Overview of Confusion & Delirium for Clinicians (July 2007)
Delirium & Confusion
Confusion over terminology
– AKA Disorientation
– Clouding of consciousness
• de lira “to wander”
• clinical syndrome (not disease) characterised by
Scope of the Problem
• 10-15% delirious on admission (Inouye 1997, Lipowski 1987)
• 5-40% incident delirium in hospital (Francis 1992)
– 11-43% post-operatively (Bryson 2006)
– 70-87% in the ICU (Pisani 2006)
– > 70% in terminal CA (Massie 1987)
Delirium: Outcomes - Duration
• More persistent than previously realised
• Up to one week in 60%
• two weeks in 20%
• four weeks in 15%
• more than four weeks in 5%
• Delirium still present at 6 months
– O'Keeffe S The prognostic significance of delirium in older hospital patients J of
the Am Geriatr Soc 1997;45(2):174-8
Delirium: Outcomes Mortality
• Delirium in hospital is associated with mortality rates
of 25 – 33%
• Most studies report higher mortality after discharge
eg 39% vs 23% at two years
– Francis J Prognosis after hospital discharge of older medical patients with
delirium. J Am Geriatr Soc 1992;40(6):601-6
• Hazard ratio of 2.11 at 1 year adjusted for
comorbidity, dementia and severity of illness
– McCusker et al Delirium predicts 12 month mortality. Arch Intern Med.
A Case That Breaks the Rules
• Ms EM, a 27 y/o with Hodgkins, two months post-natal
• EM experienced disturbed sleep-wake cycle, disorientation, distractibility,
and a sub-acute onset of confusion over seven days. There was also mild
daytime somnolence but no changes in consciousness, no psychotic
symptoms or perceptual disturbance, and no convincing fluctuations. She
was not unduly agitated or over-aroused.
• She scored 6 out of 10 on the clock-drawing test (CDT), and 22/30 on the
mini-mental state examination (MMSE).
• On the Delirium Rating Scale she scored 11 out of a possible 32.
Functionally, she stopped working and driving, and required assistance
with everyday household tasks.
• At one year the symptoms had not changed.
EssentialQualifyingNoRapid onset and fluctuation of symptoms
Not requiredEssentialYesEmotional disturbance
Not requiredQualifyingYesImpairment of abstract thinking or comprehension
Not requiredQualifyingNoIncreased or decreased motor activity
Not requiredQualifyingYesDisturbance of sleep-wake cycle
QualifyingNot requiredYesDisorganized thinking/incoherent speech
EssentialEssentialYesImpairment of attention
QualifyingEssentialNoClouding/disturbance of consciousness
Laurila (2003) 425 patients hospital & nursing home
• Prospective & descriptive observational study
• 6 hours before meeting DSM IV criteria
• Behavioural symptoms noticed
• Urgent calls for attention
• Decreased psychomotor activity
– Altered sleep pattern
Sorensen & Wickbald (2004), J of Clin Nursing, 13
• Delirium often missed
• 32 – 67% of delirious patients are not diagnosed
• Cognitive assessment should be standard
– MMSE or AMTS
• Serial testing to monitor progress and to detect
delirium arising during an admission
• Mental status = a “vital sign”
Educational intervention => recognition
Rockwood et al (1994)
• Simple educational intervention at monthly
• Diagnosed 3% pre intervention (187 pts)
• Diagnosed 9% post intervention (247 pts)
• Frequent comments on various aspects of
mental state (15.6% Vs. 8.5%)
Rockwood et al (1994) J of Am Ger Soc, 42
Delirium: Differential Diagnosis
Meagher, D J Delirium BMJ 2001; 322: 144 -149
Delirium Dementia Depression
Onset Acute Insidious Variable
Course Fluctuating Steadily progressive Diurnal variation
Clear until late
Poor short term
Poor short term
Poor attention but
Psychosis present? Common (psychotic
Less common Occurs in small
EEG Abnormal in 80-
diffuse slowing in
Abnormal in 80-
diffuse slowing in
The Clock Drawing Test
•Used extensively in assessment of cognitive
function, especially as a screen for dementia
•Administration is quick, easy and non-threatening
•Several studies assessing its validity as a screen
for delirium with conflicting results
•Multiple scoring methods, >12 reported in the
J Geriatr Psychiatry Neurol 2005;18:129-133
Int J Geriatr Psychiatry 2000;15:548-561
Draw a clock face. Set the time at 10 past 11.
