Psychosomatics 41:519-522, December 2000
© 2000 The Academy of Psychosomatic Medicine
Prevalence of Psychotic Symptoms in Delirium
Robert Webster, M.D., and
Suzanne Holroyd, M.D.
Received January 21, 2000; revised April 3, 2000; accepted July 20, 2000. From Department of Psychiatric Medicine, University of Virginia Health Sciences Center, Box 623, Charlottesville, Virginia. Address correspondence and reprint requests to Dr. Holroyd, Department of Psychiatric Medicine, University of Virginia Health Sciences Center, Box 623, Charlottesville, VA 22908; e-mail: sh4s{at}virginia.edu
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ABSTRACT
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Psychosis in delirium has been an underresearched area. The authors retrospectively examined the prevalence of psychotic symptoms and possible associated factors in the records of 227 consecutive hospitalized patients. These patients had been diagnosed with delirium, according to the DSM-IV criteria and referred to a psychiatry consult service. The authors compared patients, with or without psychosis, on demographic variables, medical and psychiatric history, number of medications, etiology of delirium, and cognitive state. The prevalence of psychotic symptoms was 42.7% (n=97) with 27% of patients (n=61) having visual hallucinations, 12.4% (n=28) having auditory hallucinations, 2.7% (n=6) having tactile hallucinations, and 25.6% (n=58) having delusions. The presence of visual hallucinations, but not delusions or auditory hallucinations, was significantly associated with more active medical diagnoses and multiple etiologies causing the delirium. Psychotic symptoms are not uncommon in delirium, but specific psychotic symptoms may have different factors contributing to their development. Visual hallucinations appear to be associated with a greater number of active medical disorders, but other factors associated with the development of psychotic symptoms in delirium are currently unknown.
Key Words: Delirium • Hallucination • Delusion
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INTRODUCTION
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Delirium is a common but serious psychiatric disorder that is regarded as often unrecognized1,2 and underresearched.2,3 Although hallucinations and delusions are a known feature of delirium, little research has been done to study these symptoms. In a classic study of delirium, Wolff et al.4 noted visual hallucinations in 67.9% of subjects, auditory hallucinations in 41.5%, followed in frequency by tactile, olfactory, and gustatory hallucinations. Although delusions were described, no prevalence was given.
Ross et al.5 differentiated "somnolent" delirium, as might be seen in hepatic encephalopathy, from "activated" delirium, as might be seen in sedative withdrawal states. Ross et al. revealed that the activated patients with delirium had significantly more hallucinations (67% vs. 3%) and delusions (50% vs. 3%) than the somnolent type. No breakdown of hallucinations by modality (e.g., visual, auditory, etc.) was provided. Interestingly, there were no differences in cognitive score between the activated and somnolent groups.
Cutting's6 study of psychotic delirium patients revealed approximately equal numbers of delusions and hallucinations (47.3% vs. 51.4%), although other studies note a predominance of hallucinations.4,7 Two studies have revealed a predominance of hallucinations in withdrawal delirium.7,8 Some have proposed that visual hallucinations in delirium reflect left-hemisphere dysfunction,9 while delusions in delirium reflect pathology of bilateral prefrontal cortex, thalamus, basal ganglia, and right posterior cortical regions.10
To our knowledge, no one has studied what factors are associated with development of psychosis in delirium, including examining the etiology of the delirium. In this retrospective study, our purpose is to study the prevalence of psychotic symptoms in delirium and examine factors that might be associated with their development.
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METHOD
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A retrospective chart review was carried out by one of the authors (RW) on 820 consecutive psychiatry consults of medical and surgical inpatients at a tertiary-care teaching hospital between January 1997 and December 1998. Of the 820 charts reviewed, 227 patients (27.7%) were diagnosed with DSM-IV delirium and were included in the study.
A structured questionnaire was used to collect data and included the following: age, race, gender, marital status, living situation (e.g., alone, with family, nursing home), number of medications, number of active medical problems, (i.e., as determined at the time of the consult), and past psychiatric diagnoses (i.e., determined by either chart review or other informant). The presence of hallucinations (e.g., auditory, visual, tactile, olfactory, gustatory) and delusions was recorded. The Mini-Mental State Exam score11 was recorded as a measure of cognitive status. The etiology of delirium (medication effect, infection, hypoxia, metabolic disarray, central nervous system disorder such as trauma, bleed or stroke, or multiple etiologies) as clinically determined by the psychiatry consult attending and written in the chart at the time of the consult was recorded.
