Studying delirium ================= * Martin G. Cole * Jane McCusker Stephen Anderson and Robert Hewko have raised 5 important issues, to which we have the following responses. First, in our study1 we included patients with delirium superimposed on dementia because dementia is the most common risk factor for delirium in elderly hospital patients2 and because most elderly hospital patients with delirium also have dementia.3 In our subgroup analysis, patients with delirium alone appeared to benefit more from the intervention, although this effect was not statistically significant. Second, we used the change in the MMSE score as our primary outcome measure because it is a reliable, valid, reasonably responsive and widely used measure of cognitive impairment, a core feature of delirium. Analysis of our secondary outcome measures (reported on page 757 of the article), the Delirium Index score (a measure of the severity of 7 delirium symptoms)4 and the Barthel Index score (a measure of basic self-care activities),5 yielded similar results. Third, we reported the results of our process of care analysis on the *CMAJ* Web site (as noted on page 755). Of course we are concerned that compliance with recommendations was not 100%. However, the rate of compliance with the consultants' recommendations in our study (about 70% for recommendations related to medications and investigations) was much higher than corresponding rates of compliance reported elsewhere.6,7 We attribute this modest success to the work of the intervention nurse, who encouraged compliance. Fourth, the pharmacologic treatment of symptoms of hyperactive delirium may involve the use of antipsychotic medication.8 However, there is no evidence that antipsychotics are useful in patients with hypoactive delirium.8 Our geriatric specialist consultants made a mean of 6 management recommendations per patient, including the appropriate use of medication. Antipsychotic medication was prescribed for 47% of patients in the intervention group and only 24% of those in the control group. Finally, we agree with Anderson and Hewko that our results should not alter current best management of delirium in elderly medical inpatients.8 Unfortunately, current best management means that in most elderly patients with delirium the condition goes undetected, and only half recover.8,9 Surely there should be continuing efforts to improve the treatment and outcomes of these patients.10 **Martin G. Cole** Professor of Psychiatry **Jane McCusker** Professor Department of Epidemiology and Biostatistics McGill University Montreal, Que. ## References 1. 1. Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 2002;167(7):753-9. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjcvNy83NTMiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY4LzUvNTQxLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 2. 2. Élie L, Cole M, Primeau F, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998;13:204-12. 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Treatment of delirium in elderly medical inpatients: a challenge for geriatric specialists. J Am Geriatr Soc 2002;50: 2101-3. [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12473034&link_type=MED&atom=%2Fcmaj%2F168%2F5%2F541.2.atom) [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000179747400034&link_type=ISI)