Feasibility and potential of a bedside mini-EEG for diagnosing delirium superimposed on dementia.

OBJECTIVE: Delirium superimposed on dementia (DSD) is difficult to diagnose because symptoms of delirium might be interpreted as symptoms of dementia. To improve diagnostic accuracy, we investigated the potential of a brief point-of-care EEG measurement. METHODS: Thirty older patients were included, all with Major Neurocognitive Disorder (i.e. dementia) according to DSM-5 criteria. EEG was registered at right prefrontal and right temporal site, with eyes either open or closed for three minutes, simultaneously with the Discomfort Scale for Dementia of Alzheimer Type. The Confusion Assessment Method for the Intensive Care Unit was administered to determine the presence of symptoms of a delirium at the time of EEG administration. Video registrations were reviewed independently by two delirium experts. RESULTS: Higher activities of delta and theta1, and lower activities of theta2, alpha, and beta activity, were found in DSD when compared to dementia only. The ratio of delta and theta power during eyes-open conditions had the highest accuracy (AUC = 0.80 [0.63-0.94]; p <.001) to distinguish DSD from dementia alone. All subjects were on benzodiazepines and half on clozapine, thus the effects of psychotropics on EEG cannot be fully excluded. CONCLUSIONS: A brief point-of-care EEG at two sites of the head has the potential to aid in the detection of DSD. SIGNIFICANCE: The diagnostic accuracy of EEG in recognizing or excluding delirium in patients who already have dementia is of large potential given the lack of proper diagnostic tools.

The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study.

OBJECTIVES: Drugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia. DESIGN: Cross-sectional multicenter study. SETTING AND PARTICIPANTS: 3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project. METHODS: Descriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load. RESULTS: 54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores). CONCLUSIONS AND IMPLICATIONS: The ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.

Performance on bedside tests of attention and organized thinking in patients with dementia free from delirium.

ABSTRACTObjectives:Bedside tests of attention and organized thinking were performed in patients with cognitive impairment or dementia but without delirium, to provide estimates of false positive rates for detecting delirium superimposed on dementia (DSD). DESIGN AND SETTING: This cross-sectional study was conducted in outpatients and institutionalized patients without delirium representing a wide spectrum of severity of cognitive impairments. PARTICIPANTS: Patients with dementia or a cognitive disorder according to DSM IV criteria, after exclusion of (suspected) delirium according to DSM IV criteria. MEASUREMENTS: Tests for inattention and disorganized thinking from the CAM-ICU were assessed. RESULTS: The sample included 163 patients (mean age 83 years (SD 6; 64% women)), with Alzheimer's disease as most prevalent (45%) diagnosis and a mean MMSE-score of 16.8 (SD 7.5). False positive rates of the test of attention varied from 0.04 in patients with normal to borderline cognitive function to 0.8 in those with severe dementia. The false positive rate of the test of disorganized thinking was zero in the normal to borderline group, increasing to 0.67 in patients with severe dementia. When combining test results false positive rates decreased to 0.03 in patients with MMSE scores above 9. CONCLUSION: Use of simple bedside tests of attention and organized thinking for the clinical diagnosis of DSD will result in high rates of false positive observations if used regardless of the severity of dementia. However, if test results are combined they may be useful to exclude DSD in patients with minimal to moderate degrees of dementia, but not in the severe group.

[Electroencephalography in delirium superimposed on dementia]. / Het electroencefalogram bij delier bij dementie (DBD).

Recognizing delirium superimposed on pre-existing cognitive impairment or dementia, 'delirium superimposed on dementia' (DSD), is challenging because signs of delirium might be interpreted as symptoms of pre-existing cognitive dysfunction.In this paper, we review the literature on the role of electrencephalography (EEG) in the differential diagnosis of delirium, dementia and DSD.Conventional EEG, applying twenty to thirty electrodes, taking thirty minutes registration, is not feasible in psychogeriatric patients. Recent studies suggest that it is possible to reliably detect delirium using only a limited number of EEG electrodes for a short period of time.With this, use of EEG in the detection of delirium in patients with cognitive impairment or clinically manifest dementia could be possible.

Ten-to-twelve years after specialized neurorehabilitation of young patients with severe disorders of consciousness: A follow-up study.

OBJECTIVE: To explore the long-term outcome of young patients with disorders of consciousness who had received intensive neurorehabilitation. METHODS: A cross-sectional cohort study, in which the survival, level of consciousness, functional independence, mobility, communication and living situation were determined by means of a structured questionnaire. The cohort consisted of 44 children and young adults, originally either in a prolonged Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS, n = 33) or a Minimally Conscious State (MCS, n = 11) who had received a specialized neurorehabilitation programme 10-12 years earlier. RESULTS: Response rate was 72% (34/44). Eleven patients were deceased, 10 of whom were in VS/UWS or MCS at discharge from the programme. Of the remaining 23 patients, 19 were conscious. Twelve lived independently, of whom six required some household support. One conscious patient lived permanently in a long-term care facility. All other patients lived either independently or with their parents. None of the VS/UWS or MCS patients showed any functional recovery. CONCLUSION: Two main long-term outcome scenarios can be recognized. Two-thirds of the participating patients who were conscious at programme discharge were able to live independently, whereas almost two-thirds of the participating patients who were in VS/UWS or MCS at discharge subsequently died.

Repeated measurements of the auditory oddball paradigm is related to recovery from the vegetative state.

The auditory oddball response has been found to be of predictive value for neurologic outcome at the early stages of coma. In the present study, the auditory oddball response was examined longitudinally during the recovery from the vegetative state to consciousness. This response was repeatedly examined every 2 weeks for an average period of 3.5 months in severely brain-injured patients. Results showed that amplitude of the auditory oddball response was unrelated to the behavioral changes during the patients' recovery from the vegetative state to consciousness. However, the presence and size of a negative potential at about 350 milliseconds predicted behavioral outcome, both for the short and long term (2 to 3 years after injury). Practical and theoretical implications of these findings are discussed.

Course of recovery and prediction of outcome in young patients in a prolonged vegetative or minimally conscious state after severe brain injury: An exploratory study.

AIMS: To explore the course of recovery of consciousness and factors predicting the outcome of severe brain injury with a prolonged period of unconsciousness in children and young adults receiving a specialized rehabilitation treatment, the Early Intensive Neurorehabilitation Programme (EINP). METHODS: A cohort of forty-four patients aged 1.6-25.5 years (M=16.0) with traumatic acquired brain injury (TBI) or non-traumatic acquired brain injury (nTBI) were examined using the Western Neuro Sensory Stimulation Profile every two weeks, from the application for EINP until discharge. The level of consciousness was assessed with the Post-Acute Level of Consciousness Scale, and the level of disability was determined by the Disability Rating Scale. Long-term level of disability of all TBI patients (N=32) was assessed between 2.0 and 4.4 years after discharge from EINP. RESULTS: Two-thirds of all patients recovered to consciousness. Three recovery patterns were identified: remaining in a vegetative state (VS), slow recovery of consciousness, and fast recovery of consciousness. In the long-term, 11 of the TBI patients were severely disabled, 13 were moderately disabled, and 4 were mildly disabled. All TBI patients who were in VS at discharge either had deceased, or recovered to a very severely disabled state. CONCLUSIONS: Three recovery patterns identified in an early stage after starting EINP made it possible to predict long-term level of disability.

Autonomic reactivity to sensory stimulation is related to consciousness level after severe traumatic brain injury.

OBJECTIVE: To examine changes in the activity of the autonomic nervous system (ANS) that are related to recovery to consciousness in the post-acute phase after severe traumatic brain injury (sTBI). METHODS: Skin conductance and heart rate reactivity to sensory stimulation were recorded every 2 weeks for an average period of 3.5 months in 16 adolescent patients, during the assessment of their level of consciousness (LoC), and their cognitive and functional behaviour. RESULTS: Both heart rate variability (HRV) and skin conductance level (SCL) in reaction to sensory stimulation changed with recovery to consciousness. Indices of HRV and SCL that represent sympathetic activity of the autonomic nervous system (ANS) increased with recovery, whereas indices that represent parasympathetic activity decreased. In addition, we observed an increase in sympathovagal balance of the ANS with recovery. CONCLUSIONS: Recovery to consciousness determined by clinical observation in sTBI in the post-acute phase is related to changes in SCL and HRV during sensory stimulation. ANS reactivity to environmental stimulation can therefore give objective supplementary information about the clinical state of sTBI patients, and can contribute to decision-making in the treatment policy of unresponsive patients. SIGNIFICANCE: These findings demonstrate that autonomic reactivity can be informative concerning how a severely damaged nervous system reacts to environmental stimulation and how, in a recovering nervous system, this reactivity changes.