Postoperative delirium: overview and opportunities to o...

Postoperative delirium: overview and opportunities to optimize outcomes

Program audience
Primary care physicians.

Educational Needs Addressed
Delirium is a common, morbid, and costly condition
in older patients. Delirium places patients at risk
for complications of hospitalization. Patients with
delirium are more likely to have iatrogenic infection,
pressure ulcers, deconditioning, falls, incontinence,
polypharmacy, and malnutrition. Ultimately, these
conditions further limit independent functioning lead-
ing to potential nursing home placement, frailty, and
death. The past 10 years have brought important
developments in the identification, treatment, and
prevention of delirium. It is essential that clinicians
understand the principles of delirium prevention and
management and apply these principles to all pa-
tients at risk for delirium.

Educational Objectives
After participating in this CME activity, primary care
physicians should be able to
1. Know how to diagnose and perform a workup for
delirium
2. Describe the treatment of delirium
3. Understand medical system barriers to care of
patients with delirium
4. Describe strategies to prevent delirium

Rudolph JL, Schreiber K, Harrington MB. Postoperative delirium: overview and opportunities to optimize outcomes. JCOM 2008; 15(10):502-511.

Case Study

Initial Presentation

A 68-year-old man is admitted to the hospital for
elective peripheral artery bypass to improve his
ability to walk without pain. Underlying medical conditions
include coronary artery disease, type 2 diabetes, hyperten-
sion, hyperlipidemia, osteoarthritis, and obesity. He had
4-vessel coronary artery bypass graft surgery 3 years ago.
Recalling the experience, the patient reports “seeing bugs”
and “being out of it” for several days after his cardiac surgery
and asks if similar effects are possible after this surgery.

>> How common is delirium in the operative patient?

Delirium, an acute change in mental status characterized by
a disturbance of attention and consciousness, is a frequent
complication after surgery. It occurs in 32% to 50% of cardiac
surgery patients, 21% to 48% of peripheral vascular surgery
patients, and 13% to 17% of head and neck surgery patients
[1]. The in-hospital mortality of postoperative delirium is
between 4% and 13% [2], which is equivalent to that for
in-hospital myocardial infarction [3]. Patients with delirium
after surgery are at risk for complications, longer length of
stay, increased likelihood of being discharged to a nursing
home, dementia, and loss of independence [4–7].

Delirium is common in older patients presenting to the
hospital, with 14% to 24% having delirium upon admission
[3]. Because of the high prevalence and poor outcomes as-
sociated with delirium, all older patients should be screened
on admission for existing (prevalent) delirium regardless
of the setting. Older patients without prevalent delirium
should be evaluated for delirium risk.

There are validated methods to identify patients at risk
for delirium in the medical and surgical populations [2,8].
Four major factors predict delirium risk in hospitalized
patients: cognitive impairment, severity of illness, visual
impairment, and dehydration [8]. Table 1 describes the risk
factors for delirium and the incidence of delirium with
increasing risk factors. Across studies, preexisting cogni-
tive impairment is consistently the strongest risk factor for
delirium [2,3,9,10]. It is important to note that age alone is
not a risk factor. Although delirium is more prevalent in the
older population, delirium can occur in all ages. Generally,
delirium is considered in the inpatient setting, but patients
in postacute, long-term, or palliative care have chronic dis-
eases that increase susceptibility to acute illness [8,11,12].
In this case, the patient’s prior delirium may also be a risk
factor for future delirium [13].


Operation and Postoperative Course

The patient undergoes an uncomplicated periph-
eral vascular bypass and is conversant with staff
and family on the operative day. His pain is controlled with
an epidural catheter, and there are no bleeding or infectious
concerns. In the evening of postoperative day 1, he gets
progressively more confused with paranoid thoughts and
hallucinations. On the morning of postoperative day 2, he
arouses to tactile stimulation but falls quickly asleep. When
questioned, he can respond to yes/no questions (eg, “Are
you in pain?”) but cannot answer open-ended questions
(eg, “Tell me about your pain”).


>> Does this patient have delirium?

