Reversible Bilateral Basal Ganglia Lesions Due to Multifactorial Toxic-Metabolic Disorders.

Bilateral basal ganglia lesions can include a wide variety of etiologies, including metabolic, toxic, degenerative, vascular, inflammatory, infectious, and neoplastic etiology. We present a case of a 78-year-old man who was hospitalized with acute behavioral changes and psychomotor slowing. His medical history included diabetes mellitus, arterial hypertension, and prostate adenocarcinoma. In his spare time, he was a pigeon fancier and regularly burned waste (including diapers) outside his home. In the initial evaluation, he was hypertensive, drowsy, disoriented in time and space, dysarthric, and with global bradykinesia. From the research carried out, we stand out the following: brain magnetic resonance imaging showing bilateral hyperintensity of the basal ganglia on T2/fluid-attenuated inversion recovery, with foci of hypersignal on T1 without diffusion restriction or contrast enhancement; CSF presenting 15 cells/uL, without other alterations; analytical results presenting hypernatremia (171 mEq/L), creatinine at 3.5 mg/dL, hyperglycemia (always <300 mg/dL), and slightly elevated C-reactive protein and anticardiolipin antibodies in addition to thrombocytopenia (107,000). After correcting the metabolic disturbances and evading the identified toxic substances, magnetic resonance imaging showed regression of the lesions, and the patient returned to a normal state. The functions of the basal ganglia are complex, requiring increased use of glucose and oxygen, therefore presenting a high metabolic activity, which makes them vulnerable to various metabolic changes. We report a rare case affected by symmetrical lesions in the basal ganglia and presenting an acute onset of altered mental status with behavioral alterations, related to hyperglycemia, acute kidney injury, hypertension, and exposure to toxic substances (smoke from bonfires and/or toxic chemical components). Complete clinical recovery, remaining negative investigation, and regression of the lesions support our diagnosis.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit.

Background: Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. Objective: A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Patients and methods: Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Results: Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Conclusion: Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU. How to cite this article: Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Pulmonary embolism presenting as delirium: an acute confusional state in an elderly patient-a case report.

Background: Large numbers of elderly patients are admitted to hospitals in acute confusional states. In many, the underlying causes are easily found; in some, correct diagnosis is difficult. Pulmonary embolism (PE), the most serious clinical presentation of venous thromboembolism, is often misdiagnosed because of its non-specific features including delirium. Case presentation: A 73-year-old woman was admitted to our hospital in a confused state with no obvious risk factors of PE. D-dimer levels were elevated and contrast-enhanced high-resolution computed tomography (HRCT) of the chest confirmed the diagnosis of PE. She was treated with enoxaparin and discharged on dabigatran. Her symptoms had resolved at the time of discharge, and she has been stable for over three month's follow-up visit. Conclusion: PE should be regarded as a differential in elderly patients with an acute confusional state despite the absence of obvious risk factors. Investigating for and treating when confirmed may save a life.

The occurrence of delirium diagnosis among youth hospitalizations in the United States: A Kids' Inpatient Database analysis.

OBJECTIVES: Delirium is an acute neuropsychiatric condition associated with increased morbidity and mortality. There is increasing recognition of delirium as a substantial health burden in younger patients, although few studies have characterized its occurrence. This study analyzes the occurrence of delirium diagnosis, its comorbidities, and cost among youth hospitalized in the United States. METHODS: The Kids' Inpatient Database, a national all-payers sample of pediatric hospitalizations in general hospitals, was examined for the year 2019. Hospitalizations with a discharge diagnosis of delirium among patients aged 1-20 years were included in the analysis. RESULTS: Delirium was diagnosed in 43,138 hospitalizations (95% CI: 41,170-45,106), or 2.3% of studied hospitalizations. Delirium was diagnosed in a broad range of illnesses, with suicide and self-inflicted injury as the most common primary discharge diagnosis among patients with delirium. In-hospital mortality was seven times greater in hospitalizations caring a delirium diagnosis. The diagnosis of delirium was associated with an adjusted increased hospital cost of $8648 per hospitalization, or $373 million in aggregate cost. CONCLUSIONS: Based on a large national claims database, delirium was diagnosed in youth at a lower rate than expected based on prospective studies. The relative absence of delirium diagnosis in claims data may reflect underdiagnosis, a failure to code, and/or a lower rate of delirium in general hospitals compared with other settings. Further research is needed to better characterize the incidence and prevalence of delirium in young people in the hospital setting.

Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge.

Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.

Patient Profile and Management of Delirium in Older Adults Hospitalized Due to COVID-19.

SARS-CoV-2 can cause neurologic symptoms, as well as respiratory ones. Older adults are at risk of developing acute delirium in older persons (ADOP). The combination of experiencing respiratory isolation due to COVID-19, as well as other associated risk factors for older adults, may have had an impact on ADOP and ADOP management in the acute hospital setting. This study aimed to analyze the characteristics of ADOP in patients admitted to a COVID-19 unit. An observational prospective study on a sample of 108 patients was carried out between November 2020 and May 2021. The following data were collected: sociodemographic characteristics, risk factors for ADOP, management of ADOP, and impact on ADOP on both functional and cognitive deterioration. A 29.6% proportion of older adults admitted to an acute COVID-19 unit presented hyperactive ADOP, mainly during the night. Management of ADOP in our sample involved mainly pharmacological treatment and had a serious impact on hospital stay and both functional and cognitive deterioration. Preventive strategies and being accompanied by a relative or a carer may be useful to manage ADOP during hospital admission due to COVID-19.

Delirium in geriatric patients.

Delirium is the most common acute disorder of cognitive function in older patients. Delirium is life threatening, often under-recognized, serious, and costly. The causes are multifactorial, with old age and neurocognitive disorders as the main risk factors. Etiologies are various and multifactorial, and often related to acute medical illness, adverse drug reactions, or medical complications. To date, diagnosis is clinically based, depending on the presence or absence of certain features. In view of the multifactorial etiology, multicomponent approaches seem most promising for facing patients' needs. Pharmacological intervention, neither for prevention nor for treatment, has been proven effective unanimously. This article reviews the current clinical practice for delirium in geriatric patients, including etiology, pathophysiology, diagnosis, prognosis, treatment, prevention, and outcomes.

Lithium Intoxication in an Elderly Woman.

Acute confusional state or delirium in the elderly frequently requires a lengthy differential diagnosis in the emergency room (ER) to determine the factors of its multiple causes. Iatrogeny can be one of the causes, especially in elderly people with polypharmacy. We present a case of a 77-year-old female, independent in activities of daily living, with no cognitive impairment and a history of hypertension, dyslipidemia, and manic-depressive disorder. She arrived at the ER with diarrhea, vomiting, and myalgias. A blood test revealed an acute kidney injury. The patient was discharged with the diagnosis of acute gastroenteritis and prerenal acute kidney injury. The patient returned to the ER two days later due to worsening symptoms, including spatial and temporary disorientation and a marked prostration. The attending physician recommended a lithium blood level test due to the patient's history and the outpatient's psychiatric medication. The tests revealed a value of 2.18 mmol/L (toxic levels: >2.0 mmol/L). Support measures were initiated with diuresis control and vigorous hydration, with subsequent clinical and biochemical improvement (lithium blood levels reduced to 0.97 mmol/L). Lithium toxicity causes acute nausea, vomiting, diarrhea, and neurological symptoms that have a slower onset and correlate with chronic toxicity. A declining renal function and reduced volume of distribution (due to increased body fat mass and decreased total body water) contribute to more significant pharmacological toxicity in the elderly. In this case, dehydration triggered by diarrhea and vomiting may have been a cause or a consequence. Reviewing chronic medication and a detailed investigation of all etiological causes was essential for the patient's rehabilitation, avoiding possible irreversible neurological damage.

Neurosyphilis: The Great Imitator.

