Delirium
Authors: Edward R. Marcantonio
Journal: Annals of Internal Medicine (2011)

In the Clinic7 June 2011DeliriumDeborah Cotton, MD, MPH, Darren Taichman, MD, PhD, Sankey Williams, MD, and Edward R. Marcantonio, MD SMDeborah Cotton, MD, MPHSearch for more papers by this author, Darren Taichman, MD, PhDSearch for more papers by this author, Sankey Williams, MDSearch for more papers by this author, and Edward R. Marcantonio, MD SMSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-154-11-201106070-01006 SectionsSupplemental MaterialAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Delirium is an acute state of confusion marked by sudden onset, fluctuating course, inattention, and at times an abnormal level of consciousness (1). Delirium is extremely common but can be challenging to diagnose. Its manifestations range from acute agitation, which accounts for less than 25% of all cases (1), to the much more common but less frequently recognized hypoactive, or quiet, variant. Delirium, which is an acute change in mental status, must be differentiated from dementia, which is usually characterized by a slower progression. However, delirium and dementia frequently coexist. Approximately one third of patients aged 70 years or older ...References1. Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157-65. [PMID: 16540616] Google Scholar2. Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271:134-9. [PMID: 8264068] Google Scholar3. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516-22. [PMID: 11380742] Google Scholar4. Rudolph JL, Jones RN, Levkoff SE, Rockett C, Inouye SK, Sellke FW, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119:229-36. [PMID: 19118253] Google Scholar5. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753-62. [PMID: 15082703] Google Scholar6. Casarett DJ, Inouye SK; American College of Physicians-American Society of Internal Medicine End-of-Life Care Consensus Panel. Diagnosis and management of delirium near the end of life. Ann Intern Med. 2001;135:32-40. [PMID: 11434730]. Google Scholar7. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304:443-51. [PMID: 20664045] Google Scholar8. Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing. 2009;38:19-26. [PMID: 19017678] Google Scholar9. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007;55:780-91. [PMID: 17493201] Google Scholar10. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275:852-7. [PMID: 8596223] Google Scholar11. Kales HC, Kamholz BA, Visnic SG, Blow FC. Recorded delirium in a national sample of elderly inpatients: potential implications for recognition. J Geriatr Psychiatry Neurol. 2003;16:32-8. [PMID: 12641371] Google Scholar12. Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ. 2002;167:753-9. [PMID: 12389836] Google Scholar13. Inouye SK, van Dyck CH, Alessi CA, 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. [PMID: 2240918] Google Scholar14. 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. [PMID: 11700159] Google Scholar15. Lemiengre J, Nelis T, Joosten E, Braes T, Foreman M, Gastmans C, et al. Detection of delirium by bedside nurses using the confusion assessment method. J Am Geriatr Soc. 2006;54:685-9. [PMID: 16686883] Google Scholar16. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA. 2010;304:779-86. [PMID: 20716741] Google Scholar17. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286:2703-10. [PMID: 11730446] Google Scholar18. O'Keeffe ST, Mulkerrin EC, Nayeem K, Varughese M, Pillay I. Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly hospital patients. J Am Geriatr Soc. 2005;53:867-70. [PMID: 15877566] Google Scholar19. Fong TG, Jones RN, Rudolph JL, Yang FM, Tommet D, Habtemariam D, et al. Development and Validation of a Brief Cognitive Assessment Tool: The Sweet 16. Arch Intern Med. 2010. [PMID: 21059967] Google Scholar20. McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK. Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. J Am Geriatr Soc. 2005;53:495-500. [PMID: 15743296] Google Scholar21. McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46:700-5. [PMID: 9625184] Google Scholar22. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669-76. [PMID: 10053175] Google Scholar23. Milisen K, Foreman MD, Abraham IL, De Geest S, Godderis J, Vandermeulen E, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc. 2001;49:523-32. [PMID: 11380743] Google Scholar24. Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005;53:622-8. [PMID: 15817008] Google Scholar25. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:1658-66. [PMID: 16181163] Google Scholar26. Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. J Pain Symptom Manage. 1997;13:128-37. [PMID: 9114631] Google Scholar27. 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. [PMID: 11449030] Google Scholar28. Kiely DK, Jones RN, Bergmann MA, Marcantonio ER. Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients. J Gerontol A Biol Sci Med Sci. 2007;62:174-9. [PMID: 17339642] Google Scholar29. Hirano LA, Bogardus ST Jr, Saluja S, Leo-Summers L, Inouye SK. Clinical yield of computed tomography brain scans in older general medical patients. J Am Geriatr Soc. 2006;54:587-92. [PMID: 16686867] Google Scholar30. Sheng AZ, Shen Q, Cordato D, Zhang YY, Yin Chan DK. Delirium within three days of stroke in a cohort of elderly patients. J Am Geriatr Soc. 2006;54:1192-8. [PMID: 16913984] Google Scholar31. Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2002;50:1723-32. [PMID: 12366629] Google Scholar32. Boland RJ, Diaz S, Lamdan RM, Ramchandani D, McCartney JR. Overdiagnosis of depression in the general hospital. Gen Hosp Psychiatry. 1996;18:28-35. [PMID: 8666210] Google Scholar33. 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. [PMID: 12757560] Google Scholar34. 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. [PMID: 12028171] Google Scholar35. Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798-808. [PMID: 16330791] Google Scholar36. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med. 2001;161:2091-7. [PMID: 11570937] Google Scholar37. Han L, McCusker J, Cole M, Abrahamowicz M, Primeau F, Elie M. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Intern Med. 2001;161:1099-105. [PMID: 11322844] Google Scholar38. Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518-22. [PMID: 7966844] Google Scholar39. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508-13. [PMID: 18332297] Google Scholar40. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301:489-99. [PMID: 19188334] Google Scholar41. Liptzin B, Laki A, Garb JL, Fingeroth R, Krushell R. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry. 2005;13:1100-6. [PMID: 16319303] Google Scholar42. van Eijk MM, Roes KC, Honing ML, Kuiper MA, Karakus A, van der Jagt M, 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. [PMID: 21056464] Google Scholar43. Bergmann MA, Murphy KM, Kiely DK, Jones RN, Marcantonio ER. A model for management of delirious postacute care patients. J Am Geriatr Soc. 2005;53:1817-25. [PMID: 16181185] Google Scholar44. Flaherty JH, Tariq SH, Raghavan S, Bakshi S, Moinuddin A, Morley JE. A model for managing delirious older inpatients. J Am Geriatr Soc. 2003;51:1031-5. [PMID: 12834527] Google Scholar45. Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005;53:622-8. [PMID: 15817008] Google Scholar46. Pitkälä KH, Laurila JV, Strandberg TE, Tilvis RS. Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61:176-81. [PMID: 16510862] Google Scholar47. Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C, et al. Pharmacological management of delirium in hospitalized adults—a systematic evidence review. J Gen Intern Med. 2009;24:848-53. [PMID: 19424763] Google Scholar48. Lacasse H, Perreault MM, Williamson DR. Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother. 2006;40:1966-73. [PMID: 17047137] Google Scholar49. Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007:CD005594. [PMID: 17443602] Google Scholar50. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a systematic review. J Clin Psychiatry. 2007;68:11-21. [PMID: 17284125] Google Scholar51. Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, 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. [PMID: 8561204] Google Scholar52. Lawrence KR, Nasraway SA. Conduction disturbances associated with administration of butyrophenone antipsychotics in the critically ill: a review of the literature. Pharmacotherapy. 1997;17:531-7. [PMID: 9165555] Google Scholar53. Inouye SK, Zhang Y, Jones RN, Kiely DK, Yang F, Marcantonio ER. Risk factors for delirium at discharge: development and validation of a predictive model. Arch Intern Med. 2007;167:1406-13. [PMID: 17620535] Google Scholar54. Kiely DK, Jones RN, Bergmann MA, Murphy KM, Orav EJ, Marcantonio ER. Association between delirium resolution and functional recovery among newly admitted postacute facility patients. J Gerontol A Biol Sci Med Sci. 2006;61:204-8. [PMID: 16510867] Google Scholar55. Shekelle PG, MacLean CH, Morton SC, Wenger NS. Acove quality indicators. Ann Intern Med. 2001;135:653-67. [PMID: 11601948] Google Scholar56. Young J, Murthy L, Westby M, Akunne A, O'Mahony R; Guideline Development Group. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ. 