Hostname: page-component-78c5997874-mlc7c Total loading time: 0 Render date: 2024-11-10T20:11:59.909Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  22 December 2015

Sarah Richardson ,
Andrew Teodorczuk ,
Giuseppe Bellelli ,
Daniel H. J. Davis ,
Karin J. Neufeld ,
Barbara A. Kamholz ,
Marco Trabucchi ,
Alasdair M. J. MacLullich  and
Alessandro Morandi
Sarah Richardson*
Affiliation:
Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK
Andrew Teodorczuk
Affiliation:
School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
Giuseppe Bellelli
Affiliation:
Department of Medicine and Surgery, University of Milano-Bicocca; Geriatric Unit, S. Gerardo Hospital, Monza, Italy; and Geriatric Research Group, Brescia, Italy
Daniel H. J. Davis
Affiliation:
University College London, London, UK
Karin J. Neufeld
Affiliation:
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Barbara A. Kamholz
Affiliation:
Department of Psychiatry, University of California at San Francisco, San Francisco, CA, USA
Marco Trabucchi
Affiliation:
Department of Neuropharmacology, Università Tor Vergata, Rome, Italy; and Geriatric Research Group, Brescia, Italy
Alasdair M. J. MacLullich
Affiliation:
University of Edinburgh, Edinburgh, UK
Alessandro Morandi
Affiliation:
Department of Rehabilitation and Aged Care “Fondazione Camplani” Hospital, Cremona, Italy; and Geriatric Research Group, Brescia, Italy
*
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.
Get access Rights & Permissions [Opens in a new window]

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.

Keywords

deliriumdementiaknowledgeEuropean delirium associationdelirium superimposed on dementiasurveyclinical practice
Type
Research Article
Information
International Psychogeriatrics , Volume 28 , Issue 5 , May 2016 , pp. 853 - 861
Copyright
Copyright © International Psychogeriatric Association 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

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, M267–M271. doi:10.1093/gerona/54.5.M267.Google Scholar
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.Google Scholar
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn, (DSM-5). Washington, DC: American Psychiatric Association.Google Scholar
Ballard, C., Corbett, A. and Howard, R. (2014). Prescription of antipsychotics in people with dementia. British Journal Psychiatry, 205, 4–5. doi:10.1192/bjp.bp.113.128710.Google Scholar
Ballard, C. et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews. Neurology, 5, 245–255. doi:10.1038/nrneurol.2009.39.Google Scholar
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, 1306–1309. doi:10.1093/gerona/62.11.1306.Google Scholar
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, 578–583. doi:10.1016/j.jamda.2010.04.010.Google Scholar
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, 859–864.Google Scholar
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, 1334–1340. doi:10.1136/jnnp.2010.208827.Google Scholar
Collins, N., Blanchard, M. R., Tookman, A. and Sampson, E. L. (2010). Detection of delirium in the acute hospital. Age and Ageing, 39, 131–135.Google Scholar
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, 2809–2816.Google Scholar
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, 2703–2710.Google Scholar
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, 1723–1732. doi:10.1046/j.1532–5415.2002.50468.x.CrossRefGoogle ScholarPubMed
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, 40–49.Google Scholar
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, 500–505. doi:10.1002/jhm.2077.Google Scholar
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, 823–832. doi:10.1016/S1474-4422(15)00101-5.Google Scholar
Fong, T. G. et al. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology, 72, 1570–1575.Google Scholar
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, 1075–1079. doi:10.1111/j.1532-5415.2008.01711.x.Google Scholar
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, 772–778.Google Scholar
Hasegawa, N. et al. (2013). Prevalence of delirium among outpatients with dementia. International Psychogeriatrics, 25, 1877–1833. doi:10.1017/S1041610213001191.Google Scholar
Holmes, J. and House, A. (2000). Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine, 30, 921–929.Google Scholar
Inouye, S. K. et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, 669–676.Google Scholar
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, 941–948.Google Scholar
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.Google Scholar
Landreville, P., Voyer, P. and Carmichael, P.-H. (2013). Relationship between delirium and behavioural symptoms of dementia. International Psychogeriatrics, 25, 635–643. doi:10.1017/S1041610212002232.Google Scholar
MacKnight, C. and Rockwood, K. (1995). A hierarchical assessment of balance and mobility. Age and Ageing, 24, 126–130.Google Scholar
MacLullich, A. M., Meagher, D. J., Laurila, J. V. and Kalisvaart, K. J. (2007). The European delirium association. Journal of Psychosomatic Research, 62, 397–398.Google Scholar
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, 876–881. doi:10.1136/jnnp.2009.200956.Google Scholar
Morandi, A. et al. (2012). Tools to detect delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 60, 2005–2013. doi:10.1111/j.1532-5415.2012.04199.x.Google Scholar
Morandi, A. et al. (2013). Consensus and variations in opinions on delirium care: a survey of European delirium specialists. International Psychogeriatriatrics, 25, 2067–2075. doi:10.1017/S1041610213001415.Google Scholar
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, 349–354. doi:10.1016/j.jamda.2013.12.084.Google Scholar
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.Google Scholar
Neef, D. and Walling, A. D. (2006). Dementia with Lewy bodies: an emerging disease. American Family Physician, 73, 1223–1229.Google Scholar
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, 804–812. doi:10.1002/gps.3900.Google Scholar
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.Google Scholar
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.Google Scholar
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, 61–66. doi:10.1192/bjp.bp.108.055335.Google Scholar
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, 642–647. doi:10.1093/ageing/afv020.Google Scholar
Sessler, C. N. et al. (2002). The richmond agitation–sedation scale. American Journal of Respiratory and Critical Care Medicine, 166, 1338–1344.Google Scholar
Teasdale, G. and Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2, 81–84.CrossRefGoogle ScholarPubMed
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, 1185–1197. doi:10.1002/gps.4131.Google Scholar
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, 1244–1253.Google Scholar
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, 229–242.Google Scholar
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, 178–181. doi:10.1002/gps.3986.Google Scholar
Voyer, P., Cole, M. G., McCusker, J. and Belzile, E. (2006). Prevalence and symptoms of delirium superimposed on dementia. Clinical Nursing Research, 15, 46–66.Google Scholar
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, 4–4.Google Scholar
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, 443–451. doi:10.1001/jama.2010.1013.Google Scholar
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, 586–589.Google Scholar
Supplementary material: File

Richardson supplementary material S1

Questionnaire

Download Richardson supplementary material S1(File)
File 84.3 KB