Beruflich Dokumente
Kultur Dokumente
review article
Current Concepts
D
elirium, an acute decline in attention and cognition, is a com- From the Department of Medicine, Har-
mon, life-threatening, and potentially preventable clinical syndrome among vard Medical School, Boston. Address
reprint requests to Dr. Inouye at the Ag-
persons who are 65 years of age or older. The development of delirium often ing Brain Center, Hebrew Senior Life,
initiates a cascade of events culminating in the loss of independence, an increased 1200 Centre St., Boston, MA 02131.
risk of morbidity and mortality, and increased health care costs.1-6 Delirium in hos-
N Engl J Med 2006;354:1157-65.
pitalized older patients has assumed particular importance because the care of such Copyright © 2006 Massachusetts Medical Society.
patients accounts for more than 49 percent of all hospital days.7 Delirium compli-
cates hospital stays for at least 20 percent of the 12.5 million patients 65 years of
age or older who are hospitalized each year and increases hospital costs by $2,500
per patient,8-10 so that about $6.9 billion (value in U.S. dollars in 2004) of Medicare
hospital expenditures are attributable to delirium. Substantial additional costs ac-
crue after hospital discharge because of the need for institutionalization, rehabili-
tation services, formal home health care, and informal caregiving.
This report examines current clinical practice in delirium, identifies areas of
controversy, and highlights areas for future research.
Acute onset
Occurs abruptly, usually over a period of hours or days
Reliable informant often needed to ascertain the time course of onset
Fluctuating course
Symptoms tend to come and go or increase and decrease in severity over a 24-hour period
Characteristic lucid intervals
Inattention
Difficulty focusing, sustaining, and shifting attention
Difficulty maintaining conversation or following commands
Disorganized thinking
Manifested by disorganized or incoherent speech
Rambling or irrelevant conversation or an unclear or illogical flow of ideas
Altered level of consciousness
Clouding of consciousness, with reduced clarity of awareness of the environment
Cognitive deficits
Typically global or multiple deficits in cognition, including disorientation, memory deficits, and language impairment
Perceptual disturbances
Illusions or hallucinations in about 30 percent of patients
Psychomotor disturbances
Psychomotor variants of delirium
Hyperactive
Marked by agitation and vigilance
Hypoactive
Marked by lethargy, with a markedly decreased level of motor activity
Mixed
Altered sleep–wake cycle
Characteristic sleep-cycle disturbances
Typically daytime drowsiness, nighttime insomnia, fragmented sleep, or complete sleep-cycle reversal
Emotional disturbances
Common
Manifested by intermittent and labile symptoms of fear, paranoia, anxiety, depression, irritability, apathy, anger,
or euphoria
lirium is often missed. Older patients should be underlying disease. All preadmission and current
aroused during rounds and evaluated daily for medications should be reviewed; even long-stand-
the hypoactive form of delirium, which is often ing medications can contribute to delirium and
overlooked. should be reevaluated. If changes in long-term
When clinicians search for the underlying cause medications are appropriate after the indications
of delirium, they need to be aware of the possibil- and risk–benefit ratios have been carefully weighed,
ity of occult or atypical presentations of many the hospital represents the ideal venue for making
diseases in the elderly, including myocardial in- these changes. A medical history must be meticu-
farction, infection, and respiratory failure, because lously obtained to detect occult alcohol or benzo-
delirium is often the sole manifestation of serious diazepine use, which can contribute to delirium.
Chronic Acute
www.nejm.org
Identify and address predisposing Provide supportive care and
Manage symptoms of delirium
current concepts
Initial evaluation Review medications Prevent complications All patients Patients with severe agitation
Obtain history (including alcohol Review the use of prescription Protect airway, prevent
and benzodiazepine use) drugs, as-needed drugs, aspiration
1163
The n e w e ng l a n d j o u r na l of m e dic i n e
ity (as explained at www.qualitymeasures.ahrq. The changes required to reduce the incidence of
gov/). After adjusting for case mix, higher deliri- delirium on a national scale would require shifts in
um rates would be expected to correlate with local and national policies and system-wide chang-
lower quality of hospital care. The Assessing Care es to provide high-quality care for older persons.9
of Vulnerable Elders Project has ranked delirium Supported in part by grants (R21AG025193 and K24AG00949)
among the top three conditions for which the from the National Institute on Aging.
