Elsevier

Critical Care Clinics

Volume 19, Issue 4, October 2003, Pages 771-787
Critical Care Clinics

Delirium, depression, and anxiety☆

https://doi.org/10.1016/S0749-0704(03)00048-4Get rights and content

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Delirium

Delirium is a disorder of cognition, particularly attention, concentration, and level of consciousness, with accompanying mood and behavioral dysfunction, which is caused by severe medical illness or medications. Delirium, the most prevalent mental disorder among older patients in an intensive care unit (ICU), is associated with poor prognosis and increased length of hospital stay. New delirium can be the first indication of impending catastrophic medical illness [1]. Its experience is

Clinical features

Several important clinical features distinguish delirium from other mental disorders. In general, delirium develops over hours to days, and the course is marked by fluctuation, at times rapid, of the clinical features. Delirious patients have disturbances in the areas of consciousness, manifest by reduced clarity of awareness, sleepiness, and lethargy; and difficulty focusing, sustaining, and shifting attention. In addition, cognition, including memory, orientation, language, and executive

Diagnosis

Clues that a patient may be delirious include inattentiveness and inability to give a reliable history. Several methods lead to reliable diagnosis. Psychiatrists use criteria from the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) (Box 1) [21]. The Confusion Assessment Method (CAM) is the most widely used, validated and reliable instrument for use by nonmental health professionals [22]. Ely et al [23] modified the CAM to overcome difficulties in assessing

Prevalence and incidence among ill populations

In general, the greater the severity of illness, the higher the likelihood of delirium. As such, among the many sites in which delirious patients are treated, the incidence and prevalence of delirium in the ICU is among the highest. The prevalence of delirium among elderly patients newly admitted to general medical units varies from 14% to 24%; 6% to 56% develop delirium during their hospital stay [13], [31]. Dyer et al [30], who reviewed 80 studies of postoperative delirium, calculated an

Predisposing and precipitating factors

Both increasing age, and illness severe enough to result in an ICU stay, are among the most important predisposing and causative factors associated with development of delirium [33]. Other predisposing factors include known brain injury or brain disease, cognitive impairment including dementing disorders, visual impairment, male gender, hypoalbuminemia, depression, and alcohol abuse [2], [30], [33], [34], [35], [36], [37], [38], [39]. Dementia increases the risk of developing delirium two- to

Outcomes

Studies of older hospital patients have documented that delirium is associated with prolonged hospital stay, increased risk of developing a hospital-acquired complications such as a fall or pressure sore, decline in functional status, readmission to the ICU [51], increased likelihood of being admitted to a long-term care facility, and death [5], [6], [30], [34], [52], [53]. Patients who recover from delirium are more likely to develop dementia over a 2-year period [54]. Delirium may be a cause

Management

The most important principle in addressing delirium is to identify and correct the causative factor [12]. Because delirium is so often multifactorial, every delirious patients should be evaluated for infection, electrolyte and metabolic abnormalities, and major organ failure. The clinician should review the patients medication and reduce, replace, or discontinue, if possible, all medications that have the potential to cause confusion. For patients in pain who require opioids, changing to an

Clinical features

In critically ill patients, depression presents with low mood, sadness, and inability to experience pleasure, as well as changes in sleep appetite and energy. Depressive diagnoses seen in medically ill patients include major depressive disorder (MDD), adjustment disorder, depression secondary to medications or substances, and depression secondary to a general medical condition. Treatment recommendations differ by diagnosis.

Of these depressive disorders, MDD is arguably the most important to

Clinical features

Anxiety disorders include phobias, panic disorder with or without agoraphobia, acute stress disorder, posttraumatic stress disorder, generalized anxiety disorder, and obsessive-compulsive disorder. In medical-surgical, inpatient, and critical care settings, anxiety is commonly attributable to situational stressors, and is seen in the form of an adjustment disorder or acute stress disorder. Clinical features of anxiety disorders can include: (1) subjective reports about excessive fears or

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References (82)

  • H.L Wong et al.