Syphilis is a sexually transmitted disease caused by spirochete Treponema pallidum, with a growing incidence documented in recent years. Its clinical course is divided into three phases - primary, secondary, and tertiary syphilis - and virtually any organ can be affected, resulting in diverse clinical manifestations, making the diagnosis challenging. Neurosyphilis is a progressive, destructive disease of the central nervous system (CNS) that can develop at any stage of the infection, leading to meningeal involvement, meningovascular disease, or parenchymal syphilis (including tabes dorsalis and general paresis). Its clinical manifestations are heterogeneous and vary from focal neurologic signs to neuropsychiatric manifestations. The diagnosis is based mainly on the clinical picture and study of cerebrospinal fluid. Neuroimaging is helpful and sometimes essential, with magnetic resonance imaging being the most sensitive radiologic method, although there are no pathognomonic radiologic signs. Treatment of all forms of neurosyphilis is based on parenteral penicillin. We present a case of neurosyphilis in a patient presenting with a subacute confusional state and initial imaging findings suggestive of metastatic CNS lesions.

Delirium disorder: Unity in diversity.

OBJECTIVE: The first objective of this review is to explore the factors that have led to and maintain the division between delirium and acute encephalopathy. The second is to explore the value of harmonizing them through the model of delirium disorder. METHOD: This narrative review outlines major distinctions between delirium and acute encephalopathy. It also compares them with the model of delirium disorder, which seeks not only to integrate them but also to offer a broader palette of treatment targets. RESULTS: Delirium implies an underlying acute encephalopathy, whereas acute encephalopathy presents as a spectrum from subsyndromal delirium to coma. Key factors that differentiate these two models include tradition, nuances of the models themselves, linguistic connotations, evoked responses from clinicians, implications of preventability and responsibility, cultural perceptions of non-pharmacological vs pharmacological interventions and economic incentives. A validated set of pathophysiological subtypes may ultimately help link the delirium-spectrum phenotype with various acute encephalopathies. CONCLUSIONS: Developing a coherent clinical and scientific approach to this set of conditions demands that we first develop a coherent understanding of the conditions themselves and how they relate to one another. Such an approach must embrace the tension between a convergent phenotype and its diverse biological underpinnings.

Impact of Acute Confusional State in Patients With COVID-19 and a Predictive Score.

BACKGROUND: Acute confusional state (ACS) in COVID-19 is shown to be associated with poor clinical outcomes. METHODS: We assessed the impact of ACS - defined as a documented deterioration of mental status from baseline on the alertness and orientation to time, place, and person - on inpatient mortality and the need for intensive care unit (ICU) transfer in inpatient admissions with active COVID-19 infection in a single-center retrospective cohort of inpatient admissions from a designated COVID-19 tertiary care center using an electronic health record system. Furthermore, we developed and validated a neurological history and symptom-based predictive score of developing ACS. RESULTS: Thirty seven out of 245 (15%) patients demonstrated ACS. Nineteen (51%) patients had multifactorial ACS, followed by 11 (30%) patients because of hypoxemia. ACS patients were significantly older (80 [70-85] years vs 50.5 [38-69] years, p < 0.001) and demonstrated more frequent history of dementia (43% vs 9%, p < 0.001) and epilepsy (16% vs 2%, p = 0.001). ACS patients observed significantly higher in-hospital mortality (45.9% vs 1.9%, aOR [adjusted odds ratio]: 15.7, 95% CI = 3.6-68.0, p < 0.001) and need for ICU transfer (64.9% vs 35.1%, aOR: 2.7, 95% CI = 1.2-6.1, p = 0.015). In patients who survived hospitalization, ACS was associated with longer hospital stay (6 [3.5-10.5] days vs 3 [2-7] day, p = 0.012) and numerically longer ICU stay (6 [4-10] days vs 3 [2-6] days, p = 0.078). A score to predict ACS demonstrated 75.68% sensitivity and 81.73% specificity at a cutoff of ≥3. CONCLUSION: A high prevalence of ACS was found in patients with COVID-19 in our study cohort. Patients with ACS demonstrated increased mortality and need for ICU care. An internally validated score to predict ACS demonstrated high sensitivity and specificity in our cohort.

Prevalence and clinical correlates of non-convulsive status epilepticus in elderly patients with acute confusional state: A systematic literature review.

