Editorial

Spring 2012 and momentum is building up as delirium features more often and more prominently in published medical literature. Last month the British Medical Journal published the largest intensive care unit (ICU) delirium study to date. In the accompanying editorial I tried to make the point that the science is clear: failing to detect and manage delirium adequately is failing the patients. Professor MacLullich went further in a personal communication excellence in delirium care should be the expectation in all ICUs; anything less, given the resources and expertise in ICU, is frankly unacceptable. Delirium in UK critical care patients has been particularly topical in the lay press with a videocast and an article from Times columnist David Aaronovitch describing his own experience then the Scottish newspaper, Sunday Post, publishing an interview with Peter Gibb of ICUsteps. Consequently the website www.icudelirium.co.uk has had an increase in patients sharing their own experiences relieved to know they are not going mad. Will this lead to patients and relatives wanting to know more about delirium and what we, the health care professionals are going to do about it? How can we influence this? Let us gather our previously low ranking cards into a winning hand. I believe we need to keep doing what we are all doing already, making a difference one patient at a time. In addition if we each aim to inform two clinicians a month one or two facts about delirium, and they inform two other clinicians a month, by the end of 10 months each of us could be responsible for an additional 500 clinicians knowing more about delirium! This bumper edition includes a collaborative article highlighting the importance of subsyndromal delirium, Dr Davis tells us all we need to know (and we do need to know) about epidemiology and Dr Wilson has provided an inspiring descriptive piece about altering the ward environment for at risk patients with dementia. The news section will bring you up to date with events and initiatives including the first European Delirium Survey and an announcement for the next annual meeting. Finally, I am pleased to announce that Dr Andrew Teodorczuk will be a co-editor of the Annals of Delirium from the next edition. Contributions all welcome for the summer edition prose or poetry! Valerie Page

Capturing psychiatric phenomena: what delirium researchers can learn from dementia epidemiologists
Daniel Davis and Carol Brayne Institute of Public Health, University of Cambridge At delirium conferences, we often hear the call for more research on the epidemiology of delirium. There have been very few studies on delirium prevalence in the general population. Perhaps this is because such studies are difficult to undertake and is compounded by problems of how to define psychiatric syndromes in epidemiology. Research in dementia has faced similar obstacles what lessons have been learned? What do we mean by population? Epidemiology is concerned with the inter-relationship between populations, exposures and outcomes. Intrinsic to this is the problem of definitions and how they are conceived, framed and articulated. In considering the importance of defining a population, we are asking: Is the chosen population one that is relevant to the full spectrum of persons with delirium? How does the approach to sampling enable a valid capture of the chosen population? These are critical questions as the provenance of the sample population has the potential to systematically bias findings both in magnitude and direction.

The majority of studies in delirium have been undertaken in hospital settings, and these have been comprehensively reviewed.1 These studies indicate that delirium is a common problem in inpatients with serious adverse outcomes. However, there are two limitations to the inferences that can be drawn about delirium as a whole. Firstly, one cannot assume that all persons with delirium will actually present to hospital. Secondly, once in hospital, there is only retrospective (and therefore limited) information of a persons cognitive and performance function before the onset of delirium. Ideally, one would start with a broad, unselected denominator (i.e. a true populationbased study) followed-up with serial cognitive assessments. This would represent a comprehensive range of symptoms (and severities), but also identify what happens, to whom, and when. This is essential if we are to understand the determinants and effects of delirium most completely. A working definition for population-based study might be: a study where all subgroups of the population are sampled, regardless of disease or residential status.2 Of course, ensuring that a study population is comprehensive in this way requires substantial effort, but there are gains of equal degree in terms of achieving results with external generalisability.

Psychiatric epidemiology: a problem of standardisation In order to reliably track states of health in populations, looking for emerging patterns and trends, one must be able to define exposures and outcomes of interest in a standardised way. All diseases can be nosologically classified, each with their reference-standard definitions. However, where these conditions are psychiatric syndromes, the reference-standard is necessarily a set of clinically agreed descriptions of psychopathology rather than any objective quantities. There are two different approaches for neuropsychiatric definitions, the International Classification of Diseases (World Health Organization) and the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association). There are some differences between these two systems (see references for a discussion on how these might affect case-ascertainment in dementia3 and delirium4). However, both are subject to common problems. Firstly, these definitions are not stable over time (ICD-9 vs 10, DSMIII-R vs DSM-IV, with further iterations in evolution). Nor are these definitions easily transferrable across cultural contexts. Yet more problematic is that these clinical criteria have the potential to vary, and so can be interpreted differently by different clinicians. An example is how the definition might be applied to persons of different ages depending on the expectations of normality for that age group. In