No potential conflict of interest relevant to this article was
quality of care needs to be improved.56 Total na- reported.
tional costs related to preventable adverse This article is dedicated to the memory of Joshua Bryan In-
events are estimated to be between $17 billion ouye Helfand.
I am indebted to Dr. Joseph Agostini for his helpful review of
and $29 billion per year,57 and delirium may ac- the manuscript and to Sarah Dowal and Patty Fugal for their
count for at least a quarter of these costs.53,54,57,58 assistance with the preparation of the manuscript.
References
1. Cole MG. Delirium in elderly patients. talized patients. Arch Intern Med 1992; PA, et al. A multicomponent intervention to
Am J Geriatr Psychiatry 2004;12:7-21. 152:334-40. prevent delirium in hospitalized older pa-
2. Inouye SK, Rushing JT, Foreman MD, 5. Murray AM, Levkoff SE, Wetle TT, et tients. N Engl J Med 1999;340:669-76.
Palmer RM, Pompei P. Does delirium con- al. Acute delirium and functional decline 9. Inouye SK, Schlesinger MJ, Lydon TJ.
tribute to poor hospital outcomes? A three- in the hospitalized elderly patient. J Geron- Delirium: a symptom of how hospital
site epidemiologic study. J Gen Intern Med tol 1993;48:M181-M186. care is failing older persons and a win-
1998;13:234-42. 6. O’Keeffe S, Lavan J. The prognostic dow to improve quality of hospital care.
3. Francis J, Kapoor WN. Prognosis after significance of delirium in older hospital Am J Med 1999;106:565-73.
hospital discharge of older medical pa- patients. J Am Geriatr Soc 1997;45:174-8. 10. Department of Health and Human
tients with delirium. J Am Geriatr Soc 1992; 7. Administration on Aging. A profile of Services. 2004 CMS statistics. Washing-
40:601-6. older Americans. Washington, D.C.: De- ton, D.C.: Centers for Medicare and Med-
4. Levkoff SE, Evans DA, Litpzin B, et partment of Health and Human Services, icaid Services, 2004. (CMS publication no.
al. Delirium: the occurrence and persis- 2000. 03445.)
tence of symptoms among elderly hospi- 8. Inouye SK, Bogardus ST Jr, Charpentier 11. Agostini JV, Inouye SK. Delirium. In:
Hazzard WR, Blass JP, Halter JB, Ouslander 28. Romano J, Engel GL. Delirium I: elec- 43. Cole M, McCusker J, Dendukuri N,
JG, Tinetti ME, eds. Principles of geriatric troencephalographic data. Arch Neurol Han L. The prognostic significance of
medicine and gerontology. 5th ed. New Psychiatry 1944;51:356-77. subsyndromal delirium in elderly medical
York: McGraw-Hill, 2003:1503-15. 29. Trzepacz P, van der Mast R. The neu- inpatients. J Am Geriatr Soc 2003;51:754-
12. Inouye SK. Delirium in hospitalized ropathophysiology of delirium. In: Linde- 60.
older patients. Clin Geriatr Med 1998; say J, Rockwood K, Macdonald A, eds. 44. McCusker J, Cole M, Dendukuri N,
14:745-64. Delirium in old age. Oxford, England: Ox- Han L, Belzile E. The course of delirium
13. Pisani MA, McNicoll L, Inouye SK. ford University Press, 2002:51-90. in older medical inpatients: a prospective
Cognitive impairment in the intensive 30. Burns A, Gallagley A, Byrne J. Deliri- study. J Gen Intern Med 2003;18:696-704.
care unit. Clin Chest Med 2003;24:727-37. um. J Neurol Neurosurg Psychiatry 2004; 45. Clarfield AM. The reversible demen-
14. Kiely DK, Bergmann MA, Jones RN, 75:362-7. tias: do they reverse? Ann Intern Med 1988;
Murphy KM, Orav EJ, Marcantonio ER. 31. Han L, McCusker J, Cole M, Abraha- 109:476-86.
