International psychogeriatrics
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Data to demonstrate that psychosocial factors, sensory deprivation, or sleep deprivation alone can cause delirium are few. Nonetheless, these factors or conditions may contribute to the development or symptom presentation of a delirium when other metabolic or toxic etiologies are present. ⋯ Clinical experience suggests that attention to the patient's psychological state through frequent orientation, emotional support, and frequent explanation can help. Low-dose neuroleptic drugs are occasionally useful and necessary.
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The EEG is a useful and, at times, an essential test in the evaluation of delirium. In most patients with delirium, the EEG will show diffuse slowing and thus is helpful in differentiating organic etiologies from functional, psychiatric disorders. ⋯ Furthermore, the EEG is the only test that can identify an ongoing epileptic state (e.g., nonconvulsive status epilepticus) as being responsible for the clinical picture of confusion. Other electrophysiological tests that may prove helpful in the evaluation of delirium, such as computerized EEG spectral analysis, topographic brain mapping, and sleep studies, are briefly reviewed.
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Characteristics of instruments developed by nurses for use in evaluating delirium/acute confusional states include relative emphasis on observable behavior and the need to impose low respondent burden. Two instruments that have been most used by nurse researchers are described: The Confusion Rating Scale and the NEECHAM Confusion Scale. The former is based on observable behavior; the latter incorporates vital function and oxygen saturation measurements that may serve as early warning signs of impending delirium.
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This prospective study determined the incidence and prevalence of delirium in 235 consecutive subjects over age 70 admitted to a general medicine hospital service. The DSM-III criteria for delirium were operationalized. ⋯ Analysis of these data indicates that the DSM-III criteria describe a discrete, recognizable syndrome. However, some of the symptoms are more specific than others in identifying the syndrome in this population.
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While all delirious patients have clouding of consciousness (alteration of attention) and cognitive dysfunction, the level of alertness of different patients may range from stuporous to hyperalert. We, therefore, developed an analog scale to rate the alertness of delirious patients, and a separate scale to rate the severity of their clouding of consciousness. Based on these scales, patients were categorized overall as relatively "activated" (relatively alert despite clouding of consciousness), or "somnolent" (relatively stuporous along with clouding of consciousness). ⋯ These data indicate that phenomenologic subtypes of delirium can be defined on the basis of level of alertness. These subtypes are validated in part by their differing associations with symptoms unrelated to alertness. These subtypes may have different pathophysiology, and thus, potentially different treatments.