other words, the threshold for abnormal cognitive or functional impairment may decrease with age, in line with a belief that some impairment is to a degree expected (and therefore not abnormal) in older age.5 Finally, in the research setting, a core problem is how to operationalise these criteria so that case-ascertainment can be achieved in a consistent manner. Underlying these difficulties is the problem of how to agree the boundaries for a spectrum of psychiatric symptoms. While there is relatively little disagreement about moderate and severe dementia, studies that include milder cognitive deficits lead to much less consistent estimates of prevalence (see references for review6). Mild cognitive impairment (MCI) has been regarded to be of possible relevance to dementia, but applying the MCI construct to populationbased cohorts has not been straightforward.7, 8 The equivalent entity in delirium i.e. subsyndromal delirium also needs to be considered in light of these issues. Dementia epidemiology: some approaches Dementia is clinically defined by identifying progressive deficits in two or more cognitive domains sufficient to impair function in activities of daily living. Three population-based studies can be used as examples to illustrate the different ways in which this definition has been operationalised in the context of research (Table 1). Vantaa 85+

defined dementia cases through the agreement of two neurologists at clinical examination.9 While this is more reliable than assessment by a single clinician, there remain difficulties with inter-rater reliability and this can hamper cross-study comparisons. In the City of Cambridge over-75 Cohort (CC75C),10 as well as other studies in both Europe11 and North America,12 this has been addressed through the agreement of dementia diagnoses at multidisciplinary consensus meetings, held after all study information becomes available. This method of case-ascertainment is labour-intensive and so limits the breadth of coverage to some extent.

Assisted Taxonomy (AGECAT).15 This allowed for much greater numbers of persons to be studied and MRC-CFAS remains one of the largest population-based studies of dementia incidence ever to be conducted. The algorithm diagnosis has been considered again more recently by studies such as the Health and Retirement Study, mainly driven by attempts to reduce the cost of case-ascertainment.16 In addition, an algorithm approach has been applied to the consensus diagnosis itself, with the aim of making the process more timeefficient.17 Accounting for attrition

In parallel to the development of the multidisciplinary conference to standardise case-ascertainment, use of the Present State Examination (PSE)13 led to the possibility of creating diagnostic categories through algorithms. The PSE and the version validated in older persons, the Geriatric Mental State (GMS)14 is a systematic operationalisation of the psychiatric mental state examination. It uses answers generated from the interview to group symptom clusters which can then be used to derive diagnostic groups. Once these categories have been validated against clinician-applied diagnoses, this algorithm approach can be automated and applied by non-medical interviewers. The MRC Cognitive Function and Ageing Study (MRC-CFAS) used such an approach with the Automated Geriatric Examination for Computer

Loss to follow-up is common to all longitudinal studies of older persons. Usually, this is due to death between interviews. This is also known as censoring where people contribute to the observed period of follow-up, but where loss to follow-up means that case-status cannot be ascertained. This information must still be included in the analysis because it is still useful to know that persons werent cases until the point they were last observed. One of the underlying assumptions of this type of cohort analysis (known as survival or time-to-event analysis) is that censoring is noninformative. This means that characteristics of persons retained in follow-up are similar to those that are lost. Particularly for studies of ageing, this assumption is overly strong. It is clear that attrition in

ageing studies does not occur at random, and lower cognitive and functional scores at last interview predict drop out. While this makes intuitive sense, very few studies explicitly use statistical techniques such as last observation carried forward to account for missing data. These approaches have been important in the dementia field18-20 but have yet to be systematically applied to follow-up studies in delirium and almost certainly under estimate the effect of drop out. Case-ascertainment in delirium epidemiology There are a handful of population-based studies in delirium. In each of these, the diagnosis of delirium was based on the DSM criteria, though again operationalised in different ways (Table 2). The East Baltimore Survey and Girona studies used validated interview schedules (Standardised Psychiatric Examination and Cambridge Mental Disorders of the Elderly Examination respectively), whereas the Canadian Study of Health and Ageing (CSHA) applied diagnoses through consensus meetings. None used an algorithm operationalisation. There is a consistent finding that community prevalence of delirium is relatively low, but it remains a condition with poor prognosis, comparable to hospital series. Nonetheless, it is important to note that intercurrent illness and/or delirium might well reduce response rates in epidemiological surveys. In this regard, while these studies have

also reported characteristics of participants and nonparticipants, none have related these to acute illness and estimates of delirium prevalence. The Vantaa 85+ did ascertain delirium. To apply a retrospective diagnosis, participants were assessed along with their informant(s) for a history of any episodes of delirium, specifically assessing: changes in cognitive functioning, level of alertness and psychotic symptoms, as an operationalisation of the DSM-III-R criteria.21 The reported history and number of episodes of delirium were corroborated with hospital case notes that were available at the time of assessment. As noted above, there are problems with the reliability of determining both delirium and dementia. However, it remains an important study because it is the only population-based cohort to have specifically attempted to relate history of delirium with dementia outcomes. Combining these approaches for delirium epidemiology It is clear that standardisation is a complex issue in psychiatric epidemiology. One general consequence of not identifying delirium accurately is a reduction in the observed effect size between the intervention and control groups (known as non-differential misclassification bias). Thus insufficient attention to standardising case-ascertainment results in loss of power in trials. At the very least,