Characteristics associated with delirium mowicz M, Primeau F, Elie M. Use of 46. Eikelenboom P, Hoogendijk WJ. Do
persistence among newly admitted post- medications with anticholinergic effect delirium and Alzheimer’s dementia share
acute facility patients. J Gerontol A Biol predicts clinical severity of delirium symp- specific pathogenetic mechanisms? De-
Sci Med Sci 2004;59:344-9. toms in older medical inpatients. Arch ment Geriatr Cogn Disord 1999;10:319-
15. Roche V. Etiology and management of Intern Med 2001;161:1099-105. 24.
delirium. Am J Med Sci 2003;325:20-30. 32. Shigeta H, Yasui A, Nimura Y, et al. 47. Jackson JC, Gordon SM, Hart RP,
16. Breitbart W, Strout D. Delirium in the Postoperative delirium and melatonin lev- Hopkins RO, Ely EW. The association be-
terminally ill. Clin Geriatr Med 2000; els in elderly patients. Am J Surg 2001; tween delirium and cognitive decline:
16:357-72. 182:449-54. a review of the empirical literature. Neu-
17. Casarett D, Inouye SK. Diagnosis and 33. Broadhurst C, Wilson K. Immunology ropsychol Rev 2004;14:87-98.
management of delirium near the end of of delirium: new opportunities for treat- 48. Yokota H, Ogawa S, Kurokawa A,
life. Ann Intern Med 2001;135:32-40. ment and research. Br J Psychiatry 2001; Yamamoto Y. Regional cerebral blood
18. Folstein MF, Bassett SS, Romanosski 179:288-9. flow in delirium patients. Psychiatry Clin
AJ, Nestadt G. The epidemiology of delir- 34. Robertsson B, Blennow K, Bråne G, et Neurosci 2003;57:337-9.
ium in the community: the Eastern Balti- al. Hyperactivity in the hypothalamic- 49. Fick D, Foreman M. Consequences of
more Mental Health Survey. Int Psycho- pituitary-adrenal axis in demented pa- not recognizing delirium superimposed
geriatr 1991;3:169-76. tients with delirium. Int Clin Psychophar- on dementia in hospitalized elderly indi-
19. Rahkonen T, Eloniemi-Sulkava U, macol 2001;16:39-47. viduals. J Gerontol Nurs 2000;26:30-40.
Paanila S, Halonen P, Sivenius J, Sulkava 35. Uno H, Ross T, Else JG, Suleman MA, 50. Rockwood K, Cosway S, Carver D, Jar-
R. Systematic intervention for supporting Sapolsky RM. Hippocampal damage as- rett P, Stadnyk K, Fisk J. The risk of demen-
community care of elderly people after a sociated with prolonged and fatal stress tia and death after delirium. Age Ageing
delirium episode. Int Psychogeriatr 2001; in primates. J Neurosci 1989;9:1705-11. 1999;28:551-6.
13:37-49. 36. Meijer OC, de Kloet ER. Corticoste- 51. McCusker J, Cole M, Dendukuri N,
20. American Psychiatric Association. rone and serotonergic neurotransmission Belzile E, Primeau F. Delirium in older
Practice guideline for the treatment of pa- in the hippocampus: functional implica- medical inpatients and subsequent cogni-
tients with delirium. Am J Psychiatry 1999; tions of central corticosteroid receptor tive and functional status: a prospective
156:Suppl:1-20. diversity. Crit Rev Neurobiol 1998;12:1-20. study. CMAJ 2001;165:575-83.
21. Moran JA, Dorevitch MI. Delirium in 37. Breitbart W, Marotta R, Platt MM, et 52. Baker FM, Wiley C, Kokmen E, Chan-
the hospitalized elderly. Aust J Hosp al. A double-blind trial of haloperidol, dra V, Schoenberg BS. Delirium episodes
Pharm 2001;31:35-40. chlorpromazine, and lorazepam in the during the course of clinically diagnosed
22. Cole MG, Dendukuri N, McCusker J, treatment of delirium in hospitalized Alzheimer’s disease. J Natl Med Assoc
Han L. An empirical study of different di- AIDS patients. Am J Psychiatry 1996; 1999;91:625-30.
agnostic criteria for delirium among el- 153:231-7. 53. Rothschild JM, Bates DW, Leape LL.