2010;341:c3704. [PMID: 20667955] Google Scholar57. O'Mahony R, Murthy L, Akunne A, Young J; on behalf of the Guideline Development Group. Synopsis of NICE Guideline for prevention of delirium. Ann Intern Med. 2011;154:746-51. Google Scholar Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDelirium in the Intensive Care UnitCentral Nervous System Risk Assessment: Preventing Postoperative Brain InjurySubjective strain of care experienced by pulmonary and critical care medical nurses when caring for patients with delirium: a cross-sectional studyDevelopment and Validation of a Postoperative Delirium Prediction Model for Elderly Orthopedic Patients in the Intensive Care UnitImplementing a Rapid, Two‐Step Delirium Screening Protocol in Acute Care: Barriers and FacilitatorsReorienting Ourselves to Delirium: Caring for Older Patients Hospitalized With Heart FailureDelirium and Functional Recovery in Patients Discharged to Skilled Nursing Facilities After Hospitalization for Heart FailurePrevention and Management of Delirium in the Intensive Care UnitDeliriumElimination of the Causes of Poor Sleep Underlying Delirium is a Basic Strategy to Prevent DeliriumBIS index monitoring and perioperative neurocognitive disorders in older adults: a systematic review and meta-analysisNeuroprotectin D1 Protects Against Postoperative Delirium-Like Behavior in Aged MiceComparative Accuracy and Efficiency of Four Delirium Screening ProtocolsDelirium prevention and treatment in the emergency department (ED): a systematic review protocolA complication of coronavirus disease 2019: deliriumEffect of a Psychiatric Department Liaison Team on Patient Treatment and OutcomesDelirium in the ElderlyResearch in brief: Inpatient hip fractures and nomenclature of delirium and acute encephalopathyThe role of physical exercise and rehabilitation in deliriumPostoperative and Preprosthetic CarePREVENTION AND PERIOPERATIVE SCREENING OF POSTOPERATIVE DELIRIUM AMONG URGENT ELDERLY PATIENTSInitiative for Prevention and Early Identification of Delirium in Medical-Surgical Units: Lessons Learned in the Past Five YearsDifferential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patientsPostoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scoresDiagnosing delirium in patients with dementia, a great challengeDiagnóstico del delirium en pacientes con demencia, un gran retoConfusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settingsDelirium is associated with increased mortality in the geriatric populationEffectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic reviewDelirium in the ElderlyRehabilitation of Older Patients with Mental DisordersDelirium and correlates of delirium among newly admitted elderly patients: a cross-sectional study in a Saudi general hospitalDelirium and correlates of delirium among newly admitted elderly patients: a cross-sectional study in a Saudi general hospitalDelirium in Hospitalized Older AdultsHospice in heart failure: why, when, and what then?DeliriumDesign considerations of a randomized controlled trial of sedation level during hip fracture repair surgery: a strategy to reduce the incidence of postoperative delirium in elderly patientsThe Diagnosis of Delirium Superimposed on Dementia: An Emerging ChallengeA Decrease in the Volume of Gray Matter as a Risk Factor for Postoperative Delirium Revealed by an Atlas-based MethodDetection of Delirium in Hospitalized Older General Medicine Patients: A Comparison of the 3D-CAM and CAM-ICUPreliminary development of an ultrabrief two-item bedside test for deliriumIssues of Capacity and Decision-Making in the Context of DeliriumHemodynamic Control and DeliriumGeriatrische Syndrome: DelirImplementing Clinical Practice Guidelines for Screening and Detection of Delirium in a 21-Hospital System in Northern CaliforniaDelirium Diagnosis Methodology Used in Research: A Survey-Based StudyA Delirium Risk Modification Program Is Associated With Hospital Outcomes3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium A Cross-sectional Diagnostic Test StudyEdward R. Marcantonio, MD, SM, Long H. Ngo, PhD, Margaret O'Connor, PhD, Richard N. Jones, ScD, Paul K. Crane, MD, MPH, Eran D. Metzger, MD, and Sharon K. Inouye, MD, MPHDelirium in elderly peopleDelirium Risk Prediction, Healthcare Use and Mortality of Elderly Adults in the Emergency DepartmentMulticomponent interventions in preventing incident delirium in elderly inpatients: a critical appraisal of literatureDelirium During Acute Illness in Nursing Home ResidentsThe Prodrome to DeliriumNeurologic DisordersClarifying Delirium Management: Practical, Evidenced-Based, Expert Recommendations for Clinical PracticeDelirium in the hospital, a narrative reviewDrug therapy for delirium in terminally ill adult patientsNovel Risk Markers and Long-Term Outcomes of Delirium: The Successful Aging after Elective Surgery (SAGES) Study Design and MethodsDrug-induced visual impairment may be a manifestation of acute angle closure glaucomaRecent Literature Feature Editor: Paul C. Rousseau 7 June 2011Volume 154, Issue 11Page: ITC6-1KeywordsAntipsychoticsConsciousnessDeliriumDementiaDrugsGeriatricsHospitalizationsIntensive care unitsMedical risk factorsTreatment guidelines ePublished: 7 June 2011 Issue Published: 7 June 2011 Copyright & PermissionsCopyright © 2011 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...