The diagnosis of delirium is generally made with the criteria
established by the Diagnostic and Statistical Manual of Mental
Disorders (DSM). An algorithm based on DSM criteria, called
the confusion assessment method (CAM), has been validated
and used in over 200 studies [14]. A variant of the CAM called
the CAM-ICU has been validated for use in intensive care unit
(ICU) patients [15]. The features of the CAM are displayed in
the Figure. For diagnosis of delirium, the CAM requires
an acute change in mental status, fluctuations throughout
the course of the day, inattention, and either disturbance of
thought or alteration in consciousness. When accompanied
with training and standard mental status testing, the CAM
has a sensitivity of 94% to 100% and a specificity of 90% to
95% [16,17].

The primary cognitive deficit in delirium is inattention.
The traditional cognitive assessment in the hospital, orienta-
tion, has poor sensitivity (23%–26%) but good specificity
(95%–96%) for inattention. Cognitive assessments that have
improved sensitivity and specificity for inattention include
registration and recall of 3 words (sensitivity, 85%; specific-
ity, 96%), days of week and months of the year backwards
(sensitivity, 66%; specificity, 99%), and digit span forward
and backward (sensitivity, 84%; specificity, 92%) [18]. The
CAM-ICU adaptation includes the Attention Screening
Exam, a nonverbal attention assessment that has been inde-
pendently validated [19,20].

There are 3 psychomotor variants to delirium: hyper-
active, hypoactive, and mixed [21]. The hyperactive variant
accounts for 15% to 30% of delirium cases [22]. This variant
is rarely missed by clinicians and nurses because patients
are acting aggressively, pulling tubes and wires, and fre-
quently experiencing psychotic symptoms (delusions, para-
noia, hallucinations). The hypoactive variant is much more
subtle and occurs in 19% to 73% of patients [22]. Patients
with hypoactive delirium are sleepy and lethargic, do not
participate in care activities (eg, physical therapy, additional
studies), and are much more likely to have the diagnosis
of delirium delayed [23]. Recent research has found that
these hypoactive patients are at substantially higher risk of
mortality, presumably related to the delay in diagnosis [24].
The final variant is the mixed disorder with features of both
hyperactive and hypoactive (42%–52%) [22]. These patients
frequently have altered sleep-wake cycles and do not act as
aggressively as hyperactive patients, but are often dismissed
as having “sundowning” or dementia.


Diagnosis

The morning of postoperative day 2, the patient’s
primary care physician visits the patient and makes
the diagnosis of delirium. The physician performs a physical
examination and reviews the medical and nursing records
with a focus on medication administration.

>> What is the appropriate workup of a patient with delirium?

Delirium is a multifactorial syndrome resulting from the
additive combination of small insults (eg, environmental
change, sleep deprivation, psychoactive medications, acute
illness) that may not have caused delirium independently.
However, the combined effect of these small insults may
cause delirium in a patient with strong predisposing factors
to develop delirium [25]. For example, a low-risk patient may
not develop delirium from surgery, but the combination of
surgery, sleep deprivation, pain, psychoactive medications,
and fluid shifts may precipitate delirium. On the converse,
patients at high risk of developing delirium will require
fewer insults; sometimes the transition between the home
environment and hospital environment is enough to pre-
cipitate delirium. The goal of the physician is to identify and
treat as many insults as possible.

Patients with delirium may not provide accurate history.
Thus, the physician unfamiliar with the patient’s history
may need to contact family, caregivers, and/or nursing staff
to identify the previous level of mental status functioning
and when the mental status changed. Other important
historical elements include accurate outpatient medication
profile, alcohol use, prehospital function, sleep habits, and
nutritional status.

