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Keywords:

  • delirium;
  • dementia;
  • infections;
  • primary care

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Delirium is a complex multifactorial neuropsychiatric syndrome with a broad range of cognitive and neurobehavioral symptoms. It is associated with major adverse events and poor outcome. Little is known about delirium in the primary care setting. A retrospective chart review was carried out for the identification of ICD-10 delirium cases presented in the regional medical office of a rural area in central Greece. Nine cases of delirium, mostly the hyperactive subtype, had been recorded. The patients tended to be elderly and suffering from dementia; infections were the underlying cause in most cases. All but one patient had been successfully treated in the primary care setting.

DELIRIUM IS A complex multifactorial neuropsychiatric syndrome with a broad range of cognitive and neurobehavioral symptoms. It is common in medical-surgical patients and those in hospice and nursing homes.1 The clinical importance of delirium is that it is associated with increased morbidity and mortality, longer lengths of hospital stay and poor functional recovery.2 Many delirious patients are discharged to be cared for by family caregivers and home health-care nurses, whereas delirium may develop in patients in home care due to exacerbations of chronic illness, the onset of an acute illness or as a medication side-effect.3

There is a growing literature on delirium, yet there is a paucity of studies in primary care settings. Little is known about the incidence of delirium and the patients' characteristics in primary care. In this study we present our findings from a rural primary care setting in central Greece.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

The study was a retrospective chart review. All medical records from patients examined at the regional medical office of Arahova Town, central Greece, during a 1-year period (from August 2008 to August 2009) were reviewed for the identification of patients who received a diagnosis of delirium, according to ICD-10 criteria. In rural areas of Greece there is a well-established primary care system organized in local units, such as regional medical offices and health centers.4 The regional medical office of Arahova Town is the only health unit in the town and provides primary care services for somatic disorders and psychiatric symptoms for a rural population of about 5000 people. The nearest health center and general hospital are about 10 and 30 kilometers away, respectively, but due to geographical reasons (the whole area is mountainous) patients almost exclusively visit the regional office first and are referred to the other health units as needed. There are no private practice physicians in the area. During the study period a total of 785 patients had been examined, many of them more than once for several medical problems. Delirious patients had been examined at the medical office or at home. Only cases in which delirium had been developed in patients in the community were considered. Cases where the symptomatology had been developed in an inpatient setting and persisted after hospitalization were not encountered. Cases of delirium tremens and cases in which delirium was associated with substance intoxication or drug overdose were also excluded.

Delirium subtypes were determined with the retrospective application of Liptzin and Levkoff5 criteria to the clinical description recorded in patients' case notes. Three subtypes (hyperactive, hypoactive, mixed) were identified. Time to remission had been estimated according to clinical judgment and was recorded in patients' charts. Data regarding the long-term course of the patients were not available.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

From a total of 785 patients examined during a 1-year period, nine cases of delirium (a rate of 1.1% in the clinical population) were identified and are presented in Table 1. Eight out of 9 (88.9%) patients were >65 years old, with a mean age of 76.3 years. Two-thirds of the patients suffered from dementia, and in five cases there was an underlying medical disease. Infections (respiratory and urinary tract infections) had been considered as the causes of delirium in seven cases and psychotropic medications in two patients. The attribution of delirium in certain drugs had been based on the time of symptom development and the exclusion of other potential causes. With the retrospective application of Liptzin and Levkoff criteria, six cases were classified as hyperactive delirium, one as hypoactive, and the two patients with both symptomatology types were considered as mixed cases.

Table 1.  Delirium cases and patients' characteristics
Sex, ageMedical conditionDelirium causeMotoric subtypeDays to remission
Male, 78Dementia, diabetes mellitusUrinary tract infectionMixed6
Male, 82DementiaRespiratory infectionHyperactive8
Female, 69Coronary heart disease, diabetes mellitusUrinary tract infectionHyperactive7
Female, 58Chronic obstructive pulmonary diseaseRespiratory infectionHyperactiveReferred to general hospital
Female, 78Dementia, arterial hypertensionAmitriptylineHyperactive6
Male, 83DementiaRespiratory infectionHyperactive6
Female, 82DementiaRespiratory infection, dehydrationHypoactive7
Male, 80Arterial hypertension, cerebrovascular diseaseLorazepamMixed3
Male, 77DementiaRespiratory infectionHyperactive5

All but one patient had been successfully managed at the primary care setting. In rural areas of Greece it is common practice that delirious patients are initially treated, both etiologically and symptomatically, at their place of residence, except in cases where the severity of the underlying medical condition or the patient's agitation justify immediate referral to the general hospital. Patients who do not respond to the initial treatment may be subsequently referred to the general hospital, such as a 58-year-old woman with chronic obstructive pulmonary disease and respiratory infection who was referred for further treatment due to deterioration of her medical condition. In five patients, apart from the treatment of the underlying condition, the administration of an antipsychotic agent had been employed for the management of agitation. Only atypical agents were given.

