursing homes: a cross-sectional study. Swiss Med Wkly 2010; 140: 376–81.
15 Zuliani, G, Bonetti, F, Magon, S, Prandini, S, Sioulis, F, D'Amato, M, et al. Subsyndromal delirium and its determinants in elderly patients hospitalized for acute medical illness. J Gerontol A Biol Sci Med Sci. 2013; 68: 1296–302.
16 Franco, JG, Trzepacz, PT, Mejía, MA, Ochoa, SB. Factor analysis of the Colombian translation of the Delirium Rating Scale (DRS), Revised-98. Psychosomatics 2009; 50: 255–62.
17 Grover, S, Mattoo, S, Chakravarty, K, Trzepacz, PT, Meagher, D, Gupta, N. Symptom profile and etiology of delirium in a referral population in Northern India: factor analysis of the DRS-R98. J Neuropsychiatry Clin Neurosci 2012; 24: 95101.
18 Meagher, D, Adamis, D, Trzepacz, P, Leonard, M. Features of subsyndromal and persistent delirium. Br J Psychiatry 2012; 200: 3744.
19 Ceriana, P, Fanfulla, F, Mazzacane, F, Santoro, C, Nava, S. Delirium in patients admitted to a step-down unit: analysis of incidence and risk factors. J Crit Care 2010; 25: 136–43.
20 Skrobik, Y, Ahern, S, Leblanc, M, Marquis, F, Awissi, DK, Kavanagh, BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improvesanalgesia and subsyndromal delirium rates. Anesth Analg 2010; 111: 451–63.
21 Hakim, SM, Othman, AI, Naoum, DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: a randomized trial. Anesthesiology 2012; 116: 987–97.
22 Voyer, P, Richard, S, Doucet, L, Carmichael, PH. Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents. J Am Med Dir Assoc 2009; 10: 181–8.
23 Ryan, DJ, O'Regan, NA, Ó Caoimh, R, Clare, J, O'Connor, M, Leonard, M, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open 2013; 3: e001772.
24 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder (4th edn) (DSM-IV). APA, 1994.
25 Hart, RP, Levenson, JL, Sessler, CN, Best, AM, Schwartz, SM, Rutherford, LE. Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 1996; 37: 533–46.
26 Blessed, G, Tomlinson, BE, Roth, M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry 1968; 114: 797811.
27 Meagher, DJ, Leonard, M, Donnelly, S, Conroy, M, Saunders, J, Trzepacz, PT. A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls. J Neurol Neurosurg Psychiatry 2010; 81: 876–81.
28 Inouye, SK, van Dyck, C. H., Balkin, S, Siegal, AP, Horwitz, RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: 941–8.
29 Trzepacz, PT, Mittal, D, Torres, R, Kanary, K, Norton, J, Jimerson, N. 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.
30 Trzepacz, PT, Maldonado, JR, Kean, J, Abell, M, Meagher, DJ. The Delirium Rating Scale-Revised-98 (DRS-R98) Administration Manual. A Guide to Increase Understanding of How to Solicit Delirium Symptoms to Administer the DRS-R98. Paula Trzepacz, 2010.
31 Franco, JG, Mejía, MA, Ochoa, SB, Ramírez, LF, Bulbena, A, Trzepacz, PT. Delirium rating scale-revised-98 (DRS-R-98): Colombian adaptation of the Spanish version. Actas Esp Psiquiatr 2007; 35: 170–5.
32 Kato, M, Kishi, Y, Okuyama, T, Trzepacz, PT, Hosaka, T. Japanese version of the Delirium Rating Scale, Revised-98 (DRS-R98-J): reliability and validity. Psychosomatics 2010; 51: 425–31.
33 Jorm, AF. The Informant Questionnaire on cognitive decline in the elderly (IQCODE): a review. IntPsychogeriatrics 2004; 16: 275–93.
34 Charlson, ME, Pompei, P, Ales, KL, Mackenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373–83.
35 World Medical Association. Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. World Medical Association, 2004 (http://www.wma.net/en/30publications/10policies/b3/).
36 Siddiqi, N, House, AO, Holmes, JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006; 35: 350–64.
37 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder (5th edn) (DSM-5). APA, 2013.
38 Inouye, SK, Foreman, MD, Mion, LC, Katz, KH, Cooney, LM Jr. Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med 2001; 161: 2467–73.
39 Ryan, K, Leonard, M, Guerin, S, Donnelly, S, Conroy, M, Meagher, D. Validation of the confusion assessment method in the palliative care setting. Palliat Med 2009; 23: 40–5.
40 Sands, MB, Dantoc, BP, Hartshorn, A, Ryan, CJ, Lujic, S. Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliat Med 2010; 24: 561–5.
41 Meagher, DJ, Leonard, M, Donnelly, S, Conroy, M, Adamis, D, Trzepacz, PT. A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis. J Psychosom Res 2011; 71: 395403.
42 Trzepacz, PT, Franco, JG, Meagher, DJ, Lee, Y, Kim, JL, Kishi, Y, et al. Phenotype of subsyndromal delirium using pooled multicultural Delirium Rating Scale—Revised-98 data. J Psychosom Res 2012; 73: 10–7.

