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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 86-93

Clinical profile of acute confusional state in elderly patients in a tertiary hospital in western Rajasthan


Department of Medicine, Dr SN Medical College, Jodhpur, Rajasthan, India

Date of Submission23-Aug-2020
Date of Decision10-Oct-2020
Date of Acceptance23-Dec-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Khushboo Agarwal
Flat No 203, Real Orchid Apt, B141 Vijaypath Tilak Nagar, Jaipur 302 004, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_36_20

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  Abstract 


Context: Acute confusional state can be predisposed by preexisting chronic health conditions and drug/substance abuse or can be precipitated by acute insults such as infections and electrolyte imbalance. It is more common in the elderly population, and adverse outcomes include prolonged hospital stay and increased risk of complication or mortality. Aims: The aim of this study was to find out the clinical profile of confusional state in western Rajasthan. Settings and Design: This was a cross-sectional prospective design. Materials and Methods: The study was conducted on 180 elderly patients presenting with acute confusional state diagnosed according to the Confusion Assessment Method Instrument. After a thorough history, all patients went through a complete physical examination and were monitored systematically every 12 h until discharge or death. Routine blood tests were done in all the patients and imaging done as indicated. Statistical Analysis: SPSS was used for statistical analysis. Results: Predominantly affected group in both the genders was 60–70 years. One hundred and fifty-one patients had a history of comorbid illnesses, 47.78' of the patients had a significant history of substance abuse, and 137 had psychosomatic disorders. Around one-third of the study population was socially isolated. The most common acute insults were metabolic encephalopathy, infection, and dehydration. Hypoactive delirium was found to be most common (72.77'). Almost half of the patients presenting with confusion (49.5') expired. Vasopressor and ventilator support were required in more than half of the patients. Most of the patients had multiple causes for confusion with only 10.5' of the patients having a single cause. Conclusion: Timely diagnosis and appropriate interventions are necessary to reduce hospital stay and further complications associated with it.

Keywords: Acute confusional state, elderly, infection, metabolic encephalopathy, mortality


How to cite this article:
Thakur D, Agarwal K, Gupta A, Gupta R. Clinical profile of acute confusional state in elderly patients in a tertiary hospital in western Rajasthan. J Geriatr Ment Health 2020;7:86-93

How to cite this URL:
Thakur D, Agarwal K, Gupta A, Gupta R. Clinical profile of acute confusional state in elderly patients in a tertiary hospital in western Rajasthan. J Geriatr Ment Health [serial online] 2020 [cited 2021 Jun 25];7:86-93. Available from: https://www.jgmh.org/text.asp?2020/7/2/86/307590




  Introduction Top


Acute confusional state, also called delirium, is an acute, fluctuating syndrome of altered attention, awareness, and cognition. It can be predisposed by preexisting chronic health conditions and drug/substance abuse or can be precipitated by acute insults such as infections, electrolyte imbalance, hypoxia, or cerebrovascular accidents (CVAs). It is generally reversible if the underlying cause is discovered and addressed, and can be fatal if overlooked and untreated.[1]

It is more common in the elderly population with various studies reporting confusion in 40' of hospital admissions above the age of 70.[2] Adverse outcomes include prolonged hospital stay[3] and increased risk of complications[4] or mortality.[5] It can have a widely variable presentation, and is often missed and underdiagnosed as a result. A high degree of clinical expertise is essential and careful monitoring of patient's mental status is to detect worsened concentration, reduced mobility or motor activity, changes in appetite, or social withdrawal.

This heterogeneous syndrome requires prompt recognition and evaluation, because the underlying medical condition may be life threatening. To this end, various screening tools have been designed to detect delirium, most common being the Confusion Assessment Method (CAM).[6] CAM has reported a sensitivity of >94' and specificity of >90' and is easy to use in a clinical setting.[7] It can be administered in a short span of time (usually 5 min) and has been shown to have good psychometric properties.

Despite progress in the understanding of its clinical presentation, analysis of its clinical epidemiology, presentation, and consequence to the overall clinical outcome remains complex.[8] This knowledge gap becomes more critical given the difference between health-care standards of the West and our country and increase in our aging population.[9] Population aging is a powerful and transforming demographic force. We need to discover the most cost-effective ways to maintain healthful life styles and everyday functioning in countries at different stages of economic development and with varying resources. An all-inclusive exhaustive survey of the health issues – diseases, disability, financial cost, mental and emotional support, and health-care availability – is needed for complete management of the elderly.

This study is thus aimed to find out the clinical profile of confusional state: prevalence, etiology, predisposing social factors, hospital stay, interventions required (surgery, vasopressor, or ventilator), and final outcome in elderly patients in western Rajasthan.


  Materials and Methods Top


The study design was an observational study and conducted after approval of the study design by the Ethics Committee. The study was conducted on 180 patients above 60 years of age presenting with acute confusional state, diagnosed according to the CAM Instrument and algorithm adapted from Inouye.[6] in a tertiary hospital in western Rajasthan. The study involved was in accordance with the ethical standards of the institution (Dr. SN Medical College, Jodhpur), and informed consent was taken from the patients' relatives. Patients with frank psychosis, advanced dementia, or incommunicability and Grade 4 comatose, nonarousable patients were excluded from the study. Patients who were unresponsive or who required ventilator at the time of admission were not included in the study.

A thorough history including previous cognitive status and past medical and drug history, hospitalizations, and comorbidities was sought from family members and previous medical notes. History also focused on previous functional status, addictions, onset and course of confusion prior to admission, sensory deficits, and social isolation, if any. All the patients were screened for confusional state at admission with the help of? CAM-S (Confusion Assessment Method Short form Severity Score) questionnaire. Patients who fulfilled the criteria were included in the study after taking consent. Delirium was categorized as:

  1. Hypoactive if the patient was hypoaroused, hypoalert, or lethargic
  2. Hyperactive if the patient was hyperaroused, hyperalert, hallucinated, had delusions, was agitated, or disorientated
  3. Mixed type if the patient was having alternating features of the hyper- and hypoactive subtypes.


All patients went through a complete general and systemic examination and were monitored systematically every 12 h until discharge or death. Assessment included vitals: BP, pulse, temperature, SpO2, a thorough neurological examination, and Glasgow Coma Scale at the presentation.

