Delirium in older persons: Advances in diagnosis and treatment

JAMA - Journal of the American Medical Association

Volumn 318, Issue 12, 2017, Pages 1161-1174

  Oh, Esther S ^a   Fong, Tamara G ^b,c   Hshieh, Tammy T ^d   Inouye, Sharon K ^b,c  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b HARVARD MEDICAL SCHOOL   (United States)

^c Aging Brain Center   (United States)

^d BRIGHAM AND WOMEN S HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BIOLOGICAL MARKER; DEXMEDETOMIDINE; DIAZEPAM; DIPHENHYDRAMINE; DONEPEZIL; GABAPENTIN; HALOPERIDOL; MELATONIN; METHYLPREDNISOLONE; MORPHINE SULFATE; ONDANSETRON; PREGABALIN; QUETIAPINE; RAMELTEON; RISPERIDONE; SEVOFLURANE; SUGAMMADEX; NEUROLEPTIC AGENT;

AGED; BRAIN DEPTH STIMULATION; CLINICAL FEATURE; CONFUSION ASSESSMENT METHOD; DELIRIUM; DIAGNOSTIC TEST ACCURACY STUDY; DISEASE SEVERITY; ELECTROENCEPHALOGRAPHY; HUMAN; MENTAL DISEASE ASSESSMENT; META ANALYSIS; PHOTOTHERAPY; PRIORITY JOURNAL; REVIEW; RISK ASSESSMENT; RISK FACTOR; SENSITIVITY AND SPECIFICITY; SLEEP; SYSTEMATIC REVIEW; THREE MINUTE DIAGNOSTIC ASSESSMENT; EMERGENCE DELIRIUM; GERIATRIC ASSESSMENT; PRACTICE GUIDELINE; SEVERITY OF ILLNESS INDEX;

AGED; ANTIPSYCHOTIC AGENTS; BIOMARKERS; DELIRIUM; ELECTROENCEPHALOGRAPHY; EMERGENCE DELIRIUM; GERIATRIC ASSESSMENT; HUMANS; PRACTICE GUIDELINES AS TOPIC; SEVERITY OF ILLNESS INDEX;

EID: 85029935173     PISSN: 00987484     EISSN: 15383598     Source Type: Journal    
DOI: 10.1001/jama.2017.12067     Document Type: Review

References (102)

1. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383 (9920):911-922.
2. Hustey FM, Meldon S, Palmer R. Prevalence and documentation of impaired mental status in elderly emergency department patients. Acad Emerg Med. 2000;7(10):1166.
3. 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(20):2467-2473.
4. de la Cruz M, Fan J, Yennu S, et al. The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center. Support Care Cancer. 2015;23(8):2427-2433.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Society; 2013.
6. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization; 1993.
7. 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(12): 941-948.
8. Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc. 2008;56 (5):823-830.
9. Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. Motor subtypes of postoperative delirium in older adults. Arch Surg. 2011;146(3):295-300.
10. Kim SY, Kim SW, Kim JM, et al. Differential associations between delirium and mortality according to delirium subtype and age: a prospective cohort study. Psychosom Med. 2015; 77(8):903-910.
11. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-1027.
12. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23 (10):433-441.
13. Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA. 2006;296 (16):2012-2022.
14. Attia J, Hatala R, Cook DJ, Wong JG. The Rational Clinical Examination: does this adult patient have acute meningitis? JAMA. 1999;282(2): 175-181.
15. Metersky ML, Williams A, Rafanan AL. Retrospective analysis: are fever and altered mental status indications for lumbar puncture in a hospitalized patient who has not undergone neurosurgery? Clin Infect Dis. 1997;25(2):285-288.
16. Lai MM, Wong Tin Niam DM. Intracranial cause of delirium: computed tomography yield and predictive factors. Intern Med J. 2012;42(4):422-427.
17. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172 (17):1324-1331.
18. Fick DM, Steis MR, Waller JL, Inouye SK. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med. 2013;8(9): 500-505.
19. Morandi A, Davis D, Fick DM, et al. Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc. 2014;15(5):349-354.
20. Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med. 1994;24(1):145-153.
21. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982-1983;17(1):37-49.
22. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.
23. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142-150.
24. Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014;370(5): 444-454.
25. Hayhurst CJ, Pandharipande PP, Hughes CG. Intensive care unit delirium: a review of diagnosis, prevention, and treatment. Anesthesiology. 2016;125(6):1229-1241.
26. Higgins JP, Altman DG, Gøtzsche PC, et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
27. Inouye SK, Marcantonio ER, Kosar CM, et al. The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimers Dement. 2016;12:766-775.
28. Marcantonio ER, Ngo LH, O’Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med. 2014;161(8):554-561.
29. Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.
30. Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43(4):496-502.
31. Tieges Z, Stíobhairt A, Scott K, et al. Development of a smartphone application for the objective detection of attentional deficits in delirium. Int Psychogeriatr. 2015;27(8):1251-1262.
32. Steis MR, Evans L, Hirschman KB, et al. Screening for delirium using family caregivers: convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method. J Am Geriatr Soc. 2012;60(11):2121-2126.
33. Rhodius-Meester HF, van Campen JP, Fung W, Meagher DJ, van Munster BC, de Jonghe JF. Development and validation of the Informant Assessment of Geriatric Delirium Scale (I-AGeD): recognition of delirium in geriatric patients [in Dutch]. Tijdschr Gerontol Geriatr. 2013;44(5): 206-214.
34. Salih SA, Paul S, Klein K, Lakhan P, Gray L. Screening for delirium within the interRAI acute care assessment system. J Nutr Health Aging. 2012; 16(8):695-700.
35. O’Regan NA, Ryan DJ, Boland E, et al. Attention! a good bedside test for delirium? J Neurol Neurosurg Psychiatry. 2014;85(10):1122-1131.
36. Voyer P, Champoux N, Desrosiers J, et al. Recognizing acute delirium as part of your routine [RADAR]: a validation study. BMC Nurs. 2015;14(19): 19.
37. Lin HS, Eeles E, Pandy S, Pinsker D, Brasch C, Yerkovich S. Screening in delirium: a pilot study of two screening tools, the Simple Query for Easy Evaluation of Consciousness and Simple Question in Delirium. Australas J Ageing. 2015;34(4):259-264.
38. Shulman RW, Kalra S, Jiang JZ. Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses. BMC Geriatr. 2016;16(1):44.
39. Bossuyt PM, Reitsma JB, Bruns DE, et al; STARD Group. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Clin Chem Lab Med. 2003;41(1): 68-73.
40. De J, Wand AP. Delirium screening: a systematic review of delirium screening tools in hospitalized patients. Gerontologist. 2015;55(6): 1079-1099.
41. Neufeld KJ, Leoutsakos JS, Sieber FE, et al. Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. Br J Anaesth. 2013;111(4):612-618.
