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Psychiatric Clinics of North America

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DELIRIUM : Advances in Diagnosis, Pathophysiology, and Treatment - 11/09/11

Doi : 10.1016/S0193-953X(05)70299-9 
Paula T. Trzepacz, MD *

Resumen

Delirium is an acute confusional state with an average prevalence of about 20% in general hospital populations, based on both referral and consecutive admission study designs. It involves alterations in cognition, mood, perception, thinking, and sleep. Symptoms tend to fluctuate in intensity over a 24-hour period, with periods of relative lucidity interspersed with periods of more severe impairment. The features of delirium are as follows:

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Diffuse cognitive impairment
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Perceptual disturbances and hallucinations (especially visual)
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Delusions (usually persecutory)
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Abnormalities of thought process
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Language alterations (especially semantic content of writing)
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Sleep–wake cycle disturbances
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Altered or labile affect
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Acute or abrupt onset of symptoms
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Fluctuation of symptom severity
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Identifiable (or presumed) physical cause

Levels of consciousness and awareness may also fluctuate, though not reaching the degree of impairment of stupor or coma. Because the sleep-wake cycle in delirium is fragmented over a 24-hour period, fluctuations in level of awareness or consciousness might be affected by alterations in sleep physiology, including ultradian rhythms.

Several studies suggest that delirium as a comorbid condition increases length of stay during general medical hospitalizations,30, 37, 128 even when diagnosis related group (DRG)-adjusted. This has economic as well as personal suffering implications.

Elderly populations experiencing an episode of delirium have an especially poor prognosis. They have longer lengths of stay,36, 56, 92 even when adjusted for DRG or illness severity,30, 92 and increased in-hospital mortality.30, 92 Delirium during an index admission is associated with postdischarge functional decline in activities of daily living,36, 52, 63, 83 persistent or progressive cognitive impairment 6 months later,29, 56 and loss of independent community living compared with prior-to-the-index admission.29, 56 Mortality postdischarge of delirious elderly is increased compared with nondelirious elderly: at 6 months after the index admission 20%,36 26%,56 and 27%52 had died, and at 1 year 37%52 and 39%29 had died. Francis et al30 found that medical illness severity predicted 6-month mortality in delirious elderly patients. In many of these reports, delirium was comorbid with dementia, as high as 81% in a study by Koponen et al.52 Cognitive deficits that appear to persist following delirium might suggest residual delirium effects,56 but more likely these deficits are related to an underlying dementia that progressed51 and that had previously increased the vulnerability to delirium on the basis of “diminished brain reserve” during the early yet undiagnosed period of dementia.30

Across a broad age range, there is significant morbidity and mortality associated with experiencing a delirium episode, even for a wide variety of underlying causes. Mortality is high: during the index admission it was 11%,92 17%,37 23%,96 and 26%140; at 3 months after admission it was 11%92 and 30%144; at 6 months it was 17%136; at 1 year it was 38%96; and at 5 years it was 51%.140 Mortality rates are significantly higher for delirious than for nondelirious cases. At 5-year follow-up, however, mortality risk was more related to the underlying medical prognosis than to the previous episode of delirium.140

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 Address reprint requests to Paula T. Trzepacz, MD, WPIC, 3811 O'Hara Street, Pittsburgh, PA 15213


© 1996  W. B. Saunders Company. Publicado por Elsevier Masson SAS. Todos los derechos reservados.
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Vol 19 - N° 3

P. 429-448 - septembre 1996 Regresar al número
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