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

  • D. Meagher (a1), N. O'Regan (a2), D. Ryan (a2), W. Connolly (a2), E. Boland (a2), R. O'Caoimhe (a2), J. Clare (a2), J. Mcfarland (a3), S. Tighe (a3), M. Leonard (a4), D. Adamis (a5), P. T. Trzepacz (a6) and S. Timmons (a2)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

  • D. Meagher (a1), N. O'Regan (a2), D. Ryan (a2), W. Connolly (a2), E. Boland (a2), R. O'Caoimhe (a2), J. Clare (a2), J. Mcfarland (a3), S. Tighe (a3), M. Leonard (a4), D. Adamis (a5), P. T. Trzepacz (a6) and S. Timmons (a2)...
Submit a response

eLetters

Delirium and Deprivation of Liberty Safeguards

Foluke Odeyale, Specialty Registrar, TEES, ESK AND WEAR VALLEYS NHS FOUNDATION TRUST
Itoro Udo, Consultant Psychiatrist, North Tees Hospital - Tees, Esk & Wear Valley Foundation Trust
Richard Arthur, Foundation Doctor, North Tees Hospital Tees - Esk & Wear Valley Foundation Trust
18 August 2015

[NB - this letter was originally published on 26 November 2014 but was re-uploaded on 18 August 2015 due to a technical error]

We have read the article by Meagher et al with interest.[1] The authors have drawn our attention to just how complex the condition of delirium may be. In doing so, they have highlighted the existence of subsyndromal delirium which may present with less specific symptoms. Usefully, they have gone on to suggest criteria for its diagnosis.

Having appraised this paper, we would like to discuss issues that have caught our attention. The authors excluded patients in the specialist units for psychiatry, intensive care and those in isolation units. No justification was made for this though they have discussed that this is likely to have affected their results. Intensive care units are one of the commoner areas where delirium may exist in acute hospitals.[2] Hence, this exclusion may have affected the face validity of the study.

In the method of the study, we observe that series of steps were taken to determine diagnosis. We wonder - without collateral history from family or carers about the onset or duration of any confusion, there is a real possibility that some patients with delirium may have been missed. In our practical experience, it does occur that acute healthcare staff may not recognise that a patient, especially where hypoalert, is confused.

In the article, it is unclear why authors relaxed the cut-off scores for the Delirum Rating Scale-Revised-98 for their particular study. We have considered that if we were repeating this study, using the same tool, with its validated cut off of ? 18 then our results could possibly vary from those of the authors.