The focus on physical examination is crucial to the work-
up of delirium. This should be individualized for each
patient based on risk factors. In this case, a careful physical
examination to assess for cardiac complications of surgery
(eg, postoperative myocardial infarction, congestive heart
failure, pulmonary embolism) would be warranted because
of the high preoperative cardiac risk. On the other hand,
stroke and seizure would be lower on the differential diag-
nosis as a cause of delirium. Thus, a thorough neurologic
examination can save the patient, physician, and care team
from unnecessary workup. Specifically, if there are no new
focal neurologic findings, then the value of brain imaging is
limited [26]. Similarly, if seizure activity is not witnessed, an
electroencephalogram has a very low pretest probability [3].
Further areas for examination would include assessment of
infectious complications, constipation, and urinary retention.
All patients with delirium should undergo a thorough
review of recent changes in medications with a focus
on medications associated with cognitive adverse effects.
Table 2 lists some medications that can precipitate delirium
[27–29]. Medications for sleep, pruritis, nausea, cardiac
protection, and muscle relaxation can precipitate delirium
[30]. While all opioid pain medications can cause delirium,
meperidine has been shown to cause delirium at 3 times
the rate of others [28]. Epidural analgesia may also be a risk
factor. Unnecessary or offending medications should be re-
evaluated and discontinued if possible or at least a reduction
of dose should be considered.


___
Table 2. Medications That May Precipitate Delirium*

Antidepressants
- Amitriptyline
- Imipramine
- Paroxetine

Antihistamines
- Diphenhydramine
- Hydroxazine
- Chlorpheniramine
- Cimetidine
- Famotidine

Antipsychotics
- Thioridazine
- Chlorpromazine
- Olanzapine

Antispasmodics
- Cyclobenzaprine
- Baclofen
- Oxybutynin
- Atropine
- Hyoscyamine

Antivertigo
- Meclizine

Benzodiazepines
- Diazepam
- Chlordiazepoxide
- Flurazepam

Cardiac drugs
- Digoxin
- Amiodarone
- Methyldopa
- Procainamide

CNS drugs
- Levodopa
- Lithium
- Phenytoin
- Divalproex

Gastrointestinal agents
- Prochlorperazine
- Loperamide
- Metoclopromide

Pain medications
- Meperidine
- Indomethacin
- Opioids
–––
CNS = central nervous system.
*The list is not comprehensive but highlights medications felt to be
inappropriate for use in older patients due to evidence that they
may cause acute cognitive change.
___


Workup

The physician considers a broad differential diag-
nosis in the management and treatment of the
patient’s delirium. Electrolytes, complete blood count, and
urinalysis are ordered. An electrocardiogram is ordered be-
cause the patient was at high risk of cardiac event. She also
follows up on a low oxygen saturation reading by ordering
arterial blood gas and chest radiograph. She considers her
past interactions with the patient to address the possibility
that the current mental status could be related to a longer-
term mental disorder.


>>> How may delirium be distinguished from other mental disorders?

Care should be taken to avoid labeling the patient with delir-
ium as having dementia or depression. While these conditions
often coexist [31], there are important differences between
these states. First, delirium is an acute change in cognitive
function occurring over hours to days [32]. Both dementia and
depression will develop over a longer time course. Second,
mental status will fluctuate throughout the course of a day
in delirium. Additionally, the cardinal cognitive deficit of de-
lirium is inattention, whereas memory is impaired in demen-
tia and cognitive function is relatively preserved in mild and
moderate depression. Finally, the disturbance of consciousness
with some delirium patients should not be present in mild to
moderate dementia and depression.


Initial Treatment

The physician asks the nurse to begin a series of
nonpharmacologic strategies to improve patient
comfort and safety. Citing concern for the patient’s safety,
the patient’s nurse asks the physician to order restraints.


>> What is first-line treatment of delirium?

While nonpharmacologic methods of behavioral manage-
ment have limited evidence to support their use, these meth-
ods are potentially able to spare patients from pharmacologic
and physical restraints. Restraints, both formal (eg, wrist, vest,
ankle) and informal (eg, urinary catheters, oxygen tubing,
continuous intravenous lines) are associated with morbidity.
The use of psychoactive medications on a malfunctioning
brain can produce unpredictable results and should be under-
taken after carefully weighing the risks and benefits. Because
nonpharmacologic methods have little potential toxicity,
these should be the first line in the behavioral management
of a patient with delirium [3]. Nonpharmacologic measures
include creating a calm environment, preserving the sleep-
wake cycle, frequent reorientation, including family members
in the patient’s care, increasing mobility, and coordinating
care delivery [3].


>> What is the role of medications in delirium?

