Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study.

OBJECTIVES: To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS: A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS: Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION: The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Clinical utility of mild cognitive impairment subtypes and number of impaired cognitive domains at predicting progression to dementia: A 20-year retrospective study.

OBJECTIVE: To determine the utility of mild cognitive impairment (MCI) subtypes and number of impaired cognitive domains on initial assessment at predicting progression to dementia in a sample of memory clinic patients over a 20-year period. METHODS: A retrospective analysis was conducted of those presenting to a memory clinic with MCI from 1 January 1999 to 31 December 2018 inclusive. Those with MCI were broken down into one of the four subtypes using recommended cut-off scores on the Cambridge Cognitive Assessment (CAMCOG). Binomial logistic regression analysis was used to determine the utility of MCI subtypes and number of impaired cognitive domains as predictors for dementia. RESULTS: Overall 1188 individuals with MCI diagnosis were identified, with 378 (32%) progressing to dementia, with median [range] time to diagnosis of 2 years [1-8.4]. Six hundred and forty-nine (55%) were identified as amnestic MCI and 539 (45%) as non-amnestic MCI. Amnestic MCI was a significant predictor of progression compared to non-amnestic MCI (OR = 1.85, df = 1, P < .001). Number of cognitive domains impaired was also a significant predictor of progression to dementia (OR = 1.07, df = 1, P = .01) but the single-/multi-domain distinction was not (OR = 1.29, df = 1, P = .36). CONCLUSION: This study shows that approximately 32% of those diagnosed with MCI in a memory clinic progressed to dementia, with a median time to progression of 2 years. Those with amnestic MCI are almost twice as likely to progress to dementia than non-amnestic MCI and that therefore this is a useful distinction. However, the utility of the single- and multi-domain MCI distinction is called into question by our findings.

Is the Quick Mild Cognitive Impairment Screen (QMCI) more accurate at detecting mild cognitive impairment than existing short cognitive screening tests? A systematic review of the current literature.

OBJECTIVES: Differentiating normal cognition, mild cognitive impairment (MCI), and dementia is important, as these conditions differ in terms of their prognosis and treatment. Existing short cognitive screening tests vary widely in their accuracy, sensitivity, and specificity at detecting MCI and dementia. The Quick Mild Cognitive Impairment Screen (QMCI) was developed in 2012 as a fast and accurate "MCI specific" screening test. The aim of the current study was to conduct a literature review to compare the accuracy, sensitivity, and specificity of the QMCI at differentiating normal cognition, MCI, and dementia to existing short cognitive screening tests at their optimal cut-off scores. METHODS: A search of the electronic journal databases EBSCO, Psych info, and Science Direct was undertaken using the keywords "Quick Mild Cognitive Impairment Screen," "QMCI," "accuracy," "sensitivity," and "specificity." Results of individual studies were examined, and 2 × 2 tables were drawn up to obtain the overall accuracy, sensitivity, and specificity of each test across the studies included. RESULTS: Results from individual studies show that the QMCI has higher accuracy at detecting MCI and dementia than these cognitive screens. Pooled analysis shows that it also has greater sensitivity and specificity at optimal cut-off points for each test. CONCLUSIONS: Based in the current review, the QMCI represents a more accurate, sensitive, and specific screening test for MCI and dementia than the SMMSE or the MoCA. This has important implications in screening for cognitive impairment.

Developing a guidance resource for managing delirium in patients with COVID-19.

As the COVID-19 pandemic escalates worldwide, it is apparent that many patients with more severe illness will also experience delirium. These patients pose a particular challenge in the application of optimal care due to issues with infectious risk, respiratory compromise and potential interactions between medications that can be used to manage delirium with antiviral and other treatments used for COVID-19. We describe a guidance resource adapted from existing guidelines for delirium management that has been tailored to the specific challenge of managing delirium in patients with COVID-19 infection. Issues around the assessment and treatment of these patients are examined and distilled into a simple (one-paged guidance resource that can assist clinicians in managing suspected delirium.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients.

OBJECTIVES: To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN: Cross-sectional study. SETTING: International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS: 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES: Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS: Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS: This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

Associative and repetition priming with the repeated masked prime technique: no priming found.

Wentura and Frings (2005) reported evidence of subliminal categorical priming on a lexical decision task, using a new method of visual masking in which the prime string consisted of the prime word flanked by random consonants and random letter masks alternated with the prime string on successive refresh cycles. We investigated associative and repetition priming on lexical decision, using the same method of visual masking. Three experiments failed to show any evidence of associative priming, (1) when the prime string was fixed at 10 characters (three to six flanking letters) and (2) when the number of flanking letters were reduced or absent. In all cases, prime detection was at chance level. Strong associative priming was observed with visible unmasked primes, but the addition of flanking letters restricted priming even though prime detection was still high. With repetition priming, no priming effects were found with the repeated masked technique, and prime detection was poor but just above chance levels. We conclude that with repeated masked primes, there is effective visual masking but that associative priming and repetition priming do not occur with experiment-unique prime-target pairs. Explanations for this apparent discrepancy across priming paradigms are discussed. The priming stimuli and prime-target pairs used in this study may be downloaded as supplemental materials from mc.psychonomic-journals.org/content/supplemental.