we can conclude that clinical delirium research would benefit from case-ascertainment consensus conferences and/or algorithmic operationalisation. It should not be considered sufficient for caseascertainment to be decided by single assessors. Scores for individual diagnostic items and their temporal fluctuations should be submitted for agreement at the level of a consensus panel. At the same time, there is potential to develop algorithm diagnoses in delirium. Already there are semi-automated some neuropsychological tests (e.g. the Edinburgh Delirium Test Box for attentional deficits22), and it would be logical to incorporate these. These new approaches will require careful validation studies. This shift toward better-informed epidemiological techniques may seem daunting, but must be regarded as essential for generating valid clinical research in delirium. The future may bring innovative approaches, as has been proposed for dementia: improving coverage through proxy / participant telephone interviews (validated against face-to-face interviews); newer versions of algorithm-generated computer information; online consensus conferences.16 Some delirium collaborations are beginning to adopt these ideas.23 Even these measures will not be enough. The challenges for delirium epidemiology are greater than those for dementia. There are particular features of the syndrome that make standardisation even

more complicated. Fluctuating symptoms are a core feature of delirium, and this will not be reliably captured without specific attention to how this is to contribute to case-ascertainment. There is scope for delirium research to benefit from approaches in other fields within neuroepidemiology, particularly acute conditions such as stroke or epilepsy. These efforts will be rewarded by generating methodologically rigorous clinical data applicable to the broad generality of patients with delirium. Table 1. Characteristics of studies comprising the EClipSE database.

Making Marjory Warren Proud

Marjory Warren ward is a 30-bedded inpatient ward at Kings College Hospital in South East London, named after the founder of modern geriatric medicine. I am lucky enough to share the consultant duties with Dr Catherine Bryant and as we both have interests in cognitive disorders the ward attracts a high number of patients with dementia, delirium or both. I have tried to write a descriptive piece that tells the story of the transformation of the ward to make it a more suitable environment for patients with cognitive problems. I make no apologies for the relatively few specific mentions of delirium. We wanted to create neither a delirium ward nor dementia ward, but a more inclusive place where expertise in managing frailty in the context of a wide range of cognitive disorders would prevent and reduce harm from delirium as one of many facets improving patient care. Before I go further however, a disclaimer. I am extremely proud to have been part of the project I am about to describe, but I want to take no credit for its inception or realisation. The transformation was due entirely to Emma Ouldred our Dementia Nurse Specialist at Kings and a team of nurses working with her. The transformation certainly would not have happened without their tireless optimism, commitment and unerring belief that the patients we treat deserve to

be cared for in an environment that is not just practical and functional but welcoming, safe, orientating and stimulating. Since 2000 the Kings Fund has been supporting a number of projects in UK hospitals under the umbrella Enhancing the Healing Environment. There are a range of projects and in 2009 some funding was specifically directed towards projects that improved the experience of patients with dementia. We applied for a second tranche of funds made available in 2010. The initial ambition was to transform the day room on one of our Gerontology wards into a sensory room that would provide a healing environment for patients with dementia, recognising that this might help treat and prevent other cognitive problems including delirium. We would promote activities such as reminiscence, in a newly designed, uncluttered room with lighting and furnishing that encouraged patients to use a space that had become increasingly used by staff to host professional meetings. Sensory equipment and memory boxes that were also portable would be available to be taken to the beds of less mobile patients. The views from our 7th floor ward are stunning, looking across to the city of London (St Pauls, the London Eye) as well as the local area. By introducing interpretation panels that described the views we hoped to stimulate conversation and reminiscence. Along with an easily

operated multi-media centre we intended build a library of music and films that patients could enjoy. The projector could be used to play other moving images (a roaring log fire was particularly popular over Christmas when the plans finally became realised) as well as stills from a staff photography competition that was run during the redesign project. During the early stages of this transformation it became clear that to focus on one room on Marjory Warren ward would not be enough to truly enhance the environment for our patients. Rather than be limited by the money (a not insignificant 50,000) from the Kings fund, supported by a further 15,000 from the hospital, the initial plans became a springboard for a complete redesign of the ward and its entrance area. Patients past and present along with their carers, as well as nursing and therapy leads and our hospital estates and communications teams all contributed to lively meetings. Redecorating the whole ward with colourful (and colour coded) simple designs, and clearly labelling bed numbers in bays and rooms was proposed. We wished to replace the highly polished, plastic flooring as patients told us they often thought the floor looked wet, leading to fear of falling. Other important equipment such as cardiac arrest trolleys and clinical waste bins needed to be housed discreetly whilst remaining clinically accessible. Artwork was proposed that was

