review article Delirium in the Elderly: a review
Suzanne Wass,1 Penelope J. Webster,2 Balakrishnan R. Nair3
Delirium is a common disorder, often under diagnosed and
mismanaged. It is becoming more prevalent, because of the ageing
Accepted: 25 May 2008From the Department of 1Geriatic Medicine, Calvary Mater Hospital, NSW
population. In this clinical review, we summarise the definition,
Australia,2 Geriatic Medicine, John Hunter Hospital, NSW, Australia,3 Continuing
diagnosis and management of delirium. Medical Professional Development, School of Medine and Public Health, niversity of Keywords: Delirium, Dementia, Depression. New Castle, and Continuing Professional Development, Hunter New England Health, NSW, Australia. Address correspondence and reprint to: Prof. Balakrishnan R. Nair, MBBS, FRACP, FRCP Clinical Professor of Medicine, Associate Dean Continuing Medical Professional Development, School of Medicine and Public Health, Director of Continuing Professional Development, Hunter New England Health, NSW, Australia Email: [email protected]
Delirium is a common syndrome affecting many elderly prevalence of delirium in the community is 1.1% amongst the
patients not only admitted into acute medical wards but also in the
general population aged over 55 years,6 and up to 14% in those
community. The syndrome of delirium can be defined as acute brain
over 85 years.7 The incidence amongst nursing home residents
failure associated with autonomic dysfunction, motor dysfunction
and homeostatic failure. It is complex and often multi-factorial, and
The consequences of delirium are considerable for the patient
hence continues to be under diagnosed and poorly managed. Despite
and the health services. In the US delirium is estimated to increase
medical progress, delirium remains a major challenge for health care
health costs by US$2500 per patient, totalling US$6.9 billion
workers with the increasing burden of an ageing population.
per year.8 If we consider that less than half of patients have fully recovered at point of discharge, this incurs additional costs in
Definition and terminology
the form of increased residential care, rehabilitation and home services.9, 2
The Diagnostic and Statistical Manual of Mental Disorders
Even when detected early and managed appropriately, delirium
can lead to significant mortality and morbidity in frail, elderly
patients. Adverse outcomes can include the following:
“a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a pre-existing or evolving dementia”.
• Prolonged hospital stay (on average 8 days longer)10
Delirium develops over a short period of time (hours to
• Increased mortality whilst in hospital (up to 75%) in the
days) and fluctuates throughout the course of the day. It is
months following Discharge (40% 1 year mortality)1, 11, 12, 13
characterised by a reduction in clarity of awareness, inability to
• Increased risk of developing complications such as hospital
focus, distractibility and change in cognition. Other terminology
acquired infection; pressure ulcers, incontinence and falls
used to describe delirium includes ‘acute confusional state’, ‘acute
brain syndrome’, ‘acute organic reaction’, ‘acute brain failure’ and
• Poor physical and cognitive recovery at 6 and 12 months,15
with lower scores on the Mini Mental State Examination
occurrence and consequences of delirium
(MMSE) at discharge compared to controls 16
The available data for the incidence and prevalence of delirium is
• Increased risk of placement in a residential home1, 13
varied. It appears that 15% to 30% of elderly patients will have
• Increased risk of developing dementia even in patients with no
delirium on admission to hospital and up to 56% will develop
delirium during their stay.4 Incidence of delirium is highest amongst certain subgroups including those with cancer, AIDS
The odds of a poor outcome are increased by the frailty of
and terminal illness and after surgical procedures such as hip
the patient and delays in diagnosis,15 highlighting the crucial
replacement and cardiac surgery. It is more common in certain
importance of early detection and proactive management.
