We have a number of concerns regarding the recent study by Martin G. Cole and associates1 of multidisciplinary care in patients with delirium.
Delirium represents a change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving dementia.2 However, given that between 60% and 70% of the patients in both the intervention and usual care groups had suspected dementia, it is difficult to interpret the results of the study. It is also unclear why improvement was measured in terms of Mini-Mental Status Exam (MMSE) scores. The MMSE was not developed as a means of rating delirium; a more appropriate scale for this purpose would be the Delirium Rating Scale.3 The authors indicated that the rates of compliance with the recommendations of a geriatric specialist were “relatively high,” but Rockwood,4 commenting on this study in the same issue of CMAJ, noted that “27% of recommendations on medication and 31% of recommendations on investigations were not followed.” This is particularly disconcerting given that delirium in the medically ill is associated with higher mortality rates.5 Also, patients with an untreated medical disorder (e.g., a urinary tract infection) remain delirious despite receiving a “nursing intervention.”
The primary treatment for the symptoms of delirium is pharmacologic, including neuroleptic medication.6 Evidence for the efficacy of antipsychotic medication has been shown in a randomized, double-blind, comparison trial.7 However, Cole and associates did not indicate what medications were given to either the intervention group or the usual care group.
The results of this study should not alter the current management of delirium, which includes reversing the underlying cause and treating agitation, psychosis and insomnia with appropriate medication.8,9
Stephen D. Anderson Robert A. Hewko Department of Psychiatry Faculty of Medicine University of British Columbia Vancouver, BC
References
- 1.Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 2002;167(7):753-9. [PMC free article] [PubMed]
- 2.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed text rev (DSM-IV-TR). Washington: The Association; 2000.
- 3.Trepacz PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988;23:89-97. [DOI] [PubMed]
- 4.Rockwood KJ. Out of the furrow and into the fire: Where do we go with delirium? [editorial]. CMAJ 2002;167(7):763-4. [PMC free article] [PubMed]
- 5.Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263:1097-101. [PubMed]
- 6.Practice guidelines for treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry 1999;156(5 Suppl):1-20. [PubMed]
- 7.Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996;153:231-7. [DOI] [PubMed]
- 8.Anderson SD. Treatment of elderly patients with delirium [letter]. CMAJ 1995;152(3):323-4. [PMC free article] [PubMed]
- 9.Hewko RA. Recognition, assessment, and management of delirium in the geriatric patient. B C Med J 1996;38:480-3.