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ASSESSMENT OF DELIRIUM
Delirium is a neuropsychiatric syndrome that involves a
number of symptoms, including diffuse cognitive impairment, psychosis, sleep-wake cycle disturbance, perceptual
disturbances, thought disorder, language impairment, and
mood lability. Symptoms of delirium typically have an
acute onset and tend to fluctuate in intensity throughout a
24-hour period. Its incidence averages about 18% to 20%
of patients admitted to general hospitals, though this figure
varies somewhat depending on the patient population and
methodology of the research.1 Despite its prevalence and
associated morbidity and mortality,1 delirium is understudied compared with dementias and other psychiatric
disorders. One of the methodological difficulties in studying delirium had been a dearth of appropriate symptomrating scales and lack of diagnostic criteria. DSM-III,
DSM-III-R, and DSM-IV diagnostic criteria have been
published as various revisions by the American Psychiatric
Association since 1980 and have been beneficial in that
Psychosomatics 40:3, May-June 1999
they list specific inclusion and exclusion criteria for diagnosing cases of delirium.2,3
Several instruments have been devised for health care
professionals or laypersons to screen for the presence of
symptoms of delirium, such as the Confusion Assessment
Method (CAM)4 and the Delirium Symptom Interview
(DSI),5 respectively. The CAM and DSI are reviewed in
more detail elsewhere.6,7 The CAM has four items that represent cardinal symptoms, three of which are required to
be present for a diagnosis of delirium. The CAM was originally reported to have sensitivity ranging from 94% to
100% and specificity ranging from 90% to 95%, compared
with diagnoses made by using DSM-III-R criteria. HowReceived August 26, 1998; revised November 24, 1998; accepted December 4, 1998. From the University of Mississippi Medical School,
Jackson, Mississippi. Previously published in similar form in Japanese in
Neuro-Psychiatric Review, Vol. 26, 1998, pp. 1631. Address correspondence and reprint requests to Dr. Trzepacz, Department of Psychiatry and
Human Behavior, University of Mississippi Medical Center, 2500 North
State St., Jackson, MS 39216; e-mail: ptrzepacz@psychiatry.umsmed.edu.
Copyright q 1999 The Academy of Psychosomatic Medicine.
193
Temporal onset
Perceptual disturbances
Hallucinations
Delusions
Psychomotor behavior
Cognitive status
Physical disorder
Sleep-wake cycle disturbance
Lability of mood
Variability of symptoms
Trzepacz
peated measurements in a drug treatment study of delirium.
Koolhoven et al.17 used a 7-item modified scale as a symptom checklist in an observational study by excluding two
items (temporal onset and physical disorder) and compressing perceptual disturbances and hallucinations into one
item.
The DRS was devised intentionally to reflect a broader
range of symptoms of delirium than was assessable by using only cognitive tests such as the Mini-Mental State
Exam (MMSE). Bedside cognitive tests alone cannot distinguish between different disorders that involve cognitive
impairment, for example, delirium and dementia. Instead,
assessment of a broad range of symptoms is necessary to
distinguish delirium from other cognitive disorders. This
includes assessing the severity and type of cognitive deficits, because different dementias affect different cognitive
functions at different stages of the illness (e.g., frontal lobe
dementias vs. Alzheimers dementia). One type of dementia Lewy body dementia has significant overlap with
delirium in its presentation, as does Alzheimers dementia
at its end-stage.
It was originally intended that the DRS be supplemented by whatever cognitive tests that the rater chooses.
The DRS has only one cognitive status item (Item #6) and
does not rate separate items for different components of
cognition (e.g., attention, memory, orientation). Though
this allows relatively more emphasis of noncognitive
symptoms, it may make the DRS less useful for phenomenological studies or repeated measurements.
Scale Attributes
The DRS has been studied in different settings and
found to have very good construct validity based on multiple lines of evidence, which are detailed in Table 2 and
Table 3 and in later sections of this article. These include
comparisons to expert diagnoses by using DSM criteria,
differences in DRS scores compared with other patient
groups, differences in DRS scores following standard delirium treatment when patients no longer meet DSM criteria for delirium, and correlations with ratings on other
scales (e.g., Brief Psychiatric Rating Scale [BPRS], cognitive tests, and global ratings) that assess some delirium
symptoms.
The DRS has excellent internal consistency, with a
Cronbachs alpha score of 0.90 in a study of elderly patients.18 In addition, principal components analysis of DRS
scores has shown that it has one major underlying dimension,19,20 supporting that it is measuring one overall conPsychosomatics 40:3, May-June 1999
196
Meagher et al.
(1996).
Rockwood et al.
(1996).
Rosen et al.
(1994)
Trzepacz et al.
(1988)
Uchiyama et al.
(1996)
Clinicians
Trzepacz et al.