Medications to manage agitation in the delirious patient do
not treat the underlying delirium and may have deleterious
effects [3]. The risks and benefits must be carefully consid-
ered in each patient prior to prescribing. Benzodiazepines
may disinhibit the older patient, cause a paradoxical reac-
tion, or may induce delirium [28]. Use should be limited
to those with Parkinson’s disease, diffuse Lewy body de-
mentia, or adverse drug reactions to antipsychotics [33].
Anticholinergic medications may precipitate or worsen the
complications of delirium [34].

Antipsychotics are the primary medications to manage
agitation associated with delirium [35]. Theoretically, the
atypical antipsychotics have fewer extrapyramidal adverse
effects, although a recent systematic review found no dif-
ference between atypical and typical antipsychotics [36].
Further, some antipsychotics may be anticholinergic [37].
Thus, the medication of choice for management of agitation
associated with delirium remains haloperidol at lower doses
(0.5–1.0 mg) [38]. As always, the geriatricians’ motto “start
low and go slow” applies to the use of any medication to
manage agitation associated with delirium.

If antipsychotics are prescribed, the patients should be
monitored for adverse effects. In older cognitively impaired
patients, antipsychotics may carry an increased risk of mor-
tality [39,40]. Electrocardiogram should be monitored for
prolongation of the QTc interval. Antipsychotic medications
have been associated with aspiration pneumonia [41], pre-
sumably from oropharyngeal dysphagia [42], which may be
an extrapyramidal side effect [43].


Treatment Plan

The physician explains to the nurse why she does
not wish to order restraints. Together they formulate
a treatment plan that addresses both the physician’s concern
that medications and restraints can be harmful and the
nurse’s concern regarding patient safety. They agree to use
nonpharmacologic, environmental, and stimulating strate-
gies prior to giving medications for agitation. The physician
prescribes a low dose of haloperidol to be used in the event
that the other strategies do not successfully manage the
patient’s agitation.

On the drive to her office, the physician reflects on her in-
teraction with the nurse. Although she feels the best patient
care would be achieved with nonpharmacologic therapies,
she understands the pressures of the nursing workload. In
this case, the physician felt that a collaborative treatment
plan had been achieved. However, she wonders if this plan
will be carried through into other shifts when she will not
be present to educate the nursing staff.


>> What medical system barriers hinder care for patients
with delirium?

Astute physicians and nurses are crucial to the identifica-
tion, management, and treatment of delirium [3]. In the
course of a given day, nurses spend more time with patients
than physicians. This increased contact presents important
opportunities to assess mental status and identify associ-
ated fluctuations, disorganized thinking, and altered levels
of consciousness. Because nursing effort and time increase
with the delirious patient, nurses may feel increased pres-
sure to complete their required duties for other patients.
Educating and empowering nurses to improve care of
patients with delirium could lead to innovative solutions in
workload parity and health care team development.

Because of the rapid changes in the understanding of
delirium over the past 10 years, medical and nursing prac-
tice has not yet fully incorporated these changes. Proactive
models of nursing education can improve the assessment for
mental status and delirium [44,45]. A short, standardized
assessment for delirium is important to nursing practice,
because it provides an understanding of mental status that
can be used to work with the patient for the remainder of the
stay [45,46]. For example, if a patient is delirious, repeated
efforts at orientation by physicians, nurses, and other staff
may help the patient recognize the hospital setting and act
accordingly. On the converse, the interactions with the non-
delirious patient can focus on management of disease, reha-
bilitation, and discharge planning. Substantial educational
effort is needed to fully incorporate such advances into the
nurse and physician care of the patient with delirium.

While medicine has traditionally utilized a hierarchal
structure with respect to the nurse-physician relationship,
the care of the patient with delirium should be more col-
legial because of the crucial role of the nurse [47–49]. Much
literature and effort has focused on team training in the
surgical setting, and the same principles apply to the care of
the patient with delirium. Principles such as “the patient as
the focus of care,” “each team member shall be heard,” and
“individualized planning and testing to meet the patient’s
needs” are important in delirium as well [50,51]. Developing
the nurse-physician relationship improves patient outcomes,
reduces liability award outcomes, and improves the job sat-
isfaction of both [52].