Non-convulsive status epilepticus (NCSE) is a potentially treatable condition that poses considerable diagnostic challenges. NCSE is thought to be more common in the elderly than in the general population, however additional diagnostic challenges complicate its recognition in older patients, because of the wide differential diagnosis with common underlying causes of acute confusional state in this age group. We set out to review the existing evidence on the clinical correlates of NCSE in the elderly population. A systematic literature review was conducted according to the methodological standards outlined in the PRISMA statement to assess the clinical correlates of NCSE in patients aged 60 or older. Our literature search identified 11 relevant studies, which confirmed that the incidence of NCSE increases with age, in particular with regard to focal forms with impairment of consciousness. Female gender, history of epilepsy (or a recently witnessed seizure with motor features), and abnormal ocular movements appeared to correlate with the diagnosis of NCSE in the elderly, prompting prioritization of electroencephalography tests for diagnostic confirmation. Epidemiological data in the elderly vary widely because of the heterogeneity of definitions and diagnostic criteria applied across different studies. Based on our findings, it is recommended to keep a low threshold for requesting electroencephalography tests to confirm the diagnosis of NCSE in elderly patients with acute confusional state, even in the presence of a presumed symptomatic cause.

The role of electroencephalography in the early diagnosis of non-convulsive status epilepticus in elderly patients with acute confusional state: Two possible strategies?

Non-convulsive status epilepticus (NCSE) can pose considerable diagnostic challenges, especially in the elderly, because of the wide differential diagnosis with common underlying causes of acute confusional state in this age group. We reviewed the proposed electroencephalography (EEG) strategies to improve the diagnostic yield of non-convulsive status epilepticus in the elderly population. Specifically, a debated topic of clinical relevance is the exact role of the EEG in the early diagnosis of NCSE in the elderly. Two EEG strategies have been proposed to improve the diagnostic yield of NCSE: emergent abbreviated EEG (EAEEG) recordings with reduced montages, and continuous EEG (CEEG) monitoring. Both approaches appear to be potentially advantageous, but at the same time subject to intrinsic limitations. Our literature review found initial evidence that the diagnostic yield for NCSE of prolonged EEG recordings is superior to routine EEGs. Further research is needed to confirm these preliminary findings and to explore strategies to improve the feasibility of a more widespread use of prolonged recordings within acute clinical settings.

Mapping the Delirium Literature Through Probabilistic Topic Modeling and Network Analysis: A Computational Scoping Review.

BACKGROUND: Delirium is an acute confusional state, associated with morbidity and mortality in diverse medically-ill populations. Delirium is recognized, through both professional competencies and instructional materials, as a core topic in consultation psychiatry. OBJECTIVE: Conduct a computational scoping review of the delirium literature to identify the overall contours of this literature and evolution of the delirium literature over time. METHODS: Algorithmic analysis of all research articles on delirium indexed in MEDLINE between 1995 and 2015 using network analysis of citation Medical Subject Headings (MeSH) tags and probabilistic topic modeling of article abstracts. RESULTS: The delirium corpus included 3591 articles in 874 unique journals, of which 95 were primarily psychiatric. The annual delirium publication volume increased from 40 in 1995 to 420 in 2015 and grew as a proportion of total indexed publications from 8.9 to 38.6 per 100,000. The psychiatric journals published 720 of the delirium publications. Articles on treatment of delirium (806) outnumber articles on prevention of delirium (432). Abstract topic modeling and Medical Subject Headings graph community analysis identified similar genres in the delirium literature, including: delirium in geriatric, critically ill, palliative care, and postsurgical patients as well as diagnostic criteria or scales, and clinical risk factors. The genres identified by topic modeling and community analysis were distributed unevenly between psychiatric journals and nonpsychiatric journals. CONCLUSION: The delirium literature is large and growing. Much of this growth is outside of psychiatric journals. Subtopics of the delirium literature can be algorithmically identified, and these subtopics are distributed unevenly across psychiatric journals.

