218
Letter to the Editor n = 118
FTD
Controls
With suicidal behaviours
10
3
13
Without suicidal behaviours
49
56
105
defined target population, the risk of selection bias and the difficulty to ascertain cause and effect because of the several confounding factors. Nevertheless, our data suggest a relevant association between FTD and suicide that can be addressed later by a prospective study.
Conflict of Interest 59
59
118
None declared.
odds ratio = 3.810
Figure 1 Calculation of the odds ratio.
dysfunction of patients with depression adding to the risk of suicide or self-harm. The 84-year-old patient mentioned earlier alerts that the initial symptom of FTD can be a behavioural act with a fatal outcome. Why this is so remains unclear. However, we can argue that the severity of the FTD-related brain changes can precipitate such a self-harm behaviour through impulsiveness, as discussed previously. Study limitations Retrospective studies have several known limitations. However, our topic seemed appropriate for such a study because we had few patients and there are few specialised units and articles addressing this issue. The specific limitations of our study included collecting data from past medical records, a poorly
References Neary D et al. 2005. Frontotemporal dementia. Lancet Neurol 4: 771–80. Knibb J et al. 2006. Frontotemporal dementia. Curr Opin Neurol 19: 565–571. Haw C et al. 2009. Dementia and suicidal behaviour: a review of the literature. Int Psychogeriatr 21: 3,440–453. Mann J. Neurobiology of suicidal behaviour. Nature Reviews|Neuroscience. Volume 4. October 2003. Rogers M et al. 2004. Executive and prefrontal dysfunction in unipolar depression: a review of the neuropsychological and imaging evidence. Neurosci Res 50: 1–11.
LUÍS FONSECA1,2*, JOAQUIM DUARTE3, ÁLVARO MACHADO4, IOANNIS SOTIROPOULOS2, CARLOS LIMA1 AND NUNO SOUSA2 1 Department of Psychiatry, Centro Hospitalar do Alto Ave, Guimarães, Portugal 2 Department of Neurosciences, Life and Health Sciences Research Institute, Braga, Portugal 3 Department of Psychiatry, Hospital de Braga, Braga, Portugal 4 Department of Neurology, Hospital de Braga, Braga, Portugal *Email: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4000
Diagnosis of delirium in older people De Lange and colleagues (2013) published an interesting review of delirium in older people. They made an exhaustive literature search and found several studies. I had not detected in reviewing 710 keydelirium articles. I would appreciate the authors' comments on several concerns: (i) Were hearing tests such as the whisper test employed prior to testing attention, memory, orientation and executive function? In my review of 710 key delirium articles, hearing testing is recorded in the methods section in less than 2%. Elderly people who cannot hear a Copyright # 2014 John Wiley & Sons, Ltd.
question seldom ask for clarification – instead, they answer the question they suspect was asked. (ii) When hearing was impaired despite hearing aids, did the investigators use an additional device such as a portable amplifier with headphones? This battery-powered instrument weighs 60 g and costs around 100 euros or 100 US dollars. Only 1.26% of the 710 articles I surveyed used portable amplifiers. (iii) Could the authors split Table 1 into two analyses: community-dwelling elderly people surveyed at home and community-dwelling elderly people surveyed Int J Geriatr Psychiatry 2014; 29: 217–220
Letter to the Editor
during a hospital admission (excluding the most minor surgical procedures with a low rate of delirium and excluding admissions requiring intensive care)? (iv) Did the methods sections of the articles cited by De Lange describe how the investigators distinguished new onset from recurrent delusions, hallucinations, inattention, memory impairment, disorientation and executive dysfunction? I routinely interview family and other informants to distinguish old from new delirium features and collect past evaluations by psychiatrists, neuropsychologists, geriatricians, neurologists, occupational therapists and general practitioners. I regard this as putting humanity back into medicine – the emphasis is on the patient and family rather than the magnetic resonance imaging scan result. (v) Did the studies cited by de Lange report the reversibility of delirium cases? In our prospectiverandomised controlled trial, Clinical Trials. gov NCT01650896 Central Coast Australia Delirium Intervention Study, the 5-Digit Span Forward reverses most quickly followed by the 6-Digit Span Forward and delirium index. New psychotic features are often the slowest components to reverse (Regal, 2013a). Distinguishing behavioural and psychological symptoms of dementia from delirium depends greatly on full
219
reports from family and informants (Regal, 2013b). (vi) In Table 2, 230 (0.41%) of the 55 833 subjects reported as long-term care residents were from geriatric unit. I suggest that these subjects be excluded from Table 2. References De Lange E, Verhaak PFM, van der Meer K. 2013. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. Int J Geriatr Psychiatry 28: 127–134. Regal P. 2013a. Confusion Assessment Method (CAM) Indicators when CAM positivity in 647 patients has good outcome. J Am Ger Soc 61: 173. Regal PJ. 2013b. Delirium admissions in dementia. JAMA Intern Med 173: 597.