ward environments like ICU and palliative care units.5 The point
Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.Classification table 1: Clinical Features of Delirium
The DSM-IV-TR classifies delirium according to aetiology, as
Essential features Variable features
1. Delirium due to a general medical condition
2. Substance Intoxication Delirium (drugs of abuse)
Disorganised thinking and speech Emotional disturbance
4. Substance Induced Delirium (medications or toxins)
6. Delirium not otherwise specified. Examination signs autonomic Dysfunction
Clinically delirium can be divided into the following three
i. Hyperactive Delirium (30%). Patients are agitated and hyper
alert with repetitive behaviours, wandering, hallucinations and
aggression. Although recognised earlier, there is association
with increased use of benzodiazepines, over sedation, use of
ii. Hypoactive Delirium (25%). Patients are quiet and
withdrawn which is often missed on a busy medical ward leading to increased length of stay, increased and more severe
Adapted from Inouye SK. Delirium in Older Persons. NEJM;
iii. Mixed Delirium. Fluctuating pattern seen in 45% of cases.3, 10, risk and precipitating factors
Most elderly patients will have multiple risk factors making them
more susceptible to delirium (see Table 2). Vulnerability is also increased when multiple precipitating factors are present, or if the
The DSM-IV-TR stipulates that, as well as matching the definition,
precipitating insult is particularly severe. It is impossible to list all
patients must have the following clinical features:
of the conditions and stressors that may precipitate delirium, but
1. Disturbance of consciousness. A reduced ability to focus, the most common (and most relevant to an elderly population) are
listed in Table 3. Delirium is often the only sign of an underlying
serious medical illness in an elderly patient and, therefore,
2. A change in cognition or perceptual disturbance including particular attention should be made to identifying and correcting
disorientation and language disturbance. 3. The above features develop over hours to days and fluctuate
table 2: Common Risk Factors for Delirium non Correctable
There are many other features that can be associated with
delirium and these are described in Table 1. It is also worth
remembering that frank delirium can be preceded by a period
Mild Cognitive Impairment, Dementia, Parkinson>s Disease
of prodromal illness (normally 1-3 days), where the patient may
appear impatient, anxious, restless, distracted, develop urinary
incontinence or start refusing investigations. In hindsight, family members are able to give a history of this prodromal period but it
is very difficult to detect clinically. Elderly patients with delirium
often do not look ill apart from the behavioural changes. Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.Correctable
the acute decline in cognition that needs to be taken into account during cognitive screening assessments. Studies show that 30%
Hearing impairment or visual impairment indicates a threefold
to 67% of patients with delirium go undetected.18, 24 Detection
can be improved by implementing cognitive testing and screening
Malnutrition, dehydration, low albumin. Associated with a
instruments, accompanied by educational programmes for staff.25
The MMSE is the most widely used instrument to test cognitive
Social Isolation, sleep deprivation, new environment, moves
function. Although it is used in the setting of delirium, it was not
designed for this purpose. To detect delirium, it is necessary to
know the patients baseline function and engage the patient in
New addition of three or more medications
repeat testing throughout their illness. This may be effective in
certain high-risk situations (i.e. post hip fracture) but further
evaluation is needed.26 A drop of >2 points from baseline indicates delirium, whilst an improvement of 3 points or more indicates
The Australian Society for Geriatric Medicine, The American
Uraemia, blood urea >10 is an independent risk factor.22
Psychiatric Association and The British Geriatrics Society
all recommend the Confusion Assessment Method (CAM), a
Prolonged hospital stay, increased risk after 9 days.5
screening tool specifically designed to detect delirium (see Table 4). This has reported sensitivity of >94%, specificity of >90% and
is easy to use in a clinical setting. Again the patient should be reassessed throughout their hospital stay to monitor progress.14
table 3: Precipitating Factors precipitating factors table 4: Confusion assessment Method (CAM) Confusion assessment Method (CaM) 1. acute onset and fluctuating course
• Is there evidence of change in cognition from baseline?
Electrolyte disturbance (sodium, calcium, magnesium, phosphate)
Endocrine disturbance (Blood sugar, thyroid)
Nutritional deficiencies (thiamine, B12, folate)
• Does the patient have difficulty focusing attention?
Pulmonary disorders (particularly in the setting of hypoxemia)
3. Disorganised thinking
• Does the patient have disorganised thinking, rambling
Post surgery, especially cardiac, orthopaedic or with ICU stay
4. altered level of consciousness
• Alert, hyper alert, lethargic or drowsy, stupor, coma
All patients must have 1 and 2 with either 3 or 4 to diagnose
Adapted from Harrisions Online, Chapter 26. Confusion and Delirium, McGraw-Hill Companies. Accessed February 2009. recognising patients with delirium
When a patient with confusion is admitted to hospital, they
The third assessment tool worth noting is the Delirium Rating
should be presumed to have delirium until proven otherwise. A
Scale (DRS). It covers a range of symptoms relating to delirium,
collaborative history from family or carers is essential to establish
not only useful for diagnostic purposes, but for assessing severity
Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.