The Clock Drawing Interpretation Scale
1. There is an attempt to indicate a time in any way.
2. All marks or items can be classified as either part of a closure figure, a hand, or a symbol for clock
3. There is a totally closed figure without gaps (closure figure).
4. A “2” is present and is pointed out in some way for the time.
5. Most symbols are distributed as a circle without major gaps.
6. Three or more clock quadrants have one or more appropriate numbers:12-3, 3-6 etc.
7. Most symbols are ordered in a clockwise or rightward direction.
8. All symbols are totally within a closure figure.
9. An “11” is present and is pointed out in some way for time.
10. All numbers 1-12 are indicated.
11. There are no repeated or duplicated number symbols.
12. There are no substitutions for Arabic or Roman numerals.
13. The numbers do not go beyond the number 12.
14. All symbols lie about equally adjacent to a closure figure edge.
15. Seven or more of the same symbol type are ordered sequentially.
16. All hands radiate from the direction of a closure figure center.
17. One hand is visibly longer than another hand.
18. There are exactly two distinct and separable hands.
19. All hands are totally within a closure figure.
20. There is an attempt to indicate a time with one or more hands.
(Score “1” per Item)
Score Only if Symbols for Clock Numbers are Present:
Score Only if One or More Hands are Present:
J Am Geriatr Soc 1992;40:1095-1099
• Rosen H, (1979) Haloperidol Vs Thioridazine
• Tsuang M, (1971) Haloperidol Vs Thioridazine
• Thomas et al (1992) Haloperidol Vs Droperidol
• Brietbart et al (1996) Haloperidol, CPZ & Lorazepam
Delirium: Non Pharmacological Mx
• Correct sensory deficits (glasses and hearing aids)
• Communication, simple instructions, avoid jargo
• Re orientation (calendars, clocks, schedules)
• A quiet, stable environment (Minimise room and
Delirium: Non Pharmacological Tips
• Avoid sleep disruption
• Encourage mobility and self care
• Avoid restraints and bed rails
• Involve family where possible
• Meaningful personal items
• A view to the outside
Non Pharmacological Mx: Does it work?
• Cole et al found 227 with incident or prevalent
delirium amongst 1925 patients in 5 general medical
• Randomised to usual care or geriatrician and nurse
consultation & follow up
• No significant differences in LOS, time to
improvement, discharge, mortality!!
• Cole MG et al. Systematic detection and multidisciplinary care of delirium in older
medical inpatients: a randomized trial. CMAJ. 2002; 167(7):753-9.
• Prospective study involving 852 patients with 426
matched pairs compared usual care of elderly
general medical patients with those receiving
– Incidence of delirium lower in intervention vs usual
care group (9.9% vs 15%)
– Total days of delirium (105 vs 160)
– Number of episodes of delirium (62 vs 90)
– No difference in severity of delirium or recurrence
– Major effect of interventions was to prevent the
primary episode of delirium
Inouye et al N Engl Med 1999;340:669-76
• Marcantonio et al. Pre-op and daily post-op geriatric
review 126 elderly patients (RCT)
• Oxygen, fluid/electrolytes
• pain, medication review/reduction
• bowel and bladder function
• nutrition, early mobilisation and rehabilitation
• prevent/detect/treat post op complications
• environmental stimuli
• treat delirium
• 126 patients > 65 y/o for hip fracture repair
• Pre-op and daily post-op geriatric review or
– Delirium: 32% vs 50% (NNT = 6) RR 0.6
– Severe delirium: 12% vs 29% (NNT = 6) RR0.4
– Those without dementia benefited most
– Marcantonio et al. Reducing Delirium after Hip Fracture J Am Geriatr
Soc 2001;49: 516-22
Delirium: Prevention Hip Fracture
Mental Capacity Act (2005)
• Premise: everyone can make their own decisions.
• Give the person all the support they can to help them
• No-one should be stopped from making a decision
just because someone else thinks it is wrong or bad.
• Anytime someone does something or decides for
someone who lacks capacity, it must be in the
person’s best interests
• When they do something or decide something for
another person, they must try to limit your own
freedom and rights as little as possible.
Advance (directives) Decisions
• An advance decision is when someone who has mental
capacity decides that they do not want a particular type of
treatment if they lack capacity in the future.
• A doctor must respect this decision.
• If the advance decision says no to treatment which may help
keep you alive, it must say this clearly and be signed by you.
Another person can sign an advance decision for you but
only if you agree and you can see them sign it.
• You are free to make an advance decision if you want to, but
no one should force you to make it.