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The Overlap of Delirium With Neuropsychiatric Symptoms Among Patients With Dementia

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Objectives

To study the frequency of overlapping of delirium with neuropsychiatric symptoms (NPS) among patients with dementia, and to investigate the prognostic value of delirium, multiple NPS without delirium, or neither during a 2-year follow-up.

Methods

We assessed 425 consecutive patients in acute geriatric wards and in seven nursing homes in Helsinki. Those 255 suffering from dementia were examined for NPS of dementia described in the Neuropsychiatric Inventory (delusions, hallucinations, agitation/aggression, depression/low mood, anxiety, euphoria/elation, apathy, disinhibition, irritability/mood changes, and aberrant motor behavior) and for delirium criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Patients were categorized into three groups: delirium with or without multiple NPS (delirium group), multiple NPS without delirium (multiple NPS group), or having neither delirium nor multiple NPS (zero or only one NPS group).

Results

A total of 66 patients suffered from delirium according to the DSM-IV, 127 had multiple NPS without delirium, and 62 had neither multiple NPS nor delirium. In the delirium group 61 individuals (92.4%) were deceased or residing in permanent institutional care at the end of the 2-year follow up period, compared to 100 individuals (78.7%) in the multiple NPS group and 48 (77.4%) in the zero or one NPS group (Pearson X2 = 6.64, df 2, p = 0.036). In logistic regression analysis adjusted for age, sex, and comorbidities, delirium was an independent predictor of this composite outcome (OR: 4.3, 95% CI: 1.4–13.6).

Conclusions

Patient groups with symptoms of delirium and multiple NPS are highly overlapping. The presence of delirium indicates poor prognosis.

Section snippets

Patients

All available patients (N = 425) in seven acute geriatric wards (N = 195) and all residents of seven nursing homes (N = 230) in Helsinki, Finland during the study period (1999–2000) were screened and assessed for dementia, delirium, and various psychotic, behavioral and emotional symptoms. The only exclusion criteria were a state of coma or age less than 70 years.

Written informed consent was obtained from each patient, and in cases of moderate or severe cognitive impairment (Mini-Mental State

RESULTS

Among all 425 patients, 255 were judged to suffer from dementia according to the geriatricians' consensus; their mean age was 86.4 years, and 85% were women. Of them, 160 resided in nursing homes and 95 were in acute geriatric wards. Of those patients in acute wards, 60 had been admitted from community care and 35 from nursing homes. In geriatric wards, 43% of the patients with dementia also had delirium whereas the respective figure in nursing homes was 16%. In nursing homes, 59% of the

DISCUSSION

In our sample of patients with dementia, multiple NPS overlapped to a great degree with patients suffering from delirium. About 85% of patients with delirium suffered from multiple NPS, and nearly one in three patients with multiple NPS fulfilled the criteria for delirium. Thus, multiple NPS in dementia may mask the underlying delirium. However, and in line with previous findings,3,10, 11, 12, 13 only patients with delirium meeting DSM-IV criteria had a poor prognosis, whereas—contrary to

CONCLUSIONS

Patient groups with symptoms of delirium and with multiple NPS in dementia are highly overlapping. In this study only delirium meeting the DSM-IV criteria had significant prognostic value among these frail patients with dementia. It thus seems important to distinguish whether NPS derive from dementia alone or whether they are a sign of acute delirium, which calls for active interventions. The wide overlapping of NPS and symptoms of delirium is a challenge for professionals, and emphasizes

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