    Effects of music therapy on anxiety in ventilator-dependent patients

    Heart Lung

    (2001)
  • J.M Flacker et al.

    Delirium in the elderly. Optimal management

    Drugs Aging

    (1998)
  • Z.J Lipowski

    Delirium: acute confusional states

    (1990)
  • B Liptzin et al.

    An empirical study of delirium subtypes

    Br J Psychiatry

    (1992)
  • O Sandberg et al.

    Clinical profile of delirium in older patients

    J Am Geriatr Soc

    (1999)
  • J Francis et al.

    A prospective study of delirium in hospitalized elderly

    JAMA

    (1990)
  • E.W Ely et al.

    The impact of delirium in the intensive care unit on hospital length of stay

    Intensive Care Med

    (2001)
  • P.G Lawlor et al.

    Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study

    Arch Intern Med

    (2000)
  • E Hassan et al.

    Therapeutic considerations in the management of agitated or delirious critically ill patients

    Pharmacotherapy

    (1998)
  • M Justic

    Does “ICU psychosis” really exist?

    Crit Care Nurs

    (2000)
  • B.E McGuire et al.

    Intensive care unit syndrome: a dangerous misnomer

    Arch Intern Med

    (2000)

  • Practice guideline for the treatment of patients with delirium

    Am J Psychiatry

    (1999)
  • M.J Tueth et al.

    Delirium: diagnosis and treatment in the older patient

    Geriatrics

    (1993)
  • R.L Green et al.

    A study of crying in medically and surgically hospitalized patients

    Am J Psychiatry

    (1987)
  • K.R Farrell et al.

    Misdiagnosing delirium as depression in medically ill elderly patients

    Arch Intern Med

    (1995)
  • S.T O'Keeffe et al.

    Clinical significance of delirium subtypes in older people

    Age Ageing

    (1999)
  • D.J Meagher et al.

    Relationship between symptoms and motoric subtype of delirium

    J Neuropsychiatr Clin Neurosci

    (2000)
  • C.A Ross et al.

    Delirium: phenomenologic and etiologic subtypes

    Int Psychogeriatr

    (1991)

  • Diagnostic and statistical manual of mental health disorders: DSM-IV

    (1994)
  • S.K Inouye et al.

    Clarifying confusion: the confusion assessment method. A new method for detection of delirium

    Ann Intern Med

    (1990)
  • E.W Ely et al.

    Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)

    JAMA

    (2001)
  • T.C Bond

    Recognition of acute delirious mania

    Arch Gen Psychiatry

    (1980)
  • J.R Fann

    The epidemiology of delirium: a review of studies and methodological issues

    Semin Clin Neuropsychiatry

    (2000)
  • M.J Massie et al.

    Delirium in terminally ill cancer patients

    Am J Psychiatry

    (1983)
  • S.K Inouye et al.

    A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics

    Ann Intern Med

    (1993)
  • S O'Keeffe et al.

    The prognostic significance of delirium in older hospital patients

    J Am Geriatr Soc

    (1997)
  • M.E Ostermann et al.

    Sedation in the intensive care unit: a systematic review

    JAMA

    (2000)
  • S.K Inouye

    Predisposing and precipitating factors for delirium in hospitalized older patients

    Dement Geriatr Cogn Disord

    (1999)
  • S.E Levkoff et al.

    Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients

    Arch Intern Med

    (1992)
  • E.R Marcantonio et al.

    The relationship of postoperative delirium with psychoactive medications

    JAMA

    (1994)
  • J.D Schor et al.

    Risk factors for delirium in hospitalized elderly

    JAMA

    (1992)

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      Admission to an intensive care unit (ICU) can have a deleterious effect on a patient's mood and quality of life (QOL) [1]. Altered mood, with a dominance of negative emotions including fear, depression and anxiety, occurs in patients while in the ICU [2–5] and after discharge from the hospital [3,5–12]. Up to 75% of patients experience anxiety and 40% report depressive symptoms from being in ICU [13].

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    This work was supported by the VA Merit Review Program.

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