relevant to our local population (a fantastically ethnically and socially diverse population) and projects were set up that the patients could contribute to during their activity groups or therapy sessions. Dulwich Picture Gallery, (Britains first public art gallery founded in 1811) brought their experience from an Art For Older People project and commissioned an artist to help patients, carers, visitors and staff create an embroidered panel fittingly titled The Urban Jungle that now sits in the entrance of the ward. The Kings Fund and hospital were delighted with the ambition encouraging Emma to apply for more funding without concerns that their own contribution might in any way become diluted or stifled. We were extremely lucky that the Friends of Kings Charity had been left a 200,000 legacy that the trustees felt was ideal to support this project. Now a much broader transformation could take place. We continued with the proposals mentioned above (the flooring is now a matt, nonslip wood effect to provide a more homely feel). Panels of pictures around the corridors of the ward reflect the London skyline outside, and new hand rails and regularly spaced seats mean patients can wander more safely and have recognisable images to look at, enjoy and discuss. More seating nearer to the two nursing stations and a very open plan design means patients at high risk of falls or those in need of company and conversation can be closer to the staff. At one

end of the ward are also some sensory panels that are very simple in design for those with more advanced cognitive problems to interact with. The experience, from ward entrance, around the ward and into the sensory room is now part of a sensory walk for patients, their carers, and staff which shows the range of the transformation which can now be experienced as a whole or in smaller chunks. Of course there is more to this than ambition and a loose sense that change was just needed and would inevitably be for the good. We tried to look for guiding principles to inform the design, though interestingly there is little out there that is evidence-based. We tapped the University of Stirlings Dementia Services Development centre, utilised extensive resources provided by the Kings Fund, and Dr Jim Georges experience from the delirium unit at Carlisle. Architects who have been involved in designing hospital and care home environments for those who are frail and with cognitive problems were consulted, as were the Alzheimers Society. We are aware that much of what we have done just makes sense to us as experts in dementia and delirium care. We hope the lessons we learn form the transformation will contribute to a future evidence base to inform others. We are also aware that changing an environment alone will not be sufficient to improve patient care. Fortunately there seems to already

be an appreciable change in both the patients and the staff working on the ward. We have also seen an increase in nursing and therapy staff expressing a desire to work on Marjory Warren. Formally measuring and evaluating both patient and staff outcomes are therefore key. We also need to continue other work we were already doing in the education and training of staff and carers about frailty and particularly dementia and delirium. Some early indicators are promising. Patient satisfaction in all areas, both clinical and environmental, measured in our How Are We Doing survey has been consistently higher for the last three months since the project was completed, exceeding our internal benchmarks. Even before completion, with some building work still going on around the patients, our length of stay had fallen. Of course the environmental effect will be difficult to prove emphatically as this is not a randomised trial. More specific indicators around delirium rates or intensity, reduction in special one: one nursing or use of more extreme measures such as sedation will take more time to collect and analyse. What does the future hold other than evaluation? Our Activities Coordinators continue to try and expand the range of groups they hold, to use art, music, reminiscence as well as tea parties or bingo mornings to engage patients. The current Occupational Therapists are setting up a lunch club and even the junior doctors have committed to

helping with that! We now have some volunteers too who provide vital support for the patients on the ward. We are meeting a film company who do stop-motion animation (the same technique used to make The Wrong Trousers). They would like to make a film, facilitating the patients on the ward to create a story and direct their own piece of work. These are therefore exciting times at Kings and the potential to influence the care of frail patients more widely (both within the hospital and outside) will hopefully come from this. We launched the ward in mid-December 2011 in a week when a high profile report on dementia care in the NHS was published. Marjory Warren ward was chosen as an exemplar for both local and national news coverage. We are very aware that with such publicity comes the need for great responsibility, to our patients first, but also to those who have backed us both financially and with moral support. We know we are one of many transformative projects and we have been exceptionally lucky to get the money we secured. We would encourage visitors, feedback and opportunities to collaborate and share experience. Sensory Room with log fire projection

Nurses Station Before

Ward Before

Nurses Station After

Ward After

Fathers with delirium

My Dad was diagnosed with lymphoma and was admitted with a huge blood clot in his arm. The pain was terrible. He was given morphine which initially resolved the acute pain. However within hours he was staring at the ceiling counting the dots. He became quiet and withdrawn and it was hard for him to break his stare to look at us. I told the nurse that I believed my Dad was suffering from delirium and she said she would call the GP. She obviously did not know the symptoms of delirium. My Dad, an Anglican priest in the community where he was in hospital (i.e. well known) had terrible dreams about robbers attacking him in his hospital bed, and he climbed out of bed in the night. After that he was physically restrained, had his glasses taken away, and he was given just 0.5 mg haloperidol IV twice a day for nausea! The delirium was never addressed by the GP because when my dad spoke to the GP, he was polite, and quiet. He wouldnt share his fears with him. The GP paid no attention to our complaints. My Dad stayed in that state for 5 weeks. He was confused, irritable and ended up in diapers because no one wanted to go near him. When a pain doctor came to visit my Dad (he happened to play golf with my Dad and saw he was in hospital), he immediately recognized the delirium and just changed the narcotic to a fentanyl patch. My Dad became reasonable again. Sadly, he died 10 days later of an aspiration pneumonia following chemotherapy. My mother grieves for him, and feels such a sense of loss for those 5 weeks when my Dad was so confused and afraid. I am an ICU nurse with many years of treating delirium. I was so frustrated by the lack of knowledge the GP seemed to have about delirium, even though he was the most responsible physician, I was powerless to convince him that he was witnessing delirium related to narcotics. I will always regret not making a big enough stink to get help for my Dad. Maybe this testimonial will help some readers understand the impact of delirium on patients and families. It was so unnecessary that my Dad had such an end of life experience when the treatment seemed to be so simple. Authors name withheld, posted on www.icudelirium.co.uk