Nurse Follow-up

At lunchtime, the physician receives a call from the
nurse manager. In the staff meeting, the nurse was
discussing the time commitment for her patient. The nurse
manager wants to discuss strategies to prevent delirium that
could be integrated into the unit routines.


>> What strategies can prevent delirium?

A key feature in management of the patient at intermediate
to high risk for delirium is to institute a surveillance program
or prevention program. In prior work, physicians miss 33% to
66% of delirium in older inpatients [53–55] and nurses identi-
fy less than 20% of patients with delirium [23]. Delay in iden-
tification and treatment of the underlying causative factors
results in increased morbidity and mortality [3]. Programs to
prevent delirium are cost-effective strategies that have been
proven in randomized trials [4,56,57]. Thus, early recognition,
surveillance, and prevention strategies are warranted.

While moderate- and high-risk patients should be
screened daily with a validated instrument for the diagnosis
and severity of delirium, recent work has called attention to
the need for a mental status vital sign to survey for delirium
[58]. A mental status vital sign would be much simpler and
much less specific than a delirium instrument. For example,
the causes of increased temperature are numerous, but the
presence of increased temperature results in an assessment
and workup. A mental status vital sign would not identify
causes for delirium, but instead only alert the nurse and
physician to complete a more thorough assessment of men-
tal status and potential causes for delirium.

There are strategies that have been shown in random-
ized controlled trials to prevent delirium. Table 3 outlines
the structure modules used in medical and surgical patients
to prevent delirium. The most comprehensive was the ini-
tiation of the Hospital Elder Life Program (HELP), which
includes 6 modules to prevent delirium [57]. Overall, the
program was able to reduce the incidence of delirium from
15% to 10%. In subsequent analyses, the HELP program was
found to be cost-neutral [56]. In surgical patients, structured
consultation by a geriatric physician within 24 hours of sur-
gery was shown to reduce delirium after hip fracture from
50% at control to 32% with intervention [4].

A recent randomized placebo-controlled study exam-
ined haloperidol prophylaxis for the prevention of delirium
after hip fracture [59]. In the single-site study, low-dose
haloperidol (1.5 mg/day) did not reduce the incidence of
delirium (relative risk, 0.9 [95% confidence interval, 0.6–1.3]).
However, haloperidol significantly reduced the severity and
duration of delirium as well as mean length of stay [59].
The results should be interpreted with caution, because the
functional impact of haloperidol on older patients at risk for
delirium is not fully understood.

Acute Care for the Elderly (ACE) units, which are de-
signed to meet the care needs of older patients, frequently
aim to specifically prevent delirium [60]. ACE units and
smaller-scale models, such as the delirium room, utilize
multidisciplinary care teams to minimize pain, disorienta-
tion, sleep disturbances, and immobilization and to prevent
hospital complications that may precipitate delirium [61].
The design of such units incorporate lighting strategies to
reduce nighttime stimulation, nonskid floors that decrease
risk of falls, and staff trained to identify and manage hyper-
active behaviors using nonpharmacologic protocols [49].


Case Resolution

The patient improved over several days and was
discharged to a postacute facility. After 3 weeks,
his delirium cleared and he resumed his activities of daily
living but did not fully resume his preoperative level of func-
tion. On the ward, the primary care physician began a series
of early-morning nursing education sessions to improve care
for delirious patients. The nurse manager is considering
implementing a delirium surveillance program.

___
Table 3. Care Strategies and Protocols to Prevent
Delirium

>> Medical patients

Cognitive stimulation and reorientation
- Clock, orientation board, staff introduction

Nonpharmacologic sleep protocol
- Lights out, warm milk, relaxation tape, back rub

Sleep enhancement
- Unit-wide noise reduction and sleep promotion

Mobilization protocol
- Ambulation or range of motion 3 times a day

Vision protocol
- Replace glasses, large-print reading material

Hearing protocol
- Cerumen disimpaction, portable amplifiers

Dehydration
- Early recognition, oral repletion, IV if needed

>> Surgical patients

Appropriate environmental stimuli
- Clock, calendar, glasses, hearing aids, etc

Elimination of unnecessary medications
- Discontinue benzodiazepines, anticholinergic, etc