(1998).
DRS Raters
Sample
Study
TABLE 2.
ICC 40.97
Other
Cutoff score410:
Sensitivity40.82
Specificity40.94
Cutoff score47.5:
Sensitivity40.90
Specificity40.82
ICC40.91
Interrater Reliability
4 psychiatrists
General hospital psychiatric referrals (n476); alcohol withdrawal excluded; mean5SD
age: 69.5512.4
Nakamura et al.
(1994)
IR40.90
Trzepacz
under the curve40.87 for the DRS, area test411.93,
P40.03).18
Though the DRS measures more than just cognition,
DRS scores have correlated with cognitive test scores in
general hospital samples. The DRS correlated with the
MMSE scores (r410.43, P40.033) and with Trailmaking Test part B scores (r40.66, P40.007) in 20 delirious
patients and with the MMSE scores (r410.78, P,0.01)
in 104 elderly delirious patients.18 In contrast, in a study
of 61 elderly delirious patients who were admitted to a
psychiatric hospital instead of a general hospital, there was
no correlation between the DRS and the MMSE
(r40.16).20 However, in that same study, the DRS was
significantly correlated with the BPRS in delirious
(r40.57, P40.017) and delirious-demented patients
(r40.35, P4 0.04). This finding suggests possible differences in the presentation of patients whose identified medical morbidity is lower and who are admitted to a psychiatric hospital instead of a general hospital.
Two studies have compared delirious, demented,
schizophrenic, and noncognitively impaired medically ill
patients and found little or no overlap in total DRS scores
among these groups when graphing scores on boxplots.18,20
Similarly, a study of postcardiotomy patients found very
little overlap in DRS scores graphed on boxplots between
the delirious and nondelirious patients;21 overlap was attributed to a methodological issue in the timing of the ratings. By using ROC analysis, Rockwood18 found the DRS
to be more accurate than the MMSE in classifying delirium
among groups of elderly patients with either delirium, dementia, or other psychiatric disorders.
Rosen et al.24 studied 791 consecutive geriatric psychiatry inpatients who were divided into three study
groups: delirium, dementia/organic mental disorder not
otherwise specified, and noncognitively impaired patients.
Rosen et al. reported that the DRS had a high predictive
negative value of 99%, but its predictive positive value was
only 33%, largely related to its difficulty differentiating the
other organic mental group from the delirium group due to
overlapping symptoms of psychosis and cognitive impairment. There were only 4 out of 70 false-negatives among
the delirium group, but 94 out of 291 other organic mental
disorder patients were rated as false-positives when using
a DRS cutoff of $10 points. However, these false-positives
in the other organic group were more likely to have significant electroencephalogram (EEG) abnormalities, with
Grades II and III dysrhythmias, higher BPRS psychosis
scores, and lower MMSE scores than the true-negatives in
that group. Abnormal EEGs of that severity are usually
197
Trzepacz
within hours of treatment with either antipsychotic drug
(even before the underlying medical problems were corrected), as evidenced by significant declines in their DRS
scores (P,0.001 for each subtype). Platt et al. suggested
that both motoric subtypes respond equally well to dopamine blockade.
Rockwood28 studied the occurrence and duration of
symptoms in 173 elderly medical inpatients in Camp Hill
Hospital, Nova Scotia. Many had concurrent dementia.
DSM-III and DSM-III-R criteria and DRS ratings were applied on admission. Delirious patients mean5standard deviation (SD) age was 8258 years and mean5SD DRS
score was 1754 points; nondelirious patients mean5SD
age was 7958. Rockwood28 found that DSM-III-R had
better sensitivity and DSM-III had better specificity in delirium diagnosis, compared with a clinical gold standard.
In addition, some delirium symptoms were found to persist
at discharge after the episode had ended.
Uchiyama et al.15 used the DRS to compare drug response between hyperactive and hypoactive presentations
of delirium in their study of 62 delirious elderly. The researchers found that 80.6% were hyperactive and 19.4%
were hypoactive on the basis of clinical observation. The
hyperactive patients responded better to mianserin than did
the hypoactive patients (P,0.05). Medication response
was defined as improvement on item scores for $4 DRS
items with worsening on #2 items. DRS scores for each
motoric subtype were not reported.
Meagher et al.23 studied hypoactive, mixed, and hyperactive subtypes in 46 delirious inpatients. By using International Classification of Diseases (ICD)-10 criteria and
Liptzin and Levkoffs definition of motoric subtypes, the
researchers found significantly higher (P,0.01) DRS
scores in hyperactive and lower (P,0.01) scores in hypoactive than in mixed subtypes (see Table 3). In addition,
the hyperactive group required significantly more nursing
management interventions (P,0.05) and hypoactive less
(P,0.01) than the mixed group. The hyperactive group
(93%) also received more psychotropic drugs prior to consultation.