We obtained descriptive statistics on all variables. Patients were divided into two groups: those with psychosis (i.e., visual hallucinations, auditory hallucinations, or delusions) and without psychosis. Student t-tests were used to compare the groups on continuous variables. Chi-square or Fisher exact tests were used to compare groups on categorical variables. A P value <0.05 is used to determine significance and all P values are two-tailed.
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RESULTS
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Of the 820 charts reviewed, 227 of the patients (27.7%) had a diagnosis of delirium. Demographic characteristics of delirious patients revealed the following: mean±SD age=60.1±18.7 years, 57.7% women (n=131), 42.3% men (n=95), 79.7% White (n=181), 19.4% Black (n=44), 0.47% Hispanic (n=1), 11.9% lived alone (n=27), 54.6% lived with family (n=124), 16.8% lived in a nursing home (n=38), and 7.0% had another living situation (n=16). Mean MMSE score for delirious patients was 11.0±9.6.
Although all patients had a primary diagnosis of delirium, many had secondary psychiatric diagnoses. In order of frequency these diagnoses included the following: dementia (33.5%, n=76), major depression (33.0%, n=75), alcohol abuse or dependence (13.2%, n=30), adjustment disorder (10.6%, n=24), bipolar disorder (4.4%, n=10), schizoaffective disorder (3.5%, n=8) and schizophrenia (0.9%, n=2). Before their current hospitalization, 131 patients (57.7%) had been diagnosed with a psychiatric disorder.
Etiology of the delirium were as follows: medication effect (15.9%, n=36), infection (8.4%, n=19), metabolic disarray (6.6%, n=15), hypoxia (2.6%, n=6), central nervous system disorder (2.6%, n=6), and other (14.1%, n=32). Multiple etiologies (49.3%, n=112) constituted the largest cause of delirium.
Of the patients diagnosed with delirium, 97 (42.7%) had psychotic features (hallucinations or delusions). Thirty-six patients (15.8%) had both hallucinations and delusions. Among the patients with delirium, 32.6% (n=74) had hallucinations, with 27% (n=61) visual hallucinations, 12.4% (n=28) auditory hallucinations, and 2.7% (n=6) tactile hallucinations. There were no olfactory or gustatory hallucinations recorded in this sample. Of the delirious patients, 25.6% (n=58) had delusions, with 15.9% (n=36) of paranoid type. The other delusions (10.6%, n=24) were either unique [example grandiose delusions in 0.4% (n=1)] or difficult to categorize (other).
Next, patients with psychotic symptoms were compared with those patients without psychotic symptoms on the variables of age, number of active medical problems, MMSE score, number of medications, multiple vs. single etiology of delirium and presence of a concurrent psychiatric diagnosis (see Table 1). As shown in Table 1, psychotic symptoms were associated with a higher number of active medical problems and multiple vs. single etiology of delirium but were not associated with MMSE score, number of medications, age, or presence of another psychiatric disorder. Individual etiologies were also compared between psychotic and nonpsychotic patients; however, there were no differences on any of these variables.
Next, we examined patients by specific type of psychotic symptoms and compared them with patients without psychotic symptoms (see Table 1). Visual hallucinations were significantly associated with number of active medical diagnoses and with multiple etiologies vs. single etiology of the delirium. No variables were found to be associated specifically with auditory hallucinations or delusions. Psychotic symptoms were not associated with presence of a concurrent psychiatric diagnosis, cognitive score (MMSE), or age. Again no specific etiology was found to be associated with any specific type of psychotic symptom.
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DISCUSSION
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In our study of delirium, slightly less than half of patients (42.7%) had psychotic features. Our results support those of others that visual hallucinations are the most common type of hallucination, while paranoia is the most common type of delusion.