and distinguishing delirium from other disorders. Although
It is important to differentiate between delirium, dementia
accurate, it is more complex than the CAM, requires specialist
and depression. Lewy Body Dementia, with its hallucinations and
trained Psychiatrists or Geriatricians and has mainly been used
fluctuations is a classic example, whilst 42% of patients referred to
psychiatric services for depression actually have delirium.28 Table 5 summarises the main differences. table 5: Differentiating between Delirium, Dementia and Depression Delirium Dementia Depression Consciousness attention Thinking perception
MMSE: Mini Mental State examinationAdapted from Milsen K et al. Nurs Clin N Am. 2006; 41: 1-22
prevention of delirium
that the approach to prevention needs to be multifactorial. The landmark study conducted by Inouye in 1999,29 and other
Prevention can be divided into primary, secondary and tertiary.
prevention studies,30, 31, 32 have demonstrated that delirium can
Primary prevention strategies are aimed at reducing the incidence
be prevented or at least moderated by addressing modifiable risk
of delirium. Given that delirium is a complex medical problem
factors. This reflects a humanistic, compassionate approach to
resulting from one or more variables involving body systems in
management based on high quality nursing and medical care (see
addition to environmental factors, as delineated above, it follows
table 6: Delirium Prevention Strategies Environmental strategies Clinical practice strategies orientation to time Ensure function is optimised
• room with an unobstructed view to the outside world
• lighting appropriate to the time of day
• provision of a clock and calendar suitable for an individual’s • encourage independence in activities of daily living
• dentures and dental appliances well fitted and in place• encourage and assist if necessary to ensure adequate hydration
• monitor and regulate bowel function • promote relaxation and sufficient sleep
Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.orientation to place facilitate communication
• avoid frequent room changes and keep room changes to a • hearing aids
• encourage family and carer’s to bring in personal and familiar • interpreters and communication aids
• dentures and dental appliances well fitted and in place
orientation to people Ensure culturally sensitive approach
• encourage family and carer involvement by facilitating • awareness and respect of cultural and religious sensitivities
• Orientate to personnel providing name and role
• single room to minimise disturbance of personnel attending • Manage reduce discomfort and pain using nonpharmacological
to other patients at any time of the night and day
• reduce incident noise especially, unpredictable sounds e.g. • minimise invasive procedures e.g. indwelling catheters; IV
buzzers, alarmed medication delivery devices, televisions,
• address issues exacerbating emotional distress
• Reduce exposure to activity/stimulation e.g. Unavoidable
disturbance if nursed in an acute environment where the likelihood of resuscitation, urgent intervention is likely
• Facilitate undisturbed sleep at night• Avoid sleep deprivation
provide routine Minimise perception of threat
• train personnel to use calm, confident manner keeping voice
• Meal times at regular intervals and times
• activities such as personal care at regular times
Caution with medication
• review and minimise medication• avoid psychoactive drugs• avoid anticholinergic drugs• take careful drug and substance history and anticipate
withdrawal syndromes from alcohol, nicotine, benzodiazepines, narcotics
Anticipate, prevent, identify and treat medically reversible problems• screen high risk patients with a validated instrument e.g.
• thorough physical examination• dehydration• malnutrition• electrolyte abnormalities• hypoalbuminaemia• anaemia• renal impairment• urinary retention• depression
Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.
Secondary prevention requires optimal clinical management
table 7: Investigation of the delirious patient
at the time of delirium and will be addressed below in the
Tertiary prevention strategies require identification of previous
episodes of delirium by taking a careful history to recognise high-
risk individuals. A randomised placebo-controlled trial using low dose haloperidol in elderly hip-surgery patients at risk of delirium
showed that although there was no difference in the incidence
of delirium, the severity and duration of delirium, and length of
investigation of the delirious patient
Delirium is generally at least partially reversible if the cause of
the delirium can be identified and treated promptly. Investigation
Targeted investigations as Electrocardiogram
of a patient presenting with an acute confusional state should
informed by the history Post void residual bladder scan
• Thorough history including: alterations to sleep-wake cycle,
nutrition, and recent misadventure including falls. It is
Further investigations to Thyroid function and thyroid be considered if no cause antibody tests
essential to access corroborative history from carers, family,
witnesses, access information including previous investigations
from doctors involved in the care of the patient, allied health
professionals, aged care assessment team members to establish
the sequence of events, identify likely precipitating factors, the
level of function and cognition prior to the presentation and if
there have been any previous episodes of suspected delirium in
• Review of medications including: medications taken prior to
presentation, new medications commenced or medications
ANA: Antinuclear Antibody; ENA: Extractable Nuclear
ceased, adherence to treatment. In addition it is important to
establish a substance use history including nicotine, ethanol, benzodiazepines, and other centrally acting drugs to identify
Current research is aimed at determining a biochemical marker
for delirium. In a recent study C-reactive protein was found to be useful not only to predict incidence of delirium but also recovery
• Thorough physical examination including: vital signs, postural
from it. These results need to be interpreted with caution pending
blood pressure measurement, pulse oximetry, urine analysis,
further investigation. C-reactive protein is well known to be a
blood sugar level, palpation of the bladder for urinary retention
marker of inflammation, however it “actual y captures only one specific
and body weight. The physical examination may need to be
aspect of inflammation, which is not necessarily the most relevant for
targeted and opportunistic in the context of a patient exhibiting
delirium and does not reflect all aspects of inflammation”.36
severe behavioural or emotional disturbance.