My Fathers Delirium
A routine hip operation. But he looks quiet now. The earlier rage all whimpered away. A ravaged body, emptied and spent. A living husk that somewhat recalls, A happier memory: a father. A routine hip operation. An apologetic limp into the ward. A nervous smile, polite handshake. An anxious curiosity of who, And what, and when. A perfectly, perfect person, Extends his gift of trust. This is routine stuff for us! We badge you, stamp, and wrap you. Then cut you, mend and dispatch you. All proclaimed with a smile, But the eyes are distant, detached. Another day, another hip. The operation was quite routine. But my father somehow troubled, Subtly not there; with us, but not of us. Tea cups lie untested; Stagnant and dismal. And a restless fidget speaks of unease. A routine hip operation. But my father visibly shrivels, Into a secret, deep, inner space. Dehydration, infection and constipation. So we are told. An oddly innocent litany, To inflict so grave an ill. And surely foreseen, and .. preventable? A routine hip operation. Now an imprisonment within an internal world, Of blazing, crazy hues. Of ghostly faces, horrid forms. Evil voices murmuring evil thoughts, Shimmering moments in bewilderment. A soul adrift, sinking, sinking, Into the unseen, the in-between. But that was yesterday, And those several days before. A perfectly, perfect man, utterly undone. Dehydration, infection and constipation. The mantra plays and plays. A well oiled machine, all spoiled, For a wink of humanity. The merest pinch of care! It was.a routine hip operation. John Young Bradford Royal Infirmary, UK

Subsyndromal delirium: Relevance to dementia

Elizabeta B. Mukaetova-Ladinska, Joaquim Cerejeira, Andrew Teodorczuk Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK Introduction With the newly published National Dementia Strategy (2009) and the recent RCPsych Dementia Audit (2011), we expect routine screening for cognitive impairment and dementia in general hospitals to increase. This will put pressure on both medical and mental health services looking after the wellbeing of the older adults to have readily access to adequate services for older adults with dementia. Only during the last year, our Liaison Old Age Psychiatry team has noted a high increase in referrals for dementia diagnosis for older adults from various medical and surgical wards in the Newcastle area, with many of them referred either shortly after their admission on medical wards in the absence of delirium symptomatology, or after a resolved delirium episode (still with some clinical symptoms of delirium) and having problems in numerous cognitive domains. Yet,

not all of them will fulfil the DSM-IV criteria either for delirium or dementia. This raises a number of clinical issues regarding the management of such patients on medical wards, including both pharmacological and non-pharmacological treatments, further investigations of their cognitive decline, discharge plans, as well as involvement of various support services to facilitate the latter. Although several parameters have been associated with full recovery of delirium (e.g. lack of apoE 4 allele, being female and lower levels of IGF-1), severity of delirium, underlying presence of dementia and/or advanced age do not appear to be relevant for the full recovery from delirium (Adamis et al, 2007), thus further arguing for the seriousness in managing of this clinical syndrome. The purpose of this opinion piece is to explore the interface between subsyndromal delirium and dementia and make recommendations for future research.

Clinical symptomatology of sybsyndromal delirium The most recent study on sybsyndromal delirium (SSD) in medically ill patients reported presence of 27% in all subjects post delirium (Maegher et al, 2012). However this figure came from a heterogeneous sample of subjects with delirium, ranging from 36-90 years of age, of which only 27% had known dementia. Marcantonio et

al (2005) reported higher prevalence rates of SSD in older adults (up to 51%), and especially those with pre-existing dementia, similar to the older subjects with delirium. In one of our studies, we have highlighted the problems in diagnosing delirium in older subjects with advanced dementia (Yates et al, 2007). We propose that delirium, including SSD, may go largely under-diagnosed in many older adults with dementia. The clinical symptoms of SSD are characterised by less severe, especially motor activity, disturbances (e.g. less agitation and hyperactivity), less psychotic symptoms (e.g. delusions and hallucinatory experiences), higher level of thinking, and higher cognitive performance (e.g. attention, orientation, better working and long-term memory) (Meagher et al, 2012) (table 1). Longitudinal studies have also shown that SSD is not characterised by unstable circadian (Meagher et al, 2012), and the lack of overt fluctuating level of consciousness and symptomatology, makes the differentiation between SSD and dementia even more difficult. This is especially so in the light of lack of adequate clinical tools and peripheral biomarkers that may aid the clinical differentiation, and thus help with the clinical management of subjects with SSD.