Our study is one of the first to explore associated factors of psychosis in delirium. Our results suggest that psychotic symptoms, but more specifically visual hallucinations, may be associated with the number of the medical disorders underlying the delirium. Interestingly, specific types of psychotic symptoms had different associated factors. For example, visual hallucinations were associated with a greater number of active medical problems, while auditory hallucinations and delusions were not. Similarly, visual hallucinations were strongly associated with multiple etiologies, while delusions and auditory hallucinations were not. This may suggest that specific types of psychotic features are derived from different pathophysiologic mechanisms. For example, visual hallucinations have been noted to predominate in alcohol withdrawal delirium.4,8
Surprisingly, psychotic features were not associated with lower cognitive score (as measured by the MMSE), although this finding is in agreement with that of Ross et al.5 In dementia, for example, lower cognitive scores are associated with psychotic symptoms12,13 except in very severe end stages.14 Also, again surprisingly, other coexisting psychiatric illnesses (e.g., dementia, bipolar disorder, schizophrenia, or schizoaffective disorder) were not associated with presence of psychosis in delirium. These results may suggest that the pathophysiologic causes of psychosis in dementia, bipolar disorder, or schizophrenia are different than that found in delirium.
In summary, psychotic features are not an uncommon feature of delirium and is an area deserving further study. One limiting factor to our study was its retrospective design. A prospective study might better be able to detect psychosis and thus better estimate the prevalence. Another limitation was that the sample was from psychiatry consultations. It is possible that delirium patients referred to a psychiatry consult service have more psychotic symptoms or different associated characteristics than those not requiring a psychiatry consult. As well, such patients may have been more likely to have preexisting psychiatric disorders because of referral bias, perhaps explaining the high frequency of coexisting psychiatric disorders. Further, no data were available regarding outcome.
Future research in this area should be prospective and should examine other factors associated with psychosis and the outcome of psychotic vs. nonpsychotic delirium. Specific psychotic symptoms should be examined separately, as they may have different risk factors. Understanding more about psychotic features in delirium may increase our understanding of delirium itself as well as increase our understanding of psychotic features in other disorders.
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ACKNOWLEDGMENTS
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This study was supported in part by a grant to Dr. Holroyd from the National Institute of Mental Health (Disorders of Aging Branch) (K07-MH01199–01A1)
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REFERENCES
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-
Inouye SK: Delirium in hospitalized older patients: Recognition and risk factors. J Geriatric Psychiat Neurol 1998, 11:118–125
-
Lipowski ZU: Delirium (Acute Confusional States). JAMA 1987; 258:1789–1792
-
Lipowski ZU: Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am J Psychiatry 1983; 140:1426– 1436
-
Wolff HG, Curran D: Nature of delirium and allied states. Arch Neurol Psychiat 1935; 33:1175–1215
-
Ross CA, Peyser CE, Shapiro I, et al: Delirium: phenomenologic and etiologic subtypes. Int Psychogeriatrics 1991; 3:135–147
-
Cutting J: The phenomenology of acute organic psychosis. Br J Psychiatry 1987; 151:324–332[Abstract/Free Full Text]
-
Sirois F: Delirium:100 cases. Can J Psychiatry 1988; 33:375–378
-
Saravoy SM, Pardes H: Auditory elementary hallucinations in alcohol withdrawal psychosis. Arch Gen Psychiat 1964; 16:652– 658
-
Cutting J: The Right Cerebral Hemisphere and Psychiatric Disorders. New York, Oxford University Press, 1990, pp 147–162
-
Trzepacz PT: The neuropathogenesis of delirium—a need to focus our research. Psychosomatics 1994; 35:374–391[Abstract/Free Full Text]
-
Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiar Res 1975; 12:189–198
-
Gilley DW, Whalan ME, Wilson RS: Hallucinations and associated factors in Alzheimer's disease. J Neuropsychiatry Clin Neurosci 1991; 3:371–376[Abstract/Free Full Text]
-
Patterson MB, Schnell AH, Martin RJ, et al: Assessment of behavioral and affective symptoms in Alzheimer's disease. J Geriatric Psychiatry Neurol 1990; 3:21–30
-
Reisberg B, Fransses E, Sclar SG et al: Stage-specific incidence of potentially remedial behavioral symptoms in aging and Alzheimer's disease. Bull Clin Neuroscience 1989; 54:95–112
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ABSTRACT
INTRODUCTION