Incidence and risk factors of delirium in patients with acute ischaemic stroke

@#Background & Objectives: The reported incidence of post-stroke delirium varies substantially in current medical literature. The impact of delirium on mortality and morbidity is significant and there is need for sustained research on the topic. We aimed to determine the incidence, risk factors and outcome of delirium in acute ischaemic stroke. Methods: We conducted a cross-sectional observational study on consecutive patients with ischaemic stroke. The Confusion Assessment Method was used to diagnose delirium within seven days of stroke onset. Results: Two hundred and eighty patients were recruited (mean age 63.6 years) and 36 (12.9%) developed delirium. After adjustments for covariates, age >65 years (odds ratio, OR 5.2; 95% confidence interval 1.6-17.5); pre-existing dementia (6.5; 1.1-38.2); TACI (7.2; 1.5-35); and a National Institute of Health Stroke Scale of ≥10 (6.8; 1.7-26.4), were independently associated with a risk of developing delirium. Lacunar infarcts were not associated with delirium (0.07; 0.03-0.16). The majority of patients with delirium were cared for in a dedicated stroke unit but this proportion was not significant compared to those without delirium (69.4% vs 58.2%, p=0.20). Delirious patients had significantly higher in-patient mortality (8.3% vs 0%, p=0.002) and longer length of hospital stay (6.94 vs 3.98 days, p< 0.001). Conclusions: One in 8 patients with ischaemic stroke in our centre developed delirium. Older age, pre-existing dementia and severe stroke were independent predictors of delirium. Patients with lacunar infarcts did not develop delirium as often as those with other stroke types. Delirium significantly increased in-patient mortality and length of hospital stay.

Delirium and Psychotic Symptoms Associated with Hyperglycemia in a Patient with Poorly controlled Type 2 Diabetes Mellitus.

Delirium, acute confusional states, and secondary psychosis have been associated with several medical conditions, including endocrine disorders. In the context of diabetes mellitus (DM), it has been mostly related to hypoglycemia and rarely occurs in association with hyperglycemia, outside of the context of a hyperglycemic hyperosmolar state or diabetic ketoacidosis. Here, we describe a case of delirium and psychotic symptoms associated with hyperglycemia in a patient with poorly controlled Type 2 DM as an attempt to alert clinicians to this rare association. We also review the pathophysiological mechanisms that might lead to the onset of delirium in the context of hyperglycemia.

Louis Delasiauve (1804-1893), an alienist at the dawn of epileptology and pediatric psychiatry.

This paper aims to honor the memory of the alienist Louis Delasiauve (1804-1893). His classification of the different types of epilepsy based on clinical symptoms is still relevant today and made him a precursor of contemporary epileptology. In 1851, Delasiauve clinically and etiologically isolated 'acute mental confusion' (acute confusional state) from all other forms of dementia. Never deviating from his republican and progressive ideals, he devoted himself throughout the 19th century to treating those insane asylum patients who received the poorest care: epileptics and children with intellectual disabilities. Studying functional cognitive disability as well as mental disability secondary to congenital malformations, Delasiauve developed a novel specific form of pedagogy to deal with delays in cognitive development. This made him one of the initiators of institutional pediatric psychiatry. His ideas would be carried forward by his favorite student, Désiré-Magloire Bourneville (1840-1909). Committed to social welfare, Delasiauve worked relentlessly to improve access to healthcare for the least fortunate throughout France. As a passionate supporter of universal, free and secular education, he participated in a major movement away from religious establishments that involved opening a public school in every French canton.

Emergency electroencephalogram: Usefulness in the diagnosis of nonconvulsive status epilepticus by the on-call neurologist. / Uso de la electroencefalografía urgente por el neurólogo de guardia: utilidad en el diagnóstico del estatus epiléptico no convulsivo.