42. Chester JG, Beth Harrington M, Rudolph JL; VA Delirium Working Group. Serial administration of a modified Richmond Agitation and Sedation Scale for delirium screening. J Hosp Med. 2012;7(5): 450-453.
43. Morandi A, Han JH, Meagher D, et al. Detecting delirium superimposed on dementia: evaluation of the diagnostic performance of the Richmond Agitation and Sedation Scale. J Am Med Dir Assoc. 2016;17(9):828-833.
44. 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 (2):229-242.
45. Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. J Pain Symptom Manage. 1997;13 (3):128-137.
46. Vasunilashorn SM, Marcantonio ER, Gou Y, et al. Quantifying the severity of a delirium episode throughout hospitalization: the combined importance of intensity and duration. J Gen Intern Med. 2016;31(10):1164-1171.
47. Scheffer AC, van Munster BC, Schuurmans MJ, de Rooij SE. Assessing severity of delirium by the Delirium Observation Screening Scale. Int J Geriatr Psychiatry. 2011;26(3):284-291.
48. Saczynski JS, Kosar CM, Xu G, et al. A tale of two methods: chart and interview methods for identifying delirium. J Am Geriatr Soc. 2014;62(3): 518-524.
49. Neufeld KJ, Nelliot A, Inouye SK, et al. Delirium diagnosis methodology used in research: a survey-based study. Am J Geriatr Psychiatry. 2014; 22(12):1513-1521.
50. Dillon ST, Vasunilashorn SM, Ngo L, et al. Higher C-reactive protein levels predict postoperative delirium in older patients undergoing major elective surgery: a longitudinal nested case-control study. Biol Psychiatry. 2017;81(2):145-153.
51. Tu TM, Loh NK, Tan NC. Clinical risk factors for non-convulsive status epilepticus during emergent electroencephalogram. Seizure. 2013;22(9):794-797.
52. Sutter R, Rüegg S, Tschudin-Sutter S. Seizures as adverse events of antibiotic drugs: a systematic review. Neurology. 2015;85(15):1332-1341.
53. Whitlock EL, Torres BA, Lin N, et al. Postoperative delirium in a substudy of cardiothoracic surgical patients in the BAG-RECALL clinical trial. Anesth Analg. 2014;118(4):809-817.
54. Chan MT, Cheng BC, Lee TM, Gin T; CODA Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25(1):33-42.
55. Wildes TS, Winter AC, Maybrier HR, et al. Protocol for the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study: a pragmatic, randomised clinical trial. BMJ Open. 2016;6(6):e011505.
56. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015;220(2):136-148.
57. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676.
58. Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? a systematic review and meta-analysis of the literature. Age Ageing. 2015;44 (2):196-204.
59. Akunne A, Davis S, Westby M, Young J. The cost-effectiveness of multi-component interventions to prevent delirium in older people undergoing surgical repair of hip fracture. Eur J Orthop Surg Traumatol. 2014;24(2):187-195.
60. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;3:CD005563.
61. Goldberg S, Bradshaw L, Whittamore K, Gladman J, Harwood R. Comparison of a specialist Medical and Mental Health Unit with standard care for older people with delirium and dementia admitted to a general hospital: a randomised controlled trial (NIHR TEAM trial). Eur Geriatr Med. 2013;4(suppl 1):S173.
62. Cheong CY, Tan JA, Foong YL, et al. Creative music therapy in an acute care setting for older patients with delirium and dementia. Dement Geriatr Cogn Dis Extra. 2016;6(2):268-275.
63. Kratz T, Heinrich M, Schlauß E, Diefenbacher A. Preventing postoperative delirium. Dtsch Arztebl Int. 2015;112(17):289-296.
64. Clegg A, Siddiqi N, Heaven A, Young J, Holt R. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database Syst Rev. 2014;(1):CD009537.
65. Gagnon P, Allard P, Gagnon B, Mérette C, Tardif F. Delirium prevention in terminal cancer: assessment of a multicomponent intervention. Psychooncology. 2012;21(2):187-194.
66. González-Gil T. Interventions for preventing delirium in older people in institutional long-term care. Int J Nurs Stud. 2016;55:133-134.
67. Fukata S, Kawabata Y, Fujisiro K, et al. Haloperidol prophylaxis does not prevent postoperative delirium in elderly patients: a randomized, open-label prospective trial. Surg Today. 2014;44(12):2305-2313.
68. 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 (5):987-997.
69. Vochteloo AJ, Moerman S, van der Burg BL, et al. Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium. BMC Geriatr. 2011;11:39.
70. Wang W, Li HL, Wang DX, et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial. Crit Care Med. 2012;40(3):731-739.
71. Al-Aama T, Brymer C, Gutmanis I, Woolmore-Goodwin SM, Esbaugh J, Dasgupta M. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26(7):687-694.
72. de Jonghe A, van Munster BC, Goslings JC, et al; Amsterdam Delirium Study Group. Effect of melatonin on incidence of delirium among patients with hip fracture: a multicentre, double-blind randomized controlled trial. CMAJ. 2014;186(14): E547-E556.
73. Hatta K, Kishi Y, Wada K, et al; DELIRIA-J Group. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry. 2014;71(4):397-403.
74. Ashraf JM, Schweiger M, Vallurupalli N, Bellantonio S, Cook JR. Effects of oral premedication on cognitive status of elderly patients undergoing cardiac catheterization. J Geriatr Cardiol. 2015;12(3):257-262.