derly medical inpatients. J Neuropsychiatry 38. Marcantonio ER, Flacker JM, Wright J, Preventable medical injuries in older pa-
Clin Neurosci 2003;15:200-7. Resnick NM. Reducing delirium after hip tients. Arch Intern Med 2000;160:2717-
23. Laurila JV, Pitkala KH, Strandberg TE, fracture: a randomized trial. J Am Geriatr 28.
Tilvis RS. Delirium among patients with Soc 2001;49:516-22. 54. Gillick MR, Serrell NA, Gillick LS. Ad-
and without dementia: does the diagnosis 39. Inouye SK. Delirium and cognitive de- verse consequences of hospitalization in
according to the DSM-IV differ from the cline: does delirium lead to dementia? In: the elderly. Soc Sci Med 1982;16:1033-8.
previous classifications? Int J Geriatr Psy- Fillit HM, Butler RN, eds. Cognitive de- 55. Williamson JW. Formulating priori-
chiatry 2004;19:271-7. cline: strategies for prevention: proceed- ties for quality assurance activity. JAMA
24. Inouye SK, Foreman MD, Mion LC, ings of a White House Conference on Ag- 1978;239:631-7.
Katz KH, Cooney LM Jr. Nurses’ recogni- ing. London: Greenwich Medical Media, 56. Sloss EM, Solomon DH, Shekelle PG,
tion of delirium and its symptoms: com- 1997:85-107. et al. Selecting target conditions for quality
parison of nurse and researcher ratings. 40. Rockwood K. The occurrence and du- of care improvement in vulnerable older
Arch Intern Med 2001;161:2467-73. ration of symptoms in elderly patients adults. J Am Geriatr Soc 2000;48:363-9.
25. Inouye SK, Charpentier PA. Precipitat- with delirium. J Gerontol Med Sci 1993;48: 57. Institute of Medicine (IOM) Commit-
ing factors for delirium in hospitalized M162-M166. tee on Quality of Health Care in America.
elderly persons: predictive model and in- 41. Levkoff SE, Liptzin B, Evans EA, et al. To err is human: building a safer health
terrelationship with baseline vulnerabili- Progression and resolution of delirium in system. Washington, D.C.: National Acad-
ty. JAMA 1996;275:852-7. elderly patients hospitalized for acute care. emy Press, 2000:26-48.
26. Gleason OC. Delirium. Am Fam Phy- Am J Geriatr Psychiatry 1994;2:230-8. 58. Thomas EJ, Studdert DM, Newhouse
sician 2003;67:1027-34. 42. Marcantonio ER, Flacker JM, Michaels JP, et al. Costs of medical injuries in Utah
27. Rolfson D. The causes of delirium. In: M, Resnick NM. Delirium is independent- and Colorado. Inquiry 1999;36:255-64.
Lindesay J, Rockwood K, Macdonald A, ly associated with poor functional recov- Copyright © 2006 Massachusetts Medical Society.
eds. Delirium in old age. Oxford, England: ery after hip fracture. J Am Geriatr Soc
Oxford University Press, 2002:101-22. 2000;48:618-24.
This appendix has been provided by the author to give readers additional information about their work.
Supplement to: Inouye SK. Delirium in Older Persons. N Engl J Med 2006;354:1157-65.
WEB-ONLY SUPPLEMENT
SUPPLEMENT TABLE 1. DIAGNOSTIC CRITERIA FOR DELIRIUM
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced
C. The disturbance develops over a short period of time (usually hours to days) and tends to
D. There is evidence from the history, physical examination, or laboratory findings that the
For a definite diagnosis, symptoms, mild or severe, should be present in each one of the following areas:
a. impairment of consciousness and attention (on a continuum from clouding to coma; reduced
b. global disturbance of cognition (perceptual distortions, illusions and hallucinations-- most often
visual; impairment of abstract thinking and comprehension, with or without transient delusions,
but typically with some degree of incoherence; impairment of immediate recall and of recent
memory but with relatively intact remote memory; disorientation for time as well as, in more
c. psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from one to the other;
increased reaction time; increased or decreased flow of speech; enhanced startle reaction);
d. disturbance of the sleep - wake cycle (insomnia or, in severe cases, total sleep loss or reversal of
the sleep - wake cycle; daytime drowsiness; nocturnal worsening of symptoms; disturbing dreams
1
SUPPLEMENT TABLE 1 (cont)
wondering perplexity.
This feature is usually obtained from a reliable reporter, such as a family member, caregiver, or
nurse and is shown by positive responses to these questions: Is there evidence of an acute change
in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the
day, that is, tend to come and go, or did it increase and decrease in severity?
