Delirium and depression: inter-relationship and overlap in elderly people

Delirium and depression are complex neuropsychiatric syndromes that are common in the elderly and associated with a variety of poor healthcare outcomes. Accurate detection is key to providing optimal care for these conditions but is complicated by their considerable clinical overlap. This includes shared symptom profiles as well as comorbidity. Careful assessment of symptom character as well as the context and course of disturbances can allow for more accurate diagnosis. Prior depressive illness is a common finding in patients with delirium, while depressive illness is a recognised sequel of delirium. Evidence points to similar pathophysiological mechanisms involving disturbances in stress and inflammatory responses, monoaminergic and melatonergic functions, that in turn point to avenues for therapeutic intervention. Development of better tools for systematic assessment for delirium and depression in populations at high risk by virtue of age, diminished cognitive reserve and frailty is a key target to achieve improved healthcare outcomes

Effect of preoperative pain and depressive symptoms on the risk of postoperative delirium: a prospective cohort study

Background Preoperative pain and depression predispose patients to delirium. We investigated whether pain and depressive symptoms interact to increase the risk of delirium.Methods We enrolled 459 people without dementia, who were aged 70 years or older and were scheduled for elective orthopaedic surgery between June, 2010, and August, 2013. At baseline, participants reported their current pain and the average and worst pain in the previous 7 days, on a scale of 0-10. Depressive symptoms before surgery were assessed with the 15-item geriatric depression scale and chart. Delirium after surgery was assessed with the confusion assessment method and chart. We used multivariable analysis to assess the relation between preoperative pain and postoperative delirium stratified by the presence of depressive symptoms.Findings Delirium was reported in 106 (23%) of patients, and was significantly more frequent in those with depressive symptoms at baseline than in those without (relative risk [RR] 1.6, 95% CI 1.2-2.3). Preoperative pain was associated with an increased adjusted risk of delirium across all pain measures (RR 1.07-1.08 per 1-point increase in pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk of delirium for each 1-point increase in worst pain score, which indicated a significant interaction (p(interaction)=0.049). Similarly, a 13% increased risk of delirium was seen per 1-point increase in average pain score, but the interaction was not significant.Interpretation Preoperative pain and depressive symptoms are associated with increased risk of delirium, independently and with substantial interaction, which suggests a cumulative effect. These factors should be assessed before surgery

Delirium superimposed on dementia: a quantitative and qualitative evaluation of informal caregivers and health care staff experience

Objective—Delirium superimposed on dementia (DSD) is common and potentially distressing for patients, caregivers, and health care staff. We quantitatively and qualitatively assessed the experience of informal caregiver and staff (staff nurses, nurse aides, physical therapists) caring for patients with DSD. Methods—Caregivers’ and staff experience was evaluated three days after DSD resolution (T0) with a standardized questionnaire (quantitative interview) and open-ended questions (qualitative interview); caregivers were also evaluated at 1-month follow-up (T1). Results—A total of 74 subjects were included; 33 caregivers and 41 health care staff (8 staff nurses, 20 physical therapists, 13 staff nurse aides/health care assistants). Overall, at both T0 and T1, the distress level was moderate among caregivers and mild among health care staff. Caregivers reported, at both T0 and T1, higher distress related to deficits of sustained attention and orientation, hypokinesia/psychomotor retardation, incoherence and delusions. The distress of health care staff related to each specific item of the Delirium-O-Meter was relatively low except for the physical therapists who reported higher level of distress on deficits of sustained/shifting attention and orientation, apathy, hypokinesia/psychomotor retardation, incoherence, delusion, hallucinations, anxiety/fear. The qualitative evaluation identified important categories of caregivers ‘and staff feelings related to the delirium experience. Conclusions—This study provides information on the implication of the experience of delirium on caregivers and staff. The distress related to DSD underlines the importance of providing continuous training, support and experience for both the caregivers and health care staff to improve the care of patients with delirium superimposed on dementia

Concordance between DSM-IV and DSM-5 criteria for delirium diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium rating scale-revised-98.

Background: The Diagnostic and Statistical Manual fifth edition (DSM-5) provides new criteria for delirium diagnosis. We examined delirium diagnosis using these new criteria compared with the Diagnostic and Statistical Manual fourth edition (DSM-IV) in a large dataset of patients assessed for delirium and related presentations. Methods: Patient data (n = 768) from six prospectively collected cohorts, clinically assessed using DSM-IV and the Delirium Rating Scale-Revised-98 (DRS-R98), were pooled. Post hoc application of DRS-R98 item scores were used to rate DSM-5 criteria. ‘Strict’ and ‘relaxed’ DSM-5 criteria to ascertain delirium were compared to rates determined by DSM-IV. Results: Using DSM-IV by clinical assessment, delirium was found in 510/768 patients (66%). Strict DSM-5 criteria categorized 158 as delirious including 155 (30%) with DSM-IV delirium, whereas relaxed DSM-5 criteria identified 466 as delirious, including 455 (89%) diagnosed by DSM-IV (P <0.001). The concordance between the different diagnostic methods was: 53% (ĸ = 0.22) between DSM-IV and the strict DSM-5, 91% (ĸ = 0.82) between the DSM-IV and relaxed DSM-5 criteria and 60% (ĸ = 0.29) between the strict versus relaxed DSM-5 criteria. Only 155 cases were identified as delirium by all three approaches. The 55 (11%) patients with DSM-IV delirium who were not rated as delirious by relaxed criteria had lower mean DRS-R98 total scores than those rated as delirious (13.7 ± 3.9 versus 23.7 ± 6.0; P <0.001). Conversely, mean DRS-R98 score (21.1 ± 6.4) for the 70% not rated as delirious by strict DSM-5 criteria was consistent with suggested cutoff scores for full syndromal delirium. Only 11 cases met DSM-5 criteria that were not deemed to have DSM-IV delirium. Conclusions: The concordance between DSM-IV and the new DSM-5 delirium criteria varies considerably depending on the interpretation of criteria. Overly-strict adherence for some new text details in DSM-5 criteria would reduce the number of delirium cases diagnosed; however, a more ‘relaxed’ approach renders DSM-5 criteria comparable to DSM-IV with minimal impact on their actual application and is thus recommende