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5 results

  • Case 25 - “I Want to Go Home”

  • Matthew Gibfried, Saint Louis University School of Medicine, Missouri, George T. Grossberg, Saint Louis University School of Medicine, Missouri
  • Book:
    Clinical Case Studies in Long-Term Care Psychiatry
    Published online:
    31 October 2024
    Print publication:
    14 November 2024, pp 121-125

  • Summary

    Delirium as a complex neuropsychiatric syndrome characterized by disturbances in attention, awareness, and cognition that are not explained by a pre-existing neurocognitive disorder. The causes of delirium are varied. The most common causes of delirium in the long-term care setting are likely urinary tract infections, untreated pain, and medication side effects. The initial steps recommended in managing delirium involve identifying and addressing underlying medical conditions, reducing environmental triggers, and minimizing exposure to drugs. Besides treatment of the cause, management of delirium primarily involves psychosocial interventions. These can include environmental modifications such as addressing poor lighting, excessive noise, or lack of orientation cues.

  • Chapter 12 - Recognition, Management, and Prevention of Delirium

  • from Section II - Geriatric Syndromes
  • Edited by Jan Busby-Whitehead, University of North Carolina, Chapel Hill, Samuel C. Durso, The Johns Hopkins University, Maryland, Christine Arenson, Thomas Jefferson University, Philadelphia, Rebecca Elon, The Johns Hopkins University School of Medicine, Mary H. Palmer, University of North Carolina, Chapel Hill, William Reichel
  • Book:
    Reichel's Care of the Elderly
    Published online:
    30 June 2022
    Print publication:
    21 July 2022, pp 129-138

  • Summary

    Delirium is a serious neuropsychiatric condition characterized by an acute change in cognition and attention that affects a significant proportion of hospitalized older adults and is associated with significant morbidity and mortality. Prevention of delirium is an important part of the care of hospitalized older adults. The Hospital Elder Life Program is a multicomponent intervention that has been shown to reduce the incidence of delirium. As many cases of delirium are overlooked, its diagnosis is important and can be achieved using the Confusion Assessment Method, which relies on four cardinal features of delirium: acute onset, inattention, altered level of consciousness, and disorganized thinking. The etiology of delirium is often multifactorial with contributions from predisposing factors (such as sensory impairment, chronic illness, and cognitive impairment) and precipitating factors (such as infection, polypharmacy, or illness). Once diagnosed, delirium should be evaluated with a thorough history, complete physical, medication review, and targeted tests in an effort to identify these factors. Management should focus on addressing the noted precipitating and predisposing factors with limited use of low-dose antipsychotic medications in patients at risk of self-harm.

  • Validation study of the European Portuguese version of the Confusion Assessment Method (CAM)

  • Sónia Martins, Carla Lourenço, João Pinto-de-Sousa, Filipe Conceição, José Artur Paiva, Mário R. Simões, Lia Fernandes
  • Journal:
    International Psychogeriatrics / Volume 27 / Issue 5 / May 2015
    Published online by Cambridge University Press:
    02 October 2014, pp. 777-784
  • Background:

    The Confusion Assessment Method (CAM) is the most widely used delirium screening instrument. The aim of this study was to evaluate the reliability and validity of the European Portuguese version of CAM.

    Methods:

    The sample included elderly patients (≥65 years), admitted for at least 48 h, into two intermediate care units (ICMU) of Intensive Medicine and Surgical Services in a university hospital. Exclusion criteria were: score ≤11 on the Glasgow Coma Scale (GCS), blindness/deafness, inability to communicate and to speak Portuguese. For concurrent validity, a blinded assessment was conducted by a psychiatrist (DSM-IV-TR, as a reference standard) and by a trained researcher (CAM). This instrument was also compared with other cognitive measures to evaluate convergent validity. Inter-rater reliability was also assessed.

    Results:

    In this sample (n = 208), 25% (n = 53) of the patients had delirium, according to DSM-IV-TR. Using this reference standard, the CAM had a moderate sensitivity of 79% and an excellent specificity of 99%. The positive predictive value was 95%, indicating a strong ability to confirm delirium with a positive test result, and the negative predictive value was lower (93%). Good convergent validity was also found, in particular with Mini-Mental State Examination (MMSE) (rs = −0.676; p ≤0.01) and Digit Span Test (DST) forward (rs = −0.605; p ≤0.01), as well as a high inter-rater reliability (diagnostic k = 1.00; single items’ k between 0.65 and 1.00).

    Conclusion:

    Robust results on concurrent and convergent validity and good reliability were achieved. This version was shown to be a valid and reliable instrument for delirium detection in elderly patients hospitalized in intermediate care units.

  • Chapter 22 - Use ofagitation treatment in the emergency department

  • from Section 4. - Treatment of the psychiatric patient
  • Edited by Leslie S. Zun
  • Edited in association with Lara G. Chepenik, Mary Nan S. Mallory
  • Book:
    Behavioral Emergencies for the Emergency Physician
    Published online:
    05 April 2013
    Print publication:
    21 March 2013, pp 164-169

  • Summary

    Patients with delirium, dementia, and those with both delirium and dementia can be the most challenging patients in the emergency department (ED). Integration of psychiatric emergency services into the ED can help with cognitive assessment and management. Patients can also have delirium superimposed on dementia, making diagnosis and management more challenging. Although delirium can occur in patients across the lifespan, most studies have focused on older adults, as does this chapter. The most popular instruments for efficient screening of patients have been the Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), CAM-ICU, Six-Item Screener (SIS), and the Mini-Cog. Treatment strategies for managing delirium are divided into non-pharmacologic and pharmacologic interventions and can definitely be implemented in the ED. Alzheimer's disease is the most common form of dementia, accounting for 50-80% of cases. The neuropsychiatric sequelae of dementia can make the diagnosis of a presenting patient more challenging.

  • The recognition and documentation of delirium in hospital palliative care inpatients

  • Julia Barnes, Suzanne Kite, Manoj Kumar
  • Journal:
    Palliative & Supportive Care / Volume 8 / Issue 2 / June 2010
    Published online by Cambridge University Press:
    23 March 2010, pp. 133-136
  • Objective:

    Delirium is a clinical syndrome that is known to be under recognized by palliative care teams. A wide variation in reported prevalence may reflect differences in definitions and assessment methods, patient characteristics, and study design. The aim of this study was to test an intervention to improve recognition of delirium in the inpatient palliative care setting.

    Method:

    We conducted a retrospective palliative care notes review of documented prevalence of delirium among 61 patients referred to the Specialist Palliative Care Advisory Team (SPCT). Subsequently, training in the use of the Confusion Assessment Method (CAM) was provided to the SPCT and a prospective survey of the prevalence of delirium measured by the CAM was undertaken with the next 59 patients referred.

    Results:

    In the retrospective chart review, the term “delirium” was not used, and synonyms were identified and used to establish a delirium prevalence of 11.5%. In the intervention utilizing the CAM in a prospective sample of 59 referred patients, a prevalence rate of 8.5–15.2% for delirium was found. Use of the CAM was received favorably by the SPCT.

    Significance of Results:

    The institution of the use of the CAM as a screening and assessment tool in the inpatient palliative care setting did not significantly increase the recognition of delirium. Reasons for the low prevalence of delirium are discussed.