INTRODUCTION: We aim to describe the use of emergency electroencephalogram (EmEEG) by the on-call neurologist when nonconvulsive status epilepticus (NCSE) is suspected, and in other indications, in a tertiary hospital. SUBJECTS AND METHODS: Observational retrospective cohort study of emergency EEG (EmEEG) recordings with 8-channel systems performed and analysed by the on-call neurologist in the emergency department and in-hospital wards between July 2013 and May 2015. Variables recorded were sex, age, symptoms, first diagnosis, previous seizure and cause, previous stroke, cancer, brain computed tomography, diagnosis after EEG, treatment, patient progress, routine control EEG (rEEG), and final diagnosis. We analysed frequency data, sensitivity, and specificity in the diagnosis of NCSE. RESULTS: The study included 135 EEG recordings performed in 129 patients; 51.4% were men and their median age was 69 years. In 112 cases (83%), doctors ruled out suspected NCSE because of altered level of consciousness in 42 (37.5%), behavioural abnormalities in 38 (33.9%), and aphasia in 32 (28.5%). The EmEEG diagnosis was NCSE in 37 patients (33%), and this was confirmed in 35 (94.6%) as the final diagnosis. In 3 other cases, NCSE was the diagnosis on discharge as confirmed by rEEG although the EmEEG missed this condition at first. EmEEG performed to rule out NCSE showed 92.1% sensitivity, 97.2% specificity, a positive predictive value of 94.6%, and a negative predictive value of 96%. CONCLUSIONS: Our experience finds that, in an appropriate clinical context, EmEEG performed by the on-call neurologist is a sensitive and specific tool for diagnosing NCSE.

Characterizing and predicting rates of delirium across general hospital settings.

OBJECTIVE: To better understand variation in reported rates of delirium, this study characterized delirium occurrence rate by department of service and primary admitting diagnosis. METHOD: Nine consecutive years (2005-2013) of general hospital admissions (N=831,348) were identified across two academic medical centers using electronic health records. The primary admitting diagnosis and the treating clinical department were used to calculate occurrence rates of a previously published delirium definition composed of billing codes and natural language processing of discharge summaries. RESULTS: Delirium rates varied significantly across both admitting diagnosis group (X210=12786, p<0.001) and department of care (X26=12106, p<0.001). In both cases obstetrical admissions showed the lowest incidences of delirium (86/109764; 0.08%) and neurological admissions the greatest (2851/25450; 11.2%). Although the rate of delirium varied across the two hospitals the relative rates within departments (r=0.96, p<0.001) and diagnostic categories (r=0.98, p<0.001) were consistent across the two institutions. CONCLUSIONS: The frequency of delirium varies significantly across admitting diagnosis and hospital department. Both admitting diagnosis and department of care are even stronger predictors of risk than age; as such, simple risk stratification may offer avenues for targeted prevention and treatment efforts.

Stroke severity predicts poststroke delirium and its association with dementia: Longitudinal observation from a low income setting.

OBJECTIVE: The effect of delirium on stroke outcome has not been quantified in sub-Saharan Africa. We investigated the prevalence of delirium occurring within one week of stroke in Nigerian survivors and its association with dementia and mortality at 3months. METHODS: Delirium was ascertained after repeated assessments within one week of stroke using the Confusion Assessment Method. Demographic and clinical characteristics, stroke severity, current and pre-morbid cognitive functioning were also assessed. Participants were then followed up for 3months using culturally-validated neuropsychological tools. Probable dementia was ascertained according to the National Institute of Neurological Disorders and Stroke (NINDS-AIREN) criteria. Associations were investigated using both binomial and multinomial logistic regression analyses and presented as odds ratios (O.R) and relative risk ratios (RRR). RESULTS: Of 101 consenting stroke survivors, 99 had two assessments for delirium within one week of the stroke. Delirium was present in 33.3% of stroke survivors (65.6% hypoactive, 21.9% hyperactive, and 12.1% mixed type). Having a severe stroke was associated with delirium (O.R=6.2, 95% C.I=1.1-13.8) after adjusting for age, gender, education and economic status, lifestyle factors, multimorbidities and laterality. At follow-up, those with severe stroke had a stronger association between delirium and dementia (RRR=4.3, 95% C.I=1.2-15.6) or death (RRR=3.7, 95% C.I=1.1-12.1). CONCLUSION: Delirium, in this sub-Saharan African sample, was already present in about one-third of survivors within one week of stroke. Survivors of severe stroke are at higher risk of delirium and its complications, and could be important target for delirium preventive interventions.