A new delirium phenotype with rapid high amplitude onset and nearly as rapid reversal: Central Coast Australia Delirium Intervention Study

Abstract

BackgroundTraditional models for delirium based on the Diagnostic and Statistical Manual for Mental Disorders and its 1990 offspring, the Confusion Assessment Method (CAM), were not designed to distinguish behavioral and psychological symptoms of dementia from rapid cognitive decline. We examined a new diagnostic criterion for delirium plus exclusion of behavioral and psychological symptoms of dementia and recent inattention with a 25% decline in digit span forward (DSF).MethodsThis was a prospective, randomized controlled trial comparing management of prevalent delirium in general medical with that in geriatric medical wards in a 370-bed hospital north of Sydney. Inclusion criteria were age ≥65 years and prevalent delirium in the emergency department based on: CAM; proof that CAM elements were not better explained by behavioral and psychological symptoms of dementia; proof of recent inattention on DSF; evidence of cognitive decline not due to sedatives or antipsychotics in the emergency department. Measurements included the Instrumental Activities of Daily Living (IADL, 22-item), Selective IADL (8-item), Mini-Mental State Examination, DSF daily, Delirium Index daily, and Apathy Evaluation Scale. Pre-delirium scores from past cognitive tests and best scores were imputed after admission. Relative change (RC) was calculated as absolute change/test range and RC/MPC ratio was calculated as RC after admission/maximal possible change.ResultsA total of 130 subjects were recruited but 14 with subsyndromal delirium were excluded, leaving 116 subjects (mean age 83.6 years). Forty-eight percent had prior dementia. RC from pre-delirium to admission was 42% for the Mini-Mental State Examination, 41% for Selective IADL, 34% for 5-DSF, 54% for 6-DSF, and 37% for the Apathy Evaluation Scale. Improvements after admission (RC and RC/MPC ratios) were 32%/98% for 5-DSF, 54%/82% for 6-DSF, and 45%/80% for the Delirium Index. General medicine and geriatric medicine groups had similar outcomes.ConclusionThis delirium phenotype selects for a rapid high amplitude critical decline in attention, executive function, IADL, and apathy that recovers almost as rapidly.

Delirium, in 405 articles of medical (non-surgical or ICU) inpatients: unproven speed of onset and recovery

“…The Central Coast Australia Delirium Intervention Study (CADIS) a prospective randomized clinical trial was compared. 7 The 116 subjects recruited from July 2012 to May 2014 were of mean age 83.6 years with prevalent delirium by CAM plus three additional criteria to make CAM more specific: 1) at least a 25% decline in attention by forward or reverse imputation, 2) not counting impaired level of consciousness toward diagnosis if this followed sedatives or antipsychotics, and 3) rigorous exclusion of BPSD. The 116 subjects had a mean onset of 1.31±1.36 days compared to 3.09±2.38 in the medical literature.…”

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“…Poor sleep may also be associated with reduced physical functioning. 2 This survey was conducted to determine if there was an unrecognised sleeping problem amongst patients and the prevalence of hypnotic drug use in a geriatric rehabilitation ward.…”

“…A prospective cohort study of older surgical inpatients examining the prevalence and implications of frailty SC Cheung 1,2 , LA Ahmad 3 , JE Hardy 3 , SN Hilmer 1,2,3 1 Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia, 2 Kolling Institute, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia, 3 Royal North Shore Hospital, St Leonards, NSW, Australia Aims: To identify the prevalence of frailty in a population of older surgical inpatients, and the association of frailty with adverse outcomes and provision of geriatric medicine assessment.…”

“…Medical students' perceptions of using logbooks in a geriatric medicine clerkship V Khokulan 1 , C Etherton-Beer 1,2 1 Geriatric Medicine, Royal Perth Hospital, Perth, WA, Australia, 2 Western Australian Centre for Health and Ageing, University of Western Australia, Perth, WA, Australia Aims: Logbooks are widely used in medical education. Logbooks can provide a systematic approach, with benefits to learners as well as their tutors.…”

Delirium After Major Elective Noncardiac Surgery: Successful Aging After Elective Surgery Study

“…It appears that the only measure of reversibility was CAM (positive to negative) and CAM‐Severity. In the Central Coast Australia Delirium Intervention Study (CADIS), a novel delirium phenotype based on the CAM plus three additional criteria (exclusion of BPSD, ≥25% decline in attention scores, and not counting disorganized thinking or confusion if sedatives or antipsychotics in or before emergency department admission could have caused them), the average reversibility of 6‐digit span forward was 43%, and the average reversibility of the delirium index was 32% in 116 CADIS participants …”