PAUL REGAL Geriatric Medicine, Wyong Hospital, Hamlyn Terrace, New South Wales, Australia *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4004
Reply to colleague Regal Thanks for your reaction to our publication on delirium. We appreciate that you read our study meticulously and pointed out problems that make the comparison between the studies included in our review even more difficult. We will give a reaction on your separate questions. (1) and (2) Your remarks on the influence of hearing capacity in older people on the outcome of cognitive tests/delirium diagnosis are very noteworthy. We do not recollect any of the methods sections mentioning anything about hearing, and we are sure nobody mentioned the use of amplifiers. Cacchione et al. (May and November 2003) found hearing deficit to be a factor associated with acute confusion, but we find no description of the use of amplifiers to rule out hearing deficit directly influencing the test result. You suggest that the accuracy of delirium diagnosis is Copyright # 2014 John Wiley & Sons, Ltd.
influenced by poor hearing. This is well imaginable. We would be interested if there was any literature on the significance of the influence of poor hearing on test results such as the Mini Mental State Examination and the Confusion Assessment Method (3) Could the authors split Table 1 into two analyses? Community-dwelling elderly surveyed at home and community-dwelling elderly surveyed during a hospital admission (excluding the most minor surgical procedures with a low rate of delirium and excluding admissions requiring intensive care). This point is partly covered by the division in Table 1 between point prevalence (all cross-sectional) studies, corresponding with ‘surveyed at home’, and the period prevalence (retrospective) studies, corresponding with incident cases of delirium (partly) found at hospital admission. It is clear that the ‘surveyed at home’ studies Int J Geriatr Psychiatry 2014; 29: 217–220
Letter to the Editor n = 118
FTD
Controls
With suicidal behaviours
10
3
13
Without suicidal behaviours
49
56
105
defined target population, the risk of selection bias and the difficulty to ascertain cause and effect because of the several confounding factors. Nevertheless, our data suggest a relevant association between FTD and suicide that can be addressed later by a prospective study.
Conflict of Interest 59
59
118
None declared.
odds ratio = 3.810
Figure 1 Calculation of the odds ratio.
dysfunction of patients with depression adding to the risk of suicide or self-harm. The 84-year-old patient mentioned earlier alerts that the initial symptom of FTD can be a behavioural act with a fatal outcome. Why this is so remains unclear. However, we can argue that the severity of the FTD-related brain changes can precipitate such a self-harm behaviour through impulsiveness, as discussed previously. Study limitations Retrospective studies have several known limitations. However, our topic seemed appropriate for such a study because we had few patients and there are few specialised units and articles addressing this issue. The specific limitations of our study included collecting data from past medical records, a poorly
References Neary D et al. 2005. Frontotemporal dementia. Lancet Neurol 4: 771–80. Knibb J et al. 2006. Frontotemporal dementia. Curr Opin Neurol 19: 565–571. Haw C et al. 2009. Dementia and suicidal behaviour: a review of the literature. Int Psychogeriatr 21: 3,440–453. Mann J. Neurobiology of suicidal behaviour. Nature Reviews|Neuroscience. Volume 4. October 2003. Rogers M et al. 2004. Executive and prefrontal dysfunction in unipolar depression: a review of the neuropsychological and imaging evidence. Neurosci Res 50: 1–11.