Adequate CNS oxygen delivery
- Supplement oxygen, transfusion if needed

Early mobilization and rehabilitation
- Out of bed on postoperative day 1, daily physical therapy

Regulation of bowel/bladder function
- Discontinue urinary catheter; bowel movement every 48 hours

Treatment of severe pain
- RTC acetaminophen; scheduled opioids

Fluid/electrolyte balance
- Identify and treat fluid and electrolyte abnormalities

Prevention, identification, and treatment of postoperative compli-
cations
- Myocardial infarction, arrhythmia, pneumonia, UTI

Adequate nutritional intake
- Dentures, positioning, oral supplementation

Treatment of agitated delirium
- Identification, nonpharmacologic management
–––
CNS = central nervous system; IV = intravenous; RTC = around
the clock; UTI = urinary tract infection. (Adapted from Inouye SK,
Bogardus ST Jr, Charpentier PA, et al. A multicomponent interven-
tion to prevent delirium in hospitalized older patients. N Engl J Med
1999;340:669–76; and Marcantonio ER, Flacker JM, Wright RJ,
Resnick NM. Reducing delirium after hip fracture: a randomized
trial. J Am Geriatr Soc 2001;49:516–22.)
–––

This article has a companion CME exam that follows
the article. To earn credit, read the article and com-
plete the CME evaluation on pages 510 and 511.
Estimated time to complete this activity is 1 hour.
Faculty disclosure information appears on page 507.
Release date: 15 October 2008; valid for credit
through 30 October 2009.

Funding/support: This work was supported in part by NIA T35 AG026781
and the American Federation for Aging Research Medical Student Train-
ing in Aging Research. Dr Rudolph receives support through a VA Reha-
bilitation Research and Development Career Development Award.

Corresponding author: James L. Rudolph, MD, SM, BWH Division of
Aging, 1620 Tremont St, 3rd Fl., Boston, MA 02120, jrudolph@partners.
org.

Financial disclosures: None.