How to diagnose subsyndromal delirium: use of clinical and peripheral blood biomarkers People with SSD have worse outcomes in terms of hospital readmissions and mortality, they are less likely to return back to the community within 30 days of admission have longer hospital stays and overall more medical complications, including higher risk for falls (Marcantonio et al, 2005), lower cognitive and functional level at follow-up (Cole et al, 2003) compared to subjects devoid of delirium. In the light of the numerous poor outcomes, there is a need not only to improve the clinical recognition of SSD, but also its proactive management. Sadly, many of the subjects with SSD will be either referred to the Liaison Psychiatry Services for diagnosis of dementia, or will be misdiagnosed for dementia rather early in the course of their delirium recovery. Since SSD can coexist with dementia, having good collateral information about baseline functioning is an imperative. However, in many of the SSD subjects this information will be unavailable. In the absence of reliable collateral history, the diagnosis of the syndrome largely relies on clinicians skills. However, since the latter are not always in place, increase in awareness, education as well as improvement of currently available diagnostic tools are urgently needed.

Future challenges and areas for further investigation In addition to the above, a number of SSD topics still remain largely unknown: the predictive value of individual symptoms in respect to poor prognosis at short and long term; the natural course of subsyndromal delirium and its temporal interrelation with syndromal delirium, severe or otherwise; the impact of non-pharmacological or pharmacological interventions on individual symptoms of delirium. An additional problem for SSD management is the current widespread clinical culture refusing to acknowledge presence of the syndrome once the causes of delirium are treated and the laboratory findings are normalised. Thus, although elevated CRP levels are largely associated with delirium (both prevalent and incident delirium; McDonald et al, 2007), these findings have not been replicated in further studies (White et al, 2008, van den Boogaard et al, 2011), and even opposite findings have been reported for older adults with co-existing dementia (Yates et al, 2009). Similarly, the values of serum albumin and blood urea appear not to be useful in discriminating between subjects with and without SSD (Cole et al, 2003, Yates et al, 2009).

Although various biomarkers have been associated with delirium (van den Boogaard et al, 2011) their relevance to SSD legs behind. Elevated levels of homocysteine are not only associated with dementia, but also with alcohol withdrawal (Bleich et al, 2000), suggesting that values of homocysteine above the 14mol/l values maybe indicative of SSD. Lower levels of esterases preoperatively also help distinguish people at risk to develop delirium post-operatively (Cerejeira et al, 2011), and this may also help identify SSD in clinical setting. However, further work is needed in older adults with coexisting dementia to validate the above findings. Conclusion The importance of correct diagnosis of the SSD in older adults, especially those with a previous diagnosis of dementia, is highlighted daily in clinical setting. One crucial question to clinicians is to determine if subtle changes in mental status (e.g. level of consciousness, disorientation) not fulfilling all the criteria for delirium should be a relevant and meaningful target for clinical attention and intervention. There are two good reasons to believe so. Firstly, in the absence of a peripheral, non-invasive and easy test to guide clinicians, SSD is the only available way to recognize early signs of brain dysfunction which has enormous clinical relevance. For example, in acute systemic inflammatory conditions, the delay between insult and

neuroinflammatory events associated with full-blown delirium offers a window of opportunity to implement therapeutic interventions. Secondly, many non-pharmacological interventions are "good clinical practice" that should be always implemented and have no associated risks. However, in the current climate of diminishing resources, lowering the threshold for clinical significance of symptoms of delirium can impose a very high burden of work for the Liaison Psychiatry services if education on medical wards, as well as nursing homes and community, is not adequately implemented. Similarly, further research into the clinical course and outcomes of SSD is urgently required. We can conceptualise SSD treatment as being similar to treating early psychosis in mental health units, and, if resourced adequately, we may even have early intervention in delirium teams. In the absence of adequate peripheral blood biomarkers at present, one of the research goals needs to be further development of novel blood peripheral biomarkers to aid the diagnosis.

References: 1. Adamis D, Treloar A, martin FC, Gregson N, Hamilton G, Macdonald AJD: APOE and cytokines as biological markers for recovery of prevalent delirium in elderly medical inpatients. Int J Geriatr Psychiatry 2007; 22: 688-94. 2. Bleich S, Degner D, Wiltfang J, Maler JM, Niedmann P, Cohrs S, Mangholz A, Porzig J, Sprung R, Rther E, Kornhuber J: Elevated homocysteine levels in alcohol withdrawl. Alcol&Alcoholism 2000; 35: 351-4. 3. Cerejeira J, Batista P, Nogueira V, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing 2011; 40: 621-6. 4. Cole M, McCusker J, Dendukuri N, Han L: The prognostic significance of subsyndromal delirium in elderly Medical inpatients. J Am Geriatr Soc 2003; 51: 754-60. 5. Department of Health: Living well with dementia: A National Dementia Strategy. 2009. 6. Macdonald A, Adamis D, Treloar A, Martin F. C-reactive protein levels predict the incidence of delirium and recovery from it. Age Ageing 2007; 36: 222-5.

