American Psychiatric Association (APA) 2013 Annual Meeting

Early Psychiatric Consultation Key to Diagnosing Delirium Early In Elderly Patients With Pneumonia

Elderly patients, particularly those residing in long-term care (LTC) settings, are vulnerable to pneumonia, which is a potentially life-threatening disease in these patients. In older adults, the clinical presentation of pneumonia can differ from that observed in younger patients, with these patients often having fewer nonspecific symptoms than their younger counterparts. Delirium is one such nonspecific symptom that has been reported to commonly occur in these patients, and it is sometimes the only indication of pneumonia in this patient group. An abstract presented at the APA meeting sought to shed light on the sociodemographic and nosological features of delirium in elderly patients with pneumonia and their response to treatment.

The study retrospectively reviewed the medical records of all patients hospitalized for pneumonia at a 200-bed private general hospital and treated for delirium by a psychiatry team over a 6-month period. Upon reviewing the records, 25 patients met the inclusion criteria for the study (17 men and 8 women). All patients were white, had a mean age of 81.76 ± 7.98 years, and had a high number of comorbidities (2.95 ± 1.30 per patient), most commonly hypertension (n=16), dementia (n=9), diabetes (n=8), chronic obstructive pulmonary disease (n=6), and arrhythmias (n=6). A few patients also had psychiatric conditions, including panic disorder (n=1), anxiety disorders not otherwise specified (n=1), and substance abuse (n=1).

All patients presented with the hyperactive form of delirium and were treated using the following antipsychotics: haloperidol (n=5), quetiapine (n=11), risperidone (n=1), olanzapine (n=2), or a combination of haloperidol and quetiapine (n=6). These interventions were not randomly assigned, as the psychiatric team chose the treatments on an individual basis using their best clinical judgment. Most patients (64%) improved upon receiving antipsychotics, as demonstrated by their Clinical Global Impression-Improvement scale scores.

In general, psychiatric consultations were sought for these patients 18.52 ± 34.25 days after hospital admission. Psychiatric treatment for delirium required 8.12 ± 5.90 visits on average for each patient during 16.28 ± 17.78 days. Patients for whom psychiatric consultation was sought in the first week of hospitalization (n=14) required fewer psychiatric visits than patients whose physicians took longer than a week to seek psychiatric consultation (n=11), with 6.35 ± 2.97 versus 10.39 ± 7.89 visits, respectively. These patients also had a shorter course of delirium treatment (14.50 ± 6.25 vs 59.73 ± 56.34 days).

Based on their findings, the authors conclude that “delirium might be effectively treated in elderly patients using psychiatric consultations and antipsychotics.” They also note that psychiatric consultation should not be delayed, as it may help speed up delirium diagnosis and treatment.—Christina Loguidice
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Two Studies Show Delirium Impacts Terminal Cognitive Decline Independent of Dementia

Terminal cognitive decline describes the period of cognitive decline before death, typically occurring over the last 3 to 8 years of life. Because delirium is common in patients with terminal decline, researchers hypothesized that delirium might influence this condition. To shed light on this issue, researchers reviewed data from The Cambridge City over-75s Cohort study (CC75C) and The Vantaa 85+ study, two population-based studies conducted in the United Kingdom and Finland, respectively, and part of a brain donation program in Europe. The results of the retrospective review were reported in an abstract presented at the APA meeting.

In the CC75C and Vantaa 85+ studies, participants were included from electoral registers or taken from a selection of geographically and socially representative general practices. Standardized neuropsychological batteries, including the Mini-Mental State Examination (MMSE), were performed at 2- to 4-year intervals, and participants were followed up for 25 years (up to 9 surveys) in CC75C (mean patient age at baseline, 81 years) and for 10 years (up to 5 surveys) in Vantaa 85+ (mean patient age at baseline, 89 years). In CC75C, the delirium diagnosis was determined through retrospective interviews with general practitioners, and in Vantaa 85+ by integrating information from participants, practitioners, and hospital records. Brain autopsies of persons who participated in these studies were conducted in accordance with the consortium to establish a registry for Alzheimer’s disease and were performed blinded to clinical data.

Autopsy data were available for 536 participants (CC75C, n=246; Vantaa 85+, n=290). Median time to death was 3.1 years from baseline. Mean MMSE scores at the start of decline were 18 points. Cognitive decline was nonlinear, with a rate of -0.96 MMSE points per year and -0.03 points for each additional year (P<.01). Individuals with a history of delirium had worse initial scores (-3.9, P<.01) and also had accelerated cognitive decline (-0.78 points per year and -0.03 points for each additional year; P<.01). When stratified by burden of pathology, the magnitude of this delirium effect was larger in those with little evidence of Alzheimer’s disease, vascular dementia, or Lewy body dementia, with borderline evidence of an interaction between delirium and terminal cognitive decline (P=.058).

The authors note in the abstract that their study is “the first demonstration of the impact of delirium on terminal cognitive decline in the general population, and the first to relate this to neuropathology.” They conclude that “a history of delirium is strongly associated with the rate of cognitive decline in the last years prior to death, and this is stronger in individuals with a lower burden of dementia pathologies, [suggesting] that where delirium is a determinant of terminal cognitive decline, this may not be mediated by conventional dementia pathology.”—Christina Loguidice