Delirium masquerading as depression.
ABSTRACT Despite the high prevalence of delirium in palliative care settings, this diagnosis is frequently missed, particularly in patients with hypoactive delirium. These patients are also commonly misdiagnosed with depression because of the overlap in symptoms between the two diagnoses. Failure to promptly diagnose delirium can have significant ramifications in terms of delirium reversal, subsequent patient involvement in end-of-life decision making, and the recognition and treatment of other symptoms.
We report a case of a 63-year-old French-speaking woman admitted to our inpatient palliative care unit with colorectal cancer and a history of depression. This case report highlights the major challenges associated with making the diagnosis of delirium in a patient with a complex medical history, including depression.
The patient presented with symptoms of depressed mood and fluctuation in psychomotor activity, but failed to respond to an increase in her fluoxetine treatment in addition to methylphenidate and treatment of her hypothyroidism. A psychiatric assessment in her own language detected features of inattention and confirmed a diagnosis of delirium that was multifactorial, secondary to a combination of posterior reversible encephalopathy syndrome (PRES), hypothyroidism, hepatic dysfunction, and medication.
Subsyndromal delirium may present with mood lability, and as delirium and depression can coexist, clinicians should perform a delirium screen for all patients presenting with symptoms of depression, preferably in the patient's first language. Cognitive testing can be particularly helpful in distinguishing delirium, especially hypoactive delirium, from depression.
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ABSTRACT: To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents. Descriptive study. LTC settings in Quebec City, Canada. Participants were 155 individuals aged 65 and older, with dementia. (1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies. Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed. Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.Journal of the American Medical Directors Association 04/2009; 10(3):181-8. · 5.30 Impact Factor
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ABSTRACT: This paper examines the pattern and frequency of implementation of environmental strategies and the use of psychotropic medication in the management of patients with delirium in an acute hospital setting. The study involved 46 consecutive referrals to a consultation psychiatry service each of whom met ICD-10 criteria for delirium. Patients were subdivided into hyperactive, hypoactive and mixed subtypes of delirium and assessed regarding severity of delirium, the use of psychotropic medication prior to consultation and the implementation of environmental measures in their management. Mean age was 60.1 years. Thirty per cent of patients were of the hyperactive subtype, 24% hypoactive and 46% mixed. Psychotropic medication was given to 56.5% prior to consultation and this is significantly associated with severity of delirium and in particular, with hyperactive delirium subtype. Of eight environmental strategies only four were instituted in over 50% of the patients prior to consultation. The application of these strategies was associated with overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance. It was not significantly associated with severity of disorientation or with disturbed perception/thinking. Simple environmental strategies such as limiting changes in staff, minimising noise levels and involving relatives in re-orientation are frequently overlooked in the management of patients with delirium. Our study suggests that the implementation of environmental strategies occurs primarily in responses to behavioural challenges rather than to limit the core features of delirium.The British Journal of Psychiatry 05/1996; 168(4):512-5. · 6.61 Impact Factor
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ABSTRACT: In some patients who are hospitalized for acute illness, we have noted a reversible syndrome of headache, altered mental functioning, seizures, and loss of vision associated with findings indicating predominantly posterior leukoencephalopathy on imaging studies. To elucidate this syndrome, we searched the log books listing computed tomographic (CT) and magnetic resonance imaging (MRI) studies performed at the New England Medical Center in Boston and Hôpital Sainte Anne in Paris; we found 15 such patients who were evaluated from 1988 through 1994. Of the 15 patients, 7 were receiving immunosuppressive therapy after transplantation or as treatment for aplastic anemia, 1 was receiving interferon for melanoma, 3 had eclampsia, and 4 had acute hypertensive encephalopathy associated with renal disease (2 with lupus nephritis, 1 with acute glomerulonephritis, and 1 with acetaminophen-induced hepatorenal failure). Altogether, 12 patients had abrupt increases in blood pressure, and 8 had some impairment of renal function. The clinical findings included headaches, vomiting, confusion, seizures, cortical blindness and other visual abnormalities, and motor signs. CT and MRI studies showed extensive bilateral white-matter abnormalities suggestive of edema in the posterior regions of the cerebral hemispheres, but the changes often involved other cerebral areas, the brain stem, or the cerebellum. The patients were treated with antihypertensive medications, and immunosuppressive therapy was withdrawn or the dose was reduced. In all 15 patients, the neurologic deficits resolved within two weeks. Reversible, predominantly posterior leukoencephalopathy may develop in patients who have renal insufficiency or hypertension or who are immunosuppressed. The findings on neuroimaging are characteristic of subcortical edema without infarction.New England Journal of Medicine 03/1996; 334(8):494-500. · 51.66 Impact Factor