Feature 2. Inattention
This feature is shown by a positive response to this question: Did the patient have difficulty
focusing attention, for example, being easily distractible, or have difficulty keeping track of what
This feature is shown by a positive response to this question: Was the patient’s thinking
This feature is shown by any answer other than “alert” to this question: Overall, how would you
rate this patient’s level of consciousness (alert [normal], vigilant [hyperalert], lethargic [drowsy,
* The ratings for the CAM should be completed following brief cognitive assessment of the patient, for example,
with the Mini-Mental State Examination. The diagnosis of delirium by CAM requires the presence of features 1
2
SUPPLEMENT TABLE 2. CLINICAL FEATURES OF DELIRIUM (DETAILED VERSION)
Acute onset Disturbance occurs abruptly, usually over hours to days, but onset over
Fluctuating course Symptoms tend to come and go, or increase and decrease in severity over a
Inattention Difficulty focusing, sustaining, and shifting attention. Patients are easily
impaired.
Altered level of consciousness Clouding of consciousness with reduced clarity of awareness of the
abnormally drowsy and difficult to keep aroused. The patient may also be
3
SUPPLEMENT TABLE 2 (cont)
Cognitive deficits Global or multiple deficits in cognition are typical. Disorientation to time
cases. Memory deficits for immediate and short-term memory are typical,
and mixed. In the hyperactive form of delirium, the patient is agitated (i.e.,
delirium, the patient has a markedly decreased level of motor activity (i.e.,
4
SUPPLEMENT TABLE 2 (cont)
Altered sleep-wake cycle Sleep cycle disturbances are characteristic. Daytime drowsiness, nighttime
with delirium.
Emotional disturbances Emotional disturbances are common, manifested by intermittent and labile
5
SUPPLEMENT TABLE 3
A PROPOSED RESEARCH AGENDA TO EXPLORE DELIRIUM AND THE INTER-
RELATIONSHIP OF DELIRIUM AND DEMENTIA
Epidemiology
• Diagnosis of delirium: What is the sensitivity, specificity, clinical yield and cost-effectiveness of
various evaluation approaches to delirium? What is the optimal diagnostic approach?
• Long-term follow-up studies of delirious patients: Does delirium itself lead to permanent
cognitive impairment? How often does delirium lead to mild cognitive impairment or dementia?
• Delirium superimposed on dementia: Does delirium alter the trajectory of cognitive decline in
patients with dementia?
• Cognitive reserve capacity/recovery from delirium: Are there factors that assist in cognitive
recovery after delirium, such as educational level, exercise, health habits, medications (e.g.,
cholinesterase inhibitors)?
• Genetic factors: Are there genetic determinants of the risk of development of delirium, or lack of
recovery from delirium? What is the role of APOE-ε4?
• Identification of high-risk populations: Does delirium exert its maximal detrimental effects only
in certain high-risk subgroups? Or high-risk settings (e.g., post-operative, intensive care)?
• Impact of delirium: What are the economic and societal costs associated with delirium and
delirium superimposed on dementia?
Pathophysiology
• Neuroimaging, neuropsychological, and neuropathological studies: Does delirium lead to
permanent neurological sequelae?
• Structural and functional imaging methods: Do preexisting abnormalities (e.g., white matter
hyperintensities, volume losses) or functional changes predict the development of delirium, as
well as longer-lasting cognitive decline?
• Amyloid imaging: Does degree of amyloid pathology correlate with the risk of delirium or the
likelihood of recovery from delirium?
• Animal models: Are there pathologic changes after induced delirium (e.g., general anesthesia) in
normal and dementia models?
• Laboratory, electrophysiologic, or neuroimaging markers: Can we identify markers that will
assist in diagnosis of delirium? Can we identify markers for delirium that is likely to lead to
chronic cognitive impairment or dementia?
6
• Behavioral manifestations: What is the underlying pathophysiology of behavioral manifestations
of delirium (e.g., hyperactive vs. hypoactive form)? Do genetic factors or neuroreceptor subtypes
play a role?
REFERENCES:
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.
Washington DC: American Psychiatric Association, 1994.
2. World Health Organization. The ICD-10 classification of mental and behavioural disorders.
Diagnostic criteria for research. Geneva: WHO, 1992;57-9.
3. 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: 941-948.