Physiology Studies
In a drug treatment study of delirious patients, Nakamura et al.16 measured plasma-free 4-methoxy-3-hydroxyphenylethylene glycol (MHPG) and homovanillic acid levels. The researchers found a significant reduction in plasma
free-MHPG over time in all delirious patients, regardless
of drug treatment using mianserin, oxypertine, or haloperPsychosomatics 40:3, May-June 1999
TABLE 3.
Authors
Diagnosis (n)
Delirious (20)
Demented (9)
Schizophrenic (9)
Other medical (9)
Delirious (18)
Delirious-demented (43)
13.655.2
14.254.0
Delirious (36)
Demented (16)
Other psychiatric (18)
Cognitively normal (27)
17.157.6
6.454.5
3.451.5
2.252.6
Delirious (48)
Nondelirious controls (125)
17.054.0
Not reported
1027
2.1752.73
016
Delirious (70)
Other organic mental disorders (291)
Nonorganic psychiatric (430)
14.553.8
8.853.6
5.652.8
726
Delirium (7)
Delirium (28):
Duration .1 week (16)
Duration #1 week (12)
200
Delirium (76):
Mianserin (46)
Baseline
Day 5
Oxypertine (17)
Baseline
Day 1
Haloperidol (13)
Baseline
Day 5
Delirium (46):
Hyperactive (14)
Hypoactive (11)
Mixed (21)
Postoperative liver transplant:
On FK506 (17)
On cyclosporine (14)
Delirium (30):
Baseline
Day 2
End of treatment
Baseline haloperidol (11)
Day 2 haloperidol
End day haloperidol
Baseline chlorpromazine (13)
Day 2 chlorpromazine
End day chlorpromazine
Baseline lorazepam (6)
Day 2 lorazepam
End day lorazepam
24
16.553.3
18.452.71
14.051.86
12-25
756
552
21.251.0
8.050.9
20.150.8
12.351.3
22.051.3
9.551.4
20.255
24.153.9
15.052.3
20.154.2
6.255.5
4.651.5
20.153.5
13.356.1
12.856.4
20.553.5
12.555.9
11.656.1
20.653.9
12.156.5
11.956.7
18.352.6
17.354.2
17.055.0
1428
326
326
Trzepacz
TABLE 3.
Delirium Rating Scale (DRS) scores reported in different patient populations (continued)
Authors
Diagnosis (n)
Delirium (62):
Mianserin responders
Mianserin nonresponders
Delirium (64):
Single day (43)
First day (20)
22.654.4
25.453.6
Delirium (43):
Admission
Discharge
14.5
6.6
Delirious (22):
Baseline haloperidol (11)
Post haloperidol
Baseline olanzapine (11)
Post olanzapine
20.155.0
11.157.1
17.954.4
10.354.8
Delirious (36):
Postop day 3
Maximum
Nondelirious (256):
Postop day 3
Maximum
21.953.2
22.253.3
1431
18-32
729
13.857.2
19.055.7
111
4.151.7
4.451.9
Trzepacz
posttreatment DRS scores were 11.157.1 for haloperidol
and 10.354.8 for olanzapine. Clinical improvement was
similar in each group, though there were methodological
issues, including nonrandomization, simultaneous use of
other neuroleptics in the olanzapine group, and delirium
being comorbid with other Axis I diagnoses that share
some of its symptoms.
Meagher et al.23 examined the pattern and frequency
of use of environmental interventions and psychotropic
drug use in delirium management. Consecutive referrals to
a consultation-liaison (C-L) psychiatry service in a large
general hospital in Dublin were prospectively assessed for
delirium by using ICD-10 criteria for diagnosis and the
DRS for symptom severity. Mean5SD age of the sample
was 60.1519.5 years, and mean5SD DRS was
20.1754.98. The patients received a mean5SD of
4.0451.87 nursing interventions. When separated into
high and low intervention groups (using cutoff of four interventions), the high group was found to have greater delirium severity (P,0.01), though the DRS score was not
reported. The DRS was also divided into two core subscales: cognitive, which included cognitive status, delusions, and hallucinations, and behavioral management,
which included psychomotor behavior, sleep-wake cycle
disturbance, and mood lability. Nursing intervention scores
were significantly associated (P,0.01) with the DRS behavioral management core scores but not with cognitive
core scores.
REVISION OF THE DRS
The DRS is very useful clinically, and its routine use can
enhance the detection of delirium symptoms as well as assist trainees to appreciate the breadth of the delirium syndrome. Use of the DRS for research purposes has highlighted some of its shortcomings. To be more useful as a
research tool, the DRS needs to be revised by separating
items more relevant for diagnosis from items more related
to symptom severity, which will allow its use during re-
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