75. Lurati Buse GA, Schumacher P, Seeberger E, et al. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation. 2012;126(23):2696-2704.
76. Oh CS, Rhee KY, Yoon TG, Woo NS, Hong SW, Kim SH. Postoperative delirium in elderly patients undergoing hip fracture surgery in the sugammadex era: a retrospective study. Biomed Res Int. 2016;2016:1054597.
77. Stoppe C, Fahlenkamp AV, Rex S, et al. Feasibility and safety of xenon compared with sevoflurane anaesthesia in coronary surgical patients: a randomized controlled pilot study. Br J Anaesth. 2013;111(3):406-416.
78. Whitlock RP, Devereaux PJ, Teoh KH, et al; SIRS Investigators. Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): a randomised, double-blind, placebo-controlled trial. Lancet. 2015;386(10000):1243-1253.
79. Djaiani G, Silverton N, Fedorko L, et al. Dexmedetomidine versus propofol sedation reduces delirium after cardiac surgery: a randomized controlled trial. Anesthesiology. 2016; 124(2):362-368.
80. Liu Y, Ma L, Gao M, Guo W, Ma Y. Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment. Aging Clin Exp Res. 2016;28 (4):729-736.
81. Li X, Yang J, Nie XL, et al. Impact of dexmedetomidine on the incidence of delirium in elderly patients after cardiac surgery: a randomized controlled trial. PLoS One. 2017;12(2):e0170757.
82. Dighe K, Clarke H, McCartney CJ, Wong CL. Perioperative gabapentin and delirium following total knee arthroplasty: a post-hoc analysis of a double-blind randomized placebo-controlled trial. Can J Anaesth. 2014;61(12):1136-1137.
83. Marcantonio ER, Palihnich K, Appleton P, Davis RB. Pilot randomized trial of donepezil hydrochloride for delirium after hip fracture. J Am Geriatr Soc. 2011;59(suppl 2):S282-S288.
84. Papadopoulos G, Pouangare M, Papathanakos G, Arnaoutoglou E, Petrou A, Tzimas P. The effect of ondansetron on postoperative delirium and cognitive function in aged orthopedic patients. Minerva Anestesiol. 2014;80(4):444-451.
85. Pesonen A, Suojaranta-Ylinen R, Hammarén E, et al. Pregabalin has an opioid-sparing effect in elderly patients after cardiac surgery: a randomized placebo-controlled trial. Br J Anaesth. 2011;106(6): 873-881.
86. Saager L, Duncan AE, Yared JP, et al. Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery. Anesthesiology. 2015;122(6):1214-1223.
87. Gruber-Baldini AL, Marcantonio E, Orwig D, et al. Delirium outcomes in a randomized trial of blood transfusion thresholds in hospitalized older adults with hip fracture. J Am Geriatr Soc. 2013;61 (8):1286-1295.
88. Radtke FM, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013;110(suppl 1):i98-i105.
89. Boockvar KS, Teresi JA, Inouye SK. Preliminary data: an adapted hospital elder life program to prevent delirium and reduce complications of acute illness in long-term care delivered by certified nursing assistants. J Am Geriatr Soc. 2016;64(5): 1108-1113.
90. Kolanowski A, Fick D, Litaker M, et al. Effect of cognitively stimulating activities for the symptom management of delirium superimposed on dementia: a randomized controlled trial. J Am Geriatr Soc. 2016;64(12):2424-2432.
91. Van Rompaey B, Elseviers MM, Van Drom W, Fromont V, Jorens PG. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Crit Care. 2012;16(3):R73.
92. Yang J, Choi W, Ko YH, Joe SH, Han C, Kim YK. Bright light therapy as an adjunctive treatment with risperidone in patients with delirium: a randomized, open, parallel group study. Gen Hosp Psychiatry. 2012;34(5):546-551.
93. Atalan N, Efe Sevim M, Akgün S, Fazlıoğulları O, Başaran C. Morphine is a reasonable alternative to haloperidol in the treatment of postoperative hyperactive-type delirium after cardiac surgery. J Cardiothorac Vasc Anesth. 2013;27(5):933-938.
94. Boettger S, Jenewein J, Breitbart W. Haloperidol, risperidone, olanzapine and aripiprazole in the management of delirium: a comparison of efficacy, safety, and side effects. Palliat Support Care. 2015;13(4):1079-1085.
95. Kishi Y, Kato M, Okuyama T, Thurber S. Treatment of delirium with risperidone in cancer patients. Psychiatry Clin Neurosci. 2012;66(5):411-417.
96. Maneeton B, Maneeton N, Srisurapanont M, Chittawatanarat K. Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial. Drug Des Devel Ther. 2013;7:657-667.
97. Schrøder Pedersen S, Kirkegaard T, Balslev Jørgensen M, Lind Jørgensen V. Effects of a screening and treatment protocol with haloperidol on post-cardiotomy delirium: a prospective cohort study. Interact Cardiovasc Thorac Surg. 2014;18 (4):438-445.
98. Yoon HJ, Park KM, Choi WJ, et al. Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium. BMC Psychiatry. 2013;13:240.
99. Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017;177(1):34-42.
100. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705-714.
101. Maclullich AM, Ferguson KJ, Miller T, de Rooij SE, Cunningham C. Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses. J Psychosom Res. 2008; 65(3):229-238.
102. Westhoff D, Witlox J, Koenderman L, et al. Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients. J Neuroinflammation. 2013;10(1): 122.