7. Maegher D, Adamis D, Trzepacs P, Leonard M. Features of subsyndromal and persistent delirium. Br J Psychiatry 2012; 200: 37-40. 8. Marcantonio ER, Kiely DK, Simon SE, Orav EJ, Jones RN, Murphy KM, Bergmann MA. Outcomes of older people admitted to postacute facilities with delirium. JAGS 2005; 53: 963-9. 9. Royal College of Psychiatrists: National Audit of Dementia: Report of the first round of the National Audit of Dementia. 2011 10. van den Boogaard M, Kox M, Quinn KL, van Achterberg T, van der Hoeven JG, Schoonhoven L, Pickkers P. Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and non-inflamed patients. Crit Care. 2011;15:R297. [Epub ahead of print] 11. White S, Eeles E, OMahony S, Bayer A. Delirium and Creactive protein. Age Ageing 2008, 37: 123-4. 12. Yates C, Stanley N, Cerejeira JM, Jay R, Mukaetova-Ladinska EB. Screening instruments for delirium in older people with an acute medical illness. Age Ageing 2009; 38: 235-7. Table 1: Symptoms of subsyndromal delirium. Please note that subsyndromal delirium does not fulfil the DSM-IV defined criteria for delirium (DSM-IV recognize subclinical presentations that precede or follow delirium, as well as presentations that never progress to delirium), and the clinical symptoms are less severe in relation to the full-blown delirium. Maegher et al (2012) suggested DRS-R98 cut-off scores of 16 for diagnosis of the syndrome. Modified according to Cole et al (2003) and Maegher et al (2012). Symptoms of subsyndromal delirium 1. Motor activity (restlessness, agitation, irritability, drowsiness, hypersensitity to stimuli) 2. Higher cognitive functioning (reduced ability to think or concentrate; impairment in attention, orientation, working memory and long-term memory) 3. Perceptual and mood disturbances (anxiety, delusions and hallucinatory experiences, nightmares) 4. Relatively stable circadian rhythm 5. ? Lack of overt fluctuating level of consciousness and symptomatology

Announcing An Italian Textbook on Delirium Alessandro Morandi, MD, MPH 1,2,3, E Wesley Ely, MD, MPH, 4,5,6,7,8 Marco Trabucchi, MD
1 9

inform health care providers on this important syndrome, which affects thousands of patients every year. Therefore, we undertook the efforts to create an Italian textbook on delirium, named Il delirium. 4 The book is

Department of Rehabilitation and Aged Care Unit, Ancelle della Carit

Hospital, Cremona, Italy; 2Geriatric Research Group, Brescia, Italy; 3Center for Quality of Aging, Vanderbilt Medical Center, Nashville, TN, USA;
4

available to buy online (http://www.vitaepensiero.it/volumi/9788834321591) and it is structured in five chapters: 1) Epidemiology, classification and risk factors of delirium in different clinical settings; 2) Pathogenesis of delirium; 3) Clinical aspects of delirium; 4) Prevention and treatment of delirium; 5) Future directions. (1) Caraceni A, Grassi L. Delirium Acute confusional states in palliative medicine. Second Edition ed. Oxford University Press, 2011.

Center for Health Services Research, Vanderbilt Medical Center,

Nashville, TN, USA;5Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt Medical Center, Nashville, TN,USA; 6VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), USA; 7 University of Tor Vergata, Rome, Italy Delirium is a complex and multifaceted syndrome, and though it has a long history in the annals of medicine, few textbooks are currently available on this geriatric syndrome. Caraceni and Grassi published The Acute Confusional States in Palliative Medicine specifically addressing the concept of delirium in palliative care patients. Subsequently, Page and Ely2 targeted a different setting focusing on Delirium in Critical Care. Lindesay3 published a textbook evaluating delirium in the elderly: Delirium in the old age. In the Italian literature there was an important existing gap on this topic. In fact no textbook has been published to
1

(2) Page V, Ely EW. Delirium in Critical Care (Core Critical Care). Cambridge University Press, 2011. (3) Lindesay J, Rockwood K, MacDonald A. Delirium in Old Age. Oxford Medical Publications. 2002 (4) Morandi A, Ely E.W., Trabucchi M. Il delirium. Vita e Pensiero, 2012.