LUÍS FONSECA1,2*, JOAQUIM DUARTE3, ÁLVARO MACHADO4, IOANNIS SOTIROPOULOS2, CARLOS LIMA1 AND NUNO SOUSA2 1 Department of Psychiatry, Centro Hospitalar do Alto Ave, Guimarães, Portugal 2 Department of Neurosciences, Life and Health Sciences Research Institute, Braga, Portugal 3 Department of Psychiatry, Hospital de Braga, Braga, Portugal 4 Department of Neurology, Hospital de Braga, Braga, Portugal *Email: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4000
Diagnosis of delirium in older people De Lange and colleagues (2013) published an interesting review of delirium in older people. They made an exhaustive literature search and found several studies. I had not detected in reviewing 710 keydelirium articles. I would appreciate the authors' comments on several concerns: (i) Were hearing tests such as the whisper test employed prior to testing attention, memory, orientation and executive function? In my review of 710 key delirium articles, hearing testing is recorded in the methods section in less than 2%. Elderly people who cannot hear a Copyright # 2014 John Wiley & Sons, Ltd.
question seldom ask for clarification – instead, they answer the question they suspect was asked. (ii) When hearing was impaired despite hearing aids, did the investigators use an additional device such as a portable amplifier with headphones? This battery-powered instrument weighs 60 g and costs around 100 euros or 100 US dollars. Only 1.26% of the 710 articles I surveyed used portable amplifiers. (iii) Could the authors split Table 1 into two analyses: community-dwelling elderly people surveyed at home and community-dwelling elderly people surveyed Int J Geriatr Psychiatry 2014; 29: 217–220
Letter to the Editor
during a hospital admission (excluding the most minor surgical procedures with a low rate of delirium and excluding admissions requiring intensive care)? (iv) Did the methods sections of the articles cited by De Lange describe how the investigators distinguished new onset from recurrent delusions, hallucinations, inattention, memory impairment, disorientation and executive dysfunction? I routinely interview family and other informants to distinguish old from new delirium features and collect past evaluations by psychiatrists, neuropsychologists, geriatricians, neurologists, occupational therapists and general practitioners. I regard this as putting humanity back into medicine – the emphasis is on the patient and family rather than the magnetic resonance imaging scan result. (v) Did the studies cited by de Lange report the reversibility of delirium cases? In our prospectiverandomised controlled trial, Clinical Trials. gov NCT01650896 Central Coast Australia Delirium Intervention Study, the 5-Digit Span Forward reverses most quickly followed by the 6-Digit Span Forward and delirium index. New psychotic features are often the slowest components to reverse (Regal, 2013a). Distinguishing behavioural and psychological symptoms of dementia from delirium depends greatly on full
219
reports from family and informants (Regal, 2013b). (vi) In Table 2, 230 (0.41%) of the 55 833 subjects reported as long-term care residents were from geriatric unit. I suggest that these subjects be excluded from Table 2. References De Lange E, Verhaak PFM, van der Meer K. 2013. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. Int J Geriatr Psychiatry 28: 127–134. Regal P. 2013a. Confusion Assessment Method (CAM) Indicators when CAM positivity in 647 patients has good outcome. J Am Ger Soc 61: 173. Regal PJ. 2013b. Delirium admissions in dementia. JAMA Intern Med 173: 597.
PAUL REGAL Geriatric Medicine, Wyong Hospital, Hamlyn Terrace, New South Wales, Australia *E-mail: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4004
Reply to colleague Regal Thanks for your reaction to our publication on delirium. We appreciate that you read our study meticulously and pointed out problems that make the comparison between the studies included in our review even more difficult. We will give a reaction on your separate questions. (1) and (2) Your remarks on the influence of hearing capacity in older people on the outcome of cognitive tests/delirium diagnosis are very noteworthy. We do not recollect any of the methods sections mentioning anything about hearing, and we are sure nobody mentioned the use of amplifiers. Cacchione et al. (May and November 2003) found hearing deficit to be a factor associated with acute confusion, but we find no description of the use of amplifiers to rule out hearing deficit directly influencing the test result. You suggest that the accuracy of delirium diagnosis is Copyright # 2014 John Wiley & Sons, Ltd.
influenced by poor hearing. This is well imaginable. We would be interested if there was any literature on the significance of the influence of poor hearing on test results such as the Mini Mental State Examination and the Confusion Assessment Method (3) Could the authors split Table 1 into two analyses? Community-dwelling elderly surveyed at home and community-dwelling elderly surveyed during a hospital admission (excluding the most minor surgical procedures with a low rate of delirium and excluding admissions requiring intensive care). This point is partly covered by the division in Table 1 between point prevalence (all cross-sectional) studies, corresponding with ‘surveyed at home’, and the period prevalence (retrospective) studies, corresponding with incident cases of delirium (partly) found at hospital admission. It is clear that the ‘surveyed at home’ studies Int J Geriatr Psychiatry 2014; 29: 217–220