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

This retrospective study provides some evidence about the rate of recent-onset delirium in outpatients in a primary care setting and the patients' characteristics. Not surprisingly, elderly demented patients were over-represented in delirium cases. Both age and pre-existing cognitive impairment are well-known predisposing factors for delirium.2 Regarding the causes of delirium, infections (both respiratory and urinary tract infections) were considered in most cases, whereas prescribed psychotropic medications were involved in 22.2% of cases. Both causative factors have been illustrated in the relative literature.1,6

The majority of patients (66.7%) were considered to have hyperactive delirium. It has been suggested that the hyperactive subtype may consist of patients who are physically well enough to get agitated,5 and this may be the case for delirium outpatients, even the elderly ones. Presumably, hyperactive delirium is more common in outpatients because they are by definition less severely ill than inpatients, otherwise they would be hospitalized. However, caution is needed when considering delirium subtypes. Delirium often remains unrecognized or misdiagnosed and this may be particularly relevant for cases of hypoactive delirium in which symptoms may be misattributed to depression with severe consequences for the patient.7 Such cases may have been missed in our patient sample, in which only one patient had the hypoactive subtype.

Few studies have addressed delirium in community settings. In a large retrospective study on delirium superimposed on dementia in a community-dwelling managed-care population, Fick et al.8 found an incidence of 13%. The majority of diagnoses occurred in the inpatient hospital and the emergency room and only 20.1% were diagnosed at the office or at home. Delirium has been associated with increased costs and service utilization. Andrew et al.9 found that delirium was very uncommon (<0.5%) in a population of old people without dementia living in their usual place of residence. Only 12 community-dwelling cases were identified. These patients had a poor outcome at the 5-year follow up. Clearly, more research on delirium in community settings is needed.

The limitations of this study include the retrospective design, and non-utilization of a standard scale for the estimation of delirium at the time of diagnosis. The retrospective application of Liptzin and Levkoff criteria for the determination of motor subtypes is another limitation, even though it was based on detailed clinical description of the patients' charts. The small number of cases does not allow the performance of statistical analysis. Furthermore, long-term outcome data were not available. On the other hand, these results involved a representative population sample of a rural area in Greece in routine primary clinical practice.

This report calls for further study on delirium in the primary care setting. Generally, it appears that recent-onset delirium in the community population may be mainly hyperactive and is associated with old age, dementia, infections, and prescribed medications. Such patients may be successfully treated in the primary care setting. Caution is warranted when certain agents that are known to be implicated in delirium are prescribed in elderly patients. Every infection should be readily appropriately managed. Primary care physicians should pay particular attention so as not to miss cases of hypoactive delirium that would increase patients' morbidity. Large, prospective studies with adequate long-term follow-up periods are needed to clarify these issues.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
    Meagher D, Trzepacz P. Delirium. In : GelderM, AndreasenN, Lopez-IborJJ, GeddesJ (eds). New Oxford Textbook of Psychiatry, 2nd edn. Oxford University Press, New York, 2009; 325333.
  • 2
    Inouye S. Delirium in older persons. N. Engl. J. Med. 2006; 354: 11571165.
  • 3
    Bond S. Delirium at home: strategies for home health clinicians. Home Healthc. Nurse 2009; 27: 2434.
  • 4
    Margiolis A, Mihas C, Alevizos A et al. Comparison of primary health care services between urban and rural settings after the introduction of the first urban health centre in Vyronas, Greece. BMC Health Serv. Res. 2008; 8: 124.
  • 5
    Liptzin B, Levkoff S. An empirical study of delirium subtypes. Br. J. Psychiatry 1992; 161: 843845.
  • 6
    Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad. Med. J. 2004; 80: 388393.
  • 7
    Farrell K, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch. Intern. Med. 1995; 155: 24592464.
  • 8
    Fick D, Kolanowski A, Waller J, Inouye S. Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization. J. Gerontol. A Biol. Sci. Med. Sci. 2005; 60: 748753.
  • 9
    Andrew M, Freter S, Rockwood K. Prevalence and outcomes of delirium in community and non-acute care settings in people without dementia: a report from the Canadian study of health and aging. BMC Psychiatry 2006; 4: 15.