Papers to look out for A: Dr Meera Agar

Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and non-inflamed patients. van den Boogaard M, Kox M, Quinn KL et al Crit Care. 2011 Dec 29;15(6):R297. [Epub ahead of print] This is an exploratory observational study of 100 ICU patients with or without delirium and with ("inflamed") and without ("non-inflamed") infection/SIRS. Delirium was diagnosed using the confusion assessment method-ICU (CAMICU), and biomarker analysis occurred 24 hours following the onset of delirium. In the non delirious group blood was taken at a similar time point as the ICU length of stay at time of delirium in the delirium group. In multivariate regression analysis this study found IL-8 was independently associated (odds ratio 9.0; 95%CI 1.8-44.0) with delirium in inflamed patients and IL-10 (OR 2.6; 95%CI 1.1 - 5.9) and A-beta1-42/40 (OR 0.03; 95%CI 0.002 0.50) with delirium in non-inflamed patients. Full abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/22206727

Randomised control trials for delirium: Current evidence and statistical methods. Tahir TA, Farewell D, Bisson J. J Psychosom Res. 2012 Jan;72(1):84-5. Epub 2011 Nov 25. This is a welcome discussion on the complexities of delirium RCT analyses, and proposes some statistical methods and approaches which have been undertaken. Well worth a read for those pondering trial design.

B: Editors Choice
Two papers with haloperidol in mind with results designed to confuse. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study Huybrechts et al. British Medical Journal 2012;344:e977 (Published 23 February 2012) Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: A randomized controlled trial*. Wang et al Critical Care Medicine 2012 Mar;40(3):731-9.

March news Conferences The Second Annual Meeting for the American Delirium Society. Indianapolis, Indiana June 3-5, 2012
The second annual conference of the American Delirium Society in Indianapolis, Indiana, June 3-5, 2012, promises to be a very exciting program with the following two main goals: To disseminate knowledge on the state-of-the-art in delirium identification, treatment, and prevention, and To discuss new directions for delirium identification, prevention and treatment strategies. Dr. Sharon Inouye, MD, MPH and Dr. Anne Kolanowski, PhD, RN as keynote speakers will be discussing current knowledge and innovations in delirium treatment and prevention from the perspectives of both medicine and nursing. Sessions include the following: 1) Pathophysiology of Delirium will examine work on biomarkers for delirium diagnosis, prognosis, and therapy response; 2) Measurement of Delirium will focus on cutting edge research on delirium identification tools; 3) Postoperative Delirium will review issues pertaining to the brain undergoing the stress of surgery and current research strategies regarding detection and treatment of delirium following surgery; 4) Long-Term Outcomes of Delirium will present current knowledge regarding the impact of delirium on subsequent mood, cognition, morbidity and mortality; 5) Delirium Care in the 21st Century will center on new prevention, evaluation and treatment techniques; and 6) Clinical Trial Updates will highlight new and ongoing treatment trials with regard to delirium and delirium prevention. Sorry about late notice but! March 15, 2012 Abstract Submission Deadline ~ submit abstracts in a Word document (for formatting and publication purposes) to abstracts@americandeliriumsociety.org.
For more information, please contact the ADS at info@americandeliriumsociety.org.

Videocast Patient experience

David Aaronovitch on the abject terror of ICU psychosis. 2011. BBC News www.bbc.co.uk/news/health-15881720.

European Delirium Congress:

7th EDA Scientific Congress: 18-19 October 2012, Bielefeld, Germany

In this Annals see how to take part in the first Europewide delirium assessment survey! Delirium and Dementia
The British Geriatric Society and Royal College of Physicians are holding a joint conference on 26 June in London. The conference was organised by Alasdair MacLullich. The keynote talk is by the excellent Ed Marcantonio (Harvard) on delirium treatment. If you were unable to get to last years European Delirium Association here is your chance to hear him speak - along with our own experts including Professor John Young, Chair of the NICE guideline committee. http://events.rcplondon.ac.uk/details.aspx?e=2573 We are delighted to announce that our 7th annual meeting will be held in Bielefeld, the principal city of Eastern Westphalia in the north west of Germany. The programme will cover the full spectrum of the latest advances in delirium research and clinical practice, from basic science to clinical implementation. Details will follow shortly. Bielefeld is easily accessible from all parts of Europe. Please see here for more details: http://www.bielefeld.de/en/travel/

Announcing the first European Delirium Association survey

Dear Colleague Although there have been many advances in our knowledge of delirium there are still substantial uncertainties and a lack of consensus over best practice. The European Delirium Association (EDA) has been disseminating knowledge of delirium within the European Union in the last several years. The EDA has decided to conduct a survey to help understand the range of opinions among mailing list members on various aspect of delirium care. We greatly appreciate your expertise and we believe that this survey will provide a significant advancement in our understanding of current practice. The findings will inform future directions in education, training, governance, and research. The results will be presented at the next EDA conference. You can find the survey following this link: http://kwiksurveys.com?s=LODJNH_6c7dc879. The survey takes about fifteen minutes to complete. We are extremely grateful for your time. Please send any queries to : morandi.alessandromail.com; dhjd2@medschl.cam.ac.uk

More information about the EDA can be found here: www.europeandeliriumassociation.com Kind Regards, Alessandro Morandi, MD, MPH Board Member, EDA Daniel Davis, MB, MPhil Board Member, EDA Alasdair MacLullich, MRCP (UK), PhD President, EDA On behalf of the EDA