Rreferences
1. Rudolph JL, Marcantonio ER. Caring for the patient with post-
operative pelirium. Hospitalist 2004;8:20–5.
2. Marcantonio ER, Goldman L, Mangione CM, et al. A clinical
prediction rule for delirium after elective noncardiac surgery.
JAMA 1994;271:134–9.
3. Inouye SK. Delirium in older persons. N Engl J Med 2006;354:
1157–65.
4. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reduc-
ing delirium after hip fracture: a randomized trial. J Am Geri-
atr Soc 2001;49:516–22.
5. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Deliri-
um is independently associated with poor functional recovery
after hip fracture. J Am Geriatr Soc 2000;48:618–24.
6. Franco K, Litaker D, Locala J, Bronson D. The cost of delirium
in the surgical patient. Psychosomatics 2001;42:68–73.
7. Lundstrom M, Edlund A, Bucht G, et al. Dementia after de-
lirium in patients with femoral neck fractures. J Am Geriatr Soc
2003;51:1002–6.
8. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model
for delirium in hospitalized elderly medical patients based on
admission characteristics. Ann Intern Med 1993;119:474–81.
9. Rudolph JL, Jones RN, Grande LJ, et al. Impaired executive
function is associated with delirium after coronary artery by-
pass graft surgery. J Am Geriatr Soc 2006;54:937–41.
10. Robertsson B, Blennow K, Gottfries CG, Wallin A. Delirium in
dementia. Int J Geriatr Psychiatry 1998;13:49–56.
11. Kiely DK, Bergmann MA, Murphy KM, et al. Delirium
among newly admitted postacute facility patients: prevalence,
symptoms, and severity. J Gerontol A Biol Sci Med Sci 2003;58:
M441–5.
12. Holroyd S, Laurie S. Correlates of psychotic symptoms among
elderly outpatients. Int J Geriatr Psychiatry 1999;14:379–84.
13. Litaker D, Locala J, Franco K, et al. Preoperative risk factors for
postoperative delirium. Gen Hosp Psychiatry 2001;23:84–9.
14. Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion
Assessment Method: a systematic review of current usage.
J Am Geriatr Soc 2008;56:823–30.
15. Ely EW, Truman B, May L, et al. Validation of the CAM-ICU
for delirium assessment in mechanically ventilated patients.
J Am Geriatr Soc 2001;49:S2.
16. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confu-
sion: the confusion assessment method. A new method for
detection of delirium. Ann Intern Med 1990;113:941–8.
17. Inouye SK. Delirium in hospitalized older patients: recognition
and risk factors. J Geriatr Psychiatry Neurol 1998;11:118–25.
18. Stavros KA, Rudolph JL, Jones RN, Marcantonio ER. Delirium
and the clinical assessment of attention in older adults. J Am
Geriatr Soc 2008;56:S199–S200.
19. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanical-
ly ventilated patients: validity and reliability of the confusion
assessment method for the intensive care unit (CAM-ICU).
JAMA 2001;286:2703–10.
20. O’Keeffe ST, Gosney MA. Assessing attentiveness in older
hospital patients: global assessment versus tests of attention.
J Am Geriatr Soc 1997;45:470–3.
21. Liptzin B, Levkoff SE. An empirical study of delirium sub-
types. Br J Psychiatry 1992;161:843–5.
22. de Rooij SE, Schuurmans MJ, van der Mast RC, Levi M. Clini-
cal subtypes of delirium and their relevance for daily clinical
practice: a systematic review. Int J Geriatr Psychiatry 2005;20:
609–15.
23. Inouye SK, Foreman MD, Mion LC, et al. Nurses’ recogni-
tion of delirium and its symptoms: comparison of nurse and
researcher ratings. Arch Intern Med 2001;161:2467–73.
24. Kiely DK, Jones RN, Bergmann MA, Marcantonio ER. Asso-
ciation between psychomotor activity delirium subtypes and
mortality among newly admitted post-acute facility patients.
J Gerontol A Biol Sci Med Sci 2007;62:174–9.
25. Inouye SK, Charpentier PA. Precipitating factors for delirium
in hospitalized elderly persons. Predictive model and interre-
lationship with baseline vulnerability. JAMA 1996;275:852–7.
26. Hirano LA, Bogardus ST Jr, Saluja S, et al. Clinical yield of
computed tomography brain scans in older general medical
patients. J Am Geriatr Soc 2006;54:587–92.
27. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers
criteria for potentially inappropriate medication use in older
adults: results of a US consensus panel of experts. Arch Intern
Med 2003;163:2716–24.
28. Marcantonio ER, Juarez G, Goldman L, et al. The relationship
of postoperative delirium with psychoactive medications.
JAMA 1994;272:1518–22.
29. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other
adverse effects of diphenhydramine use in hospitalized older
patients. Arch Intern Med 2001;161:2091–7.
30. Flacker JM, Cummings V, Mach JR Jr, et al. The association of
serum anticholinergic activity with delirium in elderly medical
patients. Am J Geriatr Psychiatry 1998;6:31–41.
31. Fick DM, Agostini JV, Inouye SK. Delirium superimposed
on dementia: a systematic review. J Am Geriatr Soc 2002;50:
1723–32.
32. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders: DSM-IV-TR. 4th ed., text revision.
Washington (DC): The Association; 2000.
33. Flacker JM, Marcantonio ER. Delirium in the elderly. Optimal
management. Drugs Aging 1998;13:119–30.
34. Han L, McCusker J, Cole M, et al. Use of medications with
anticholinergic effect predicts clinical severity of delirium
symptoms in older medical inpatients. Arch Intern Med 2001;
161:1099–105.
35. Breitbart W, Marotta R, Platt MM, 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.
36. Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics
for delirium. Cochrane Database Syst Rev 2007;(2):CD005594.
37. Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic
activity of 107 medications commonly used by older adults.
J Am Geriatr Soc 2008;56:1333–41.
38. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment
of delirium: a systematic review. J Clin Psychiatry 2007;68:
11–21.
39. Schneider LS, Dagerman KS, Insel P. Risk of death with atypi-
cal antipsychotic drug treatment for dementia: meta-analy-
sis of randomized placebo-controlled trials. JAMA 2005;294:
1934–43.
40. Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly
users of conventional vs. atypical antipsychotic medications.
N Engl J Med 2005;353:2335–41.
41. Wada H, Nakajoh K, Satoh-Nakagawa T, et al. Risk factors of
aspiration pneumonia in Alzheimer’s disease patients. Geron-
tology 2001;47:271–6.
42. Rudolph JL, Gardner KF, Gramigna GD, McGlinchey RE.
Antipsychotics and oropharyngeal dysphagia in hospitalized
older patients. J Clin Psychopharm. In press 2008.
43. Gareri P, De Fazio P, De Fazio S, et al. Adverse effects of atypi-
cal antipsychotics in the elderly: a review. Drugs Aging 2006;23:
937–56.
44. Bergmann MA, Murphy KM, Kiely DK, et al. A model for
management of delirious postacute care patients. J Am Geriatr
Soc 2005;53:1817–25.
45. Soja SL, Pandharipande PP, Fleming SB, et al. Implementation,
reliability testing, and compliance monitoring of the Confu-
sion Assessment Method for the Intensive Care Unit in trauma
patients. Intensive Care Med 2008;34:1263–8.
46. de Jonghe JF, Kalisvaart KJ, Timmers JF, et al. Delirium-O-
Meter: a nurses’ rating scale for monitoring delirium severity
in geriatric patients. Int J Geriatr Psychiatry 2005;20:1158–66.
47. Callahan CM, Boustani MA, Unverzagt FW, et al. Effectiveness
of collaborative care for older adults with Alzheimer disease
in primary care: a randomized controlled trial. JAMA 2006;
295:2148–57.
48. Melis RJ, van Eijken MI, Teerenstra S, et al. A randomized
study of a multidisciplinary program to intervene on geriatric
syndromes in vulnerable older people who live at home (Dutch
EASYcare Study). J Gerontol A Biol Sci Med Sci 2008;63:283–90.
49. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized
trial of care in a hospital medical unit especially designed to
improve the functional outcomes of acutely ill older patients.
N Engl J Med 1995;332:1338–44.
50. Schmalenberg C, Kramer M, King CR, et al. Excellence
through evidence: securing collegial/collaborative nurse-
physician relationships, part 2. J Nurs Adm 2005;35:507–14.
51. Strasser DC, Falconer JA, Stevens AB, et al. Team training and
stroke rehabilitation outcomes: a cluster randomized trial.
Arch Phys Med Rehabil 2008;89:10–5.
52. Erickson JI, Clifford JC. Building a foundation for nurse-
physician collaboration. CRICO Forum 2008;26:6–7.
53. Levkoff SE, Besdine RW, Wetle T. Acute confusional states (de-
lirium) in the hospitalized elderly. Annu Rev Gerontol Geriatr
1986;6:1–26.
54. Levkoff SE, Evans DA, Liptzin B, et al. Delirium. The occur-
rence and persistence of symptoms among elderly hospital-
ized patients. Arch Intern Med 1992;152:334–40.
55. Gustafson Y, Brannstrom B, Norberg A, et al. Underdiagnosis
and poor documentation of acute confusional states in elderly
hip fracture patients. J Am Geriatr Soc 1991;39:760–5.
56. Rizzo JA, Bogardus ST Jr, Leo-Summers L, et al. Multicompo-
nent targeted intervention to prevent delirium in hospitalized
older patients: what is the economic value? Med Care 2001;
39:740–52.
57. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicom-
ponent intervention to prevent delirium in hospitalized older
patients. N Engl J Med 1999;340:669–76.
58. Flaherty JH, Rudolph J, Shay K, et al. Delirium is a serious and
under-recognized problem: why assessment of mental status
should be the sixth vital sign. J Am Med Dir Assoc 2007;8:
273–5.
59. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol
prophylaxis for elderly hip-surgery patients at risk for de-
lirium: a randomized placebo-controlled study. J Am Geriatr
Soc 2005;53:1658–66.
60. Simon L, Jewell N, Brokel J. Management of acute delirium in
hospitalized elderly: a process improvement project. Geriatr
Nurs 1997;18:150–4.
61. Flaherty JH, Tariq SH, Raghavan S, et al. A model for managing
delirious older inpatients. J Am Geriatr Soc 2003;51:1031–5.