• Initially, investigations should be targeted at identifying
or ruling out common causes of delirium in addition to
non-pharmacological management of delirium
investigations targeted at issues arising from history and
Non-pharmacological strategies similar to the interventions
examination. (Table 7) If the cause of delirium is not identified
listed for prevention should be implemented whenever possible.
by this approach it may be necessary to conduct additional
Logically, if delirium is a multi-factorial problem, it follows that
investigations aimed at identifying less common causes.
multidisciplinary interventions are likely to provide most success
Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.
in management. Bergmann et al,37 have proposed a model or care
In patients with co-existing medical conditions where use of
for management of delirious patients in the acute setting with
dopamine antagonists are contraindicated, such as Lewy Body
a standardised approach involving “ four key steps: assessment of dementia and Parkinson’s Disease, low doses of risperidone can be delirium symptoms in new admissions, evaluation and treatment of tried with careful monitoring. reversible causes of delirium, prevention and management of common
Benzodiazepines are well recognised as appropriate treatment
complications of delirium, and restoration of cognitive and self-care for alcohol or drug withdrawal. In practice, benzodiazepines with function in delirious patients”. A randomised trial involving a a short half-life and no active metabolites, for example, lorazepam, multidisciplinary intervention encompassing: a standardised
oxazepam, or midazolam may be of benefit for patients with excessive
nursing intervention protocol, review by a geriatric specialist
anxiety symptoms, with severe agitation not responding to anti-
consultant and follow-up by an intervention nurse who liaised
psychotics, or when antipsychotic medication is contraindicated.14
with all team members compared with usual care, conducted
Benzodiazepine use can be associated with a worsening of
by Cole et al38 failed to demonstrate that multidisciplinary care
confusion and sedation. A Cochrane Review pertaining to the use
was more beneficial compared with usual care. A Cochrane
of benzodiazepines for delirium is pending.47
Systematic Review is currently pending.39 In the setting of delirium
multicomponent intervention directed at prevention of delirium is likely to have much greater impact than stratagems aimed at
Studies have shown that nearly half of patients with delirium
are discharged from the acute hospital setting with persistent symptoms and of these, 20-40% still have delirium at 12 months.48
pharmacological Management of Delirium
Longer term outcomes in these patients are consistently worse
Administration of pharmacological agents should be reserved
than in those patients who fully recover by point of discharge, and
for patients with severe agitation or behavioural disturbance
it is unknown whether these patients will ever recover.
who are at risk of interrupting essential medical care and risk of
It is essential to use a multidisciplinary team approach to
causing harm to them self or others. This strategy outweighs risk
discharge to ensure adequate support for patients and their carers.
associated with administration of the medication when symptoms
Ideally, there should be close communication between the hospital
team, primary care and the patients’ family or caregivers. Education
There are numerous guidelines available providing advice
should be provided on what to expect with regards to the patient’s
on approach to pharmacological management of delirium.2, 5, 11,
function and prognosis. The patient should have regular review
14, 21, 25, 26 Many institutions have developed their own protocols,
every few days in the community and minimum follow up should
procedures and guidelines adapted to local conditions.
Consensus opinion based on evidence from the literature
practical Key points
supports the use of antipsychotics for the treatment of delirium. Traditionally low dose haloperidol has been considered the drug
• Every elderly patient admitted with confusion should be
of choice as haloperidol is available in oral and parenteral dose
presumed to have delirium until proven otherwise.
forms, and has a lower incidence of adverse effects including
• Improve early detection using the CAM and serial cognitive
anticholinergic side effects, postural hypotension, and sedation
• Implement clinical guidelines, practice changes and education
when compared with other traditional antipsychotic agents.26
programmes for all medical, nursing and allied health staff.49, 50
A recent Cochrane review conducted a literature review and
• Education and support of families and carers is essential
metanalysis “comparing the efficacy and incidence of adverse effects • Ensure close follow up in the community and good
of haloperidol with risperidone, olanzapine and quetiapine in the
communication between hospital staff and primary care. treatment of delirium”.41 The authors concluded that there was no evidence that the atypical antipsychotics offered any advantage
over low dose haloperidol. Higher doses of haloperidol (more
1. Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders.
than 4.5mg per day) were associated with an increased incidence
4th edition. Text revision (DSM-IV-TR). American Psychiatric Association,
of adverse reactions, mainly extrapyramidal side effects. The
use of atypical antipsychotics remains controversial, as their
2. Brown TM, Boyle MF. ABC of Psychological medicine: Delirium. BMJ 2002;
administration has been associated with an increase in all cause
3. Harrison’s Online textbook. Chapter 26: Confusion and Delirium. McGraw-
mortality in the elderly population.42-46
Hill Companies. Accessed February 2009. Oman Medical Journal 2008, Volume 23, Issue 3, July 2008 Delirium in the Elderly . Wass et al.
4. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998;
30. Inouye SK. Prevention of delirium in hospitalised older patients: risk factors
and targeted intervention strategies. Ann Med 2000; 32:257.
5. Delirium Clinical guidelines Expert Working Group. Clinical practice Guidelines
31. Bonaventura M, Zanotti R. Effectiveness of IPD treatment for delirium
for the management of Delirium in Older People. Department of Health and Ageing
prevention in hospitalised elderly. A controlled randomised clinical trial. Prof
(Canberra) and Department of Human Services, Melbourne, Victoria. 2006.
6. Roche V. Etiology and management of delirium. Am J Med Sci 2003; 325:20-30.
32. Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for
7. Rahkonen T, Eloniemi-Sulkava U, Paanila S, Halonen P, Sivenius J, Sulkava R.
preventing delirium in hospitalised patients. Cochrane database Syst Rev
Systematic intervention for supporting community care of elderly people after a
delirium episode. Int Psychogeriatr 2001; 13:37-49.
33. Kalisvaart KJ, de Jonghe JFM, Bogaards MJ, Vreewijk R, Egberts TCG, Burger
8. Inouye SK. Delirium in Older Persons. NEJM 2006; 345:1157-1165.
BJ. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53:1658-1666.
9. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium
contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen
34. Schrader SLP, Wellik KE, Demaerschalk BM, Caselli RJ, Woodruff BK,
Wingerchuk DM. Adjuctive Haloperidol Prophylaxis Reduces Postoperative Delirium Severity and Duration in At-Risk Elderly Patients. The Neurologist
10. McCusker J, Cole M, Dendukuri N, Han L, Bedzile E. The course of delirium in
older medical inpatients: a prospective study. J Gen Intern Med 2003; 18:696-704.
35. Macdonald A, Adamis D, Treloar A, Martin F. C-reactive protein levels predict
11. Trzepacz P, Breitbart W, Franklin J, Levenson J, Martini DR, Wang P. Working
the incidence to delirium and recovery from it. Age & Ageing 2007; 36:222-225.
Group on Delirium: Practice Guidelines for the Treatment of Patients with delirium. American Psychiatric Association, 1999.
36. Speciale S, Bellelli G, Guerini F, Trabucchi M. C-reactive protein levels and
delirium in a rehabilitation ward (letter). Age & Ageing 2008; 37:122-123.
12. Maran JA, Dorevitch MI. Delirium in the hospitalized elderly. Aust J Hosp
37. Bergmann MA, Murphy KM, Kiely DK, Jones RN, Marcantonio ER. A Model
for Management of Delirious Postacute Care Patients. J Am Geriatr Soc 2005;
13. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical
in-patients: a systematic literature review. Age & Ageing 2006; 35:350-364.
38. Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ et
14. Australian Society for Geriatric Medicine Position Statement No. 13. Delirium
al. Systematic detection and multidisciplinary care of delirium in older medical
in Older people. www.anzsgm.org.au. Accessed February 2009.
inpatients: a randomised trial. CMAJ 2002; 167:753-759.
15. Andrew MK, Freter SH, Rockwood K. Incomplete functional recovery after
39. Britton AM, Hogan-Doran JJ, Siddiqi N. Multidisciplinary Team Interventions
delirium in elderly people: a prospective cohort study. BMC Geriatrics 2005; 5:5.
for the management of delirium in hospitalised patients (Protocol) Cochrane
16. Rockwood K. the occurrence and duration of symptoms in elderly patients with
delirium. J Gerontology 1993; 48:162-166.
40. Milisen K, Memiengre J, Braes T, Foreman MD. Multicomponent intervention
17. Rockwood K, Cosway S, Carver D, Jarrett P, Stadnyk K, Fisk J. The risk of
strategies for managing delirium in hospitalised older people: systematic review.
dementia and death after delirium. Age & Ageing 1999; 28:551-556.
Journal of Advanced Nursing 2005; 52:79-90.
18. O’Keeffe ST, Lavan JN. Clinical significance of delirium subtypes in older
41. Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium (Review).
people. Age & Ageing 1999; 28:115-119.
Cochrane Database of Syst Rev 2007; CD005594.
19. Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a
42. Kuehn BM. FDA warns antipsychotic drugs may be risky for elderly. JAMA
systematic review. J Am Geriatr Soc 2003; 51:1002.
20. Inouye SK. Prevention of delirium in hospitalized older patients: risk factors
43. Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH
and targeted intervention strategies. Ann Med 2000; 32:257-263.
et al. Risk of death in elderly users of conventional vs. atypical antipsychotic
21. Young J, Inouye SK. Delirium in Older People. BMJ 2007; 334:842-846.
medications. N Engl J Med 2005; 353:2335-2341.
22. O’Keeffe ST, Lavan JN. Predicting delirium in elderly patients; development
44. Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of
death associated with the use of conventional versus atypical antipsychotic drugs
and validation of a risk-stratification model. Age & Ageing 1996; 25:317-321.
among elderly patients. CMAJ 2007; 176:627-632.
23. Rudolph JL, Jones RN, Rasmussen LS, Silverstein JH, Inouye SK, Marcantonio
45. Raivo MM, Laurila JV, Strandberg TE, Tilvis RS, Pitkala KH. Neither atypical
ER. Independent vascular and cognitive risk factors for postoperative delirium.
nor conventional antipsychotics increase mortality or hospital admissions
among elderly patients with dementia: a two-year prospective study. Am J
24. Korevaar JC, van Munster BC, de Rooij SE. Risk factors for delirium in acutely
Geriatr Psychiatry 2007; 15:416-424.
admitted elderly patients; a prospective cohort study. BMC Geriatrics 2005; 5:6.
46. Setoguchi S, Wang PS, Brookhart MA, Canning CF, Kaci L, Schneeweiss S.
25. Meagher DJ. Regular review: Delirium: Optimizing management. BMJ 2001;
Potential causes of higher mortality in elderly users of conventional and atypical
antipsychotic medications. J Am Geriatr Soc 2008; 56:1644-1650.
26. Tropea J, Slee JA, Brand CA. Policy and Practice Update. Clinical practice
47. Lonergan ET, Luxenberg J, Areosa Sastre A, Wyller T. Benzodiazepines for
guidelines for the management of delirium in older people in Australia. Aust J
delirium (Protocol). Cochrane Database of Syst Rev 2007;CD006379.
48. Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital
27. Trzepacz PT. The delirium rating scale. Its use in consultation – liaison research.
patients: a systematic review of frequency and prognosis. Age & Ageing 2009;
28. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill
49. Tabet N, Hudson S, Sweeney V, Sauer J, Bryant C, Macdonald A, et al. An
elderly patients. Arch Intern Med 1995; 155:2459-2464.
education intervention can prevent delirium on acute medical wards. Age &
29. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D,
Holford TR, et al. A multicomponent intervention to prevent delirium in
50. Young LJ, George J. Do guidelines improve the process and outcomes in
hospitalised older patients. N Engl J Med 1999; 340:669-676.
delirium? Age & Ageing 2003; 32:525-528. Oman Medical Journal 2008, Volume 23, Issue 3, July 2008
Messages, Micro-targeting, and New Media Technologies Final draft of paper to be published in The Forum: A Journal of Applied Research in Contemporary Politics Volume 11, Issue No. 3 (October 2013), p. 429-435. Please note that this is a final draft submitted to The Forum, subject to slight last minute editing by The Forum. Consult the published version for exact quotations. This p
EVolUCiÓN dEl trataMiENto dE la EYaCUlaCiÓN Director del Instituto Andaluz de Sexología y Psicología (IASP) Resumen Hasta la aparición de los inhibidores de la fosfodiesterasa cinco —IPDE5—, la eficacia de la terapia sexual había sido superior al resto de las intervenciones —fármacos u otros aborda- jes—. El empleo de IPDE5 por millones de usuarios ha servido para que la indust