We have considered the authors' suggested criteria for diagnosing subsyndromal delirum against our recent clinical experiences in which medicine and psychiatric teams varied in opinions about the existence or not of delirium. The authors suggested criteria would have been of use in those circumstances.

In considering the implications of the findings of the paper in England and Wales, we observe that a quarter of an acute hospital population may potentially be deemed to lack capacity during some parts of their hospital journey and may potentially be subject to legislation like Deprivation of Liberty Safeguards (DOLs).[3] From our practical experience, given the vast administration involved in requesting and coordinating DOLs assessments, we wonder whether this is a good use of finite health resources including nursing time.

References:

1. Meagher D et al. Frequency of delirium and subsyndromal delirium in an adult acute hospital population. British Journal of Psychiatry 2014. Epud ahead of print 30 October 2014. doi:10.1192/bjp.bp.113.139865.(accessed 18 November 2014).

2. Morandi A, Jackson JC. Delirium in the Intensive Care Unit: A Review. Neurologic Clinics 2011; 29(4):749-763. doi: 10.1016/j.ncl.2011.08.004.

3. Department of Health. Mental Capacity Act 2005: Deprivation of Liberty Safeguards. Code of Practice to Supplement the Main Mental Capacity Act 2005 Code of Practice. Norwich: The Stationery Office; 2008.

... More

Conflict of interest: None declared

Write a reply

Delirium and Deprivation of Liberty Safeguards

Foluke Odeyale, Specialty Registrar
26 November 2014

We have read the article by Meagher et al with interest.[1] The authors have drawn our attention to just how complex the condition of delirium may be. In doing so, they have highlighted the existence of subsyndromal delirium which may present with less specific symptoms. Usefully, they have gone on to suggest criteria for its diagnosis.

Having appraised this paper, we would like to discuss issues that have caught our attention. The authors excluded patients in the specialistunits for psychiatry, intensive care and those in isolation units. No justification was made for this though they have discussed that this is likely to have affected their results. Intensive care units are one of thecommoner areas where delirium may exist in acute hospitals.[2] Hence, thisexclusion may have affected the face validity of the study.

In the method of the study, we observe that series of steps were taken to determine diagnosis. We wonder - without collateral history from family or carers about the onset or duration of any confusion, there is a real possibility that some patients with delirium may have been missed. Inour practical experience, it does occur that acute healthcare staff may not recognise that a patient, especially where hypoalert, is confused.

In the article, it is unclear why authors relaxed the cut-off scores for the Delirum Rating Scale-Revised-98 for their particular study. We have considered that if we were repeating this study, using the same tool,with its validated cut off of ? 18 then our results could possibly vary from those of the authors.

We have considered the authors' suggested criteria for diagnosing subsyndromal delirum against our recent clinical experiences in which medicine and psychiatric teams varied in opinions about the existence or not of delirium. The authors suggested criteria would have been of use in those circumstances.

In considering the implications of the findings of the paper in England and Wales, we observe that a quarter of an acute hospital population may potentially be deemed to lack capacity during some parts oftheir hospital journey and may potentially be subject to legislation like Deprivation of Liberty Safeguards (DOLs).[3] From our practical experience, given the vast administration involved in requesting and coordinating DOLs assessments, we wonder whether this is a good use of finite health resources including nursing time.

References:

1.Meagher D et al. Frequency of delirium and subsyndromal delirium in an adult acute hospital population. British Journal of Psychiatry 2014.Epud ahead of print 30 October 2014. doi:10.1192/bjp.bp.113.139865.(accessed 18 November 2014).

2.Morandi A, Jackson JC. Delirium in the Intensive Care Unit: A Review. Neurologic Clinics 2011; 29(4):749-763. doi: 10.1016/j.ncl.2011.08.004.

3.Department of Health. Mental Capacity Act 2005: Deprivation of Liberty Safeguards. Code of Practice to Supplement the Main Mental Capacity Act 2005 Code of Practice. Norwich: The Stationery Office; 2008.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *