Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The Meaning of Delirium

The Meaning of Delirium We read with interest the Invited Commentary by Vasilevskis and Ely1 entitled “The Danger of Delirium” on the article by Gross and colleagues2 evaluating delirium and long-term cognitive trajectories in patients with dementia. We agree with the authors' indication on the need to preserve the “functional integrity of the brain,” and we want to highlight the importance to identify the most appropriate means to reach this objective, since we still currently lack information on the pathological basis explaining the negative long-term effects of delirium. As stated by the authors,1 it is challenging to clarify if some of the mechanisms involved in delirium pathogenesis such as sepsis, hypotension, or polypharmacy act directly on cognitive outcomes or their effect is mediated by delirium itself. The question is relevant to the understanding of the pathophysiological construct of this syndrome because in the former condition delirium may be seen as a clinical sign accompanying the effect of different noxious stimuli, similarly to fever for pneumonia, whereas in the latter delirium may be regarded as an independent clinical condition with a direct biological effect. In addition, in the first case it could be hypothesized that treatment of delirium may have only a symptomatic value and does not play a critical role to improve the patients' cognitive and clinical conditions, whereas if delirium is a mediator of long-term consequences, its prevention could have a crucial role, synergic with the cure of the causative diseases. In the case of patients with dementia, the need to distinguish these 2 mutually exclusive pathways is of particular relevance owing to the criticism of prescribing drugs to control hyperactive symptoms of delirium (ie, antipsychotics), which may be harmful in patients with impaired brain and low cognitive reserve. These considerations are also of value in the perspective of educating physicians and nurses; in fact, as stated by the authors,2(p1329) [l]ack of recognition may be attributed . . . to the notion that delirium is unimportant . . . and has no long-term significance in patients with AD. We need to use existing data and develop further studies to convince the most reluctant colleagues not only on the “danger” but also on the “meaning” of delirium and its implications, especially in an understudied population such as subjects with dementia. Back to top Article Information Correspondence: Dr Bellelli, Department of Health Science, University of Milano-Bicocca and Geriatric Clinic, S. Gerardo Hospital, via Cadore 48, Monza, MB 20900, Italy (giuseppe.bellelli@unimib.it). Conflict of Interest Disclosures: None reported. References 1. Vasilevskis EE, Ely EW. The danger of delirium. Arch Intern Med. 2012;172(17):1331-133222911486PubMedGoogle ScholarCrossref 2. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172(17):1324-133123403619PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Loading next page...
 
/lp/american-medical-association/the-meaning-of-delirium-2b7Lq40OYV
Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.3293
Publisher site
See Article on Publisher Site

Abstract

We read with interest the Invited Commentary by Vasilevskis and Ely1 entitled “The Danger of Delirium” on the article by Gross and colleagues2 evaluating delirium and long-term cognitive trajectories in patients with dementia. We agree with the authors' indication on the need to preserve the “functional integrity of the brain,” and we want to highlight the importance to identify the most appropriate means to reach this objective, since we still currently lack information on the pathological basis explaining the negative long-term effects of delirium. As stated by the authors,1 it is challenging to clarify if some of the mechanisms involved in delirium pathogenesis such as sepsis, hypotension, or polypharmacy act directly on cognitive outcomes or their effect is mediated by delirium itself. The question is relevant to the understanding of the pathophysiological construct of this syndrome because in the former condition delirium may be seen as a clinical sign accompanying the effect of different noxious stimuli, similarly to fever for pneumonia, whereas in the latter delirium may be regarded as an independent clinical condition with a direct biological effect. In addition, in the first case it could be hypothesized that treatment of delirium may have only a symptomatic value and does not play a critical role to improve the patients' cognitive and clinical conditions, whereas if delirium is a mediator of long-term consequences, its prevention could have a crucial role, synergic with the cure of the causative diseases. In the case of patients with dementia, the need to distinguish these 2 mutually exclusive pathways is of particular relevance owing to the criticism of prescribing drugs to control hyperactive symptoms of delirium (ie, antipsychotics), which may be harmful in patients with impaired brain and low cognitive reserve. These considerations are also of value in the perspective of educating physicians and nurses; in fact, as stated by the authors,2(p1329) [l]ack of recognition may be attributed . . . to the notion that delirium is unimportant . . . and has no long-term significance in patients with AD. We need to use existing data and develop further studies to convince the most reluctant colleagues not only on the “danger” but also on the “meaning” of delirium and its implications, especially in an understudied population such as subjects with dementia. Back to top Article Information Correspondence: Dr Bellelli, Department of Health Science, University of Milano-Bicocca and Geriatric Clinic, S. Gerardo Hospital, via Cadore 48, Monza, MB 20900, Italy (giuseppe.bellelli@unimib.it). Conflict of Interest Disclosures: None reported. References 1. Vasilevskis EE, Ely EW. The danger of delirium. Arch Intern Med. 2012;172(17):1331-133222911486PubMedGoogle ScholarCrossref 2. Gross AL, Jones RN, Habtemariam DA, et al. Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med. 2012;172(17):1324-133123403619PubMedGoogle ScholarCrossref

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Apr 8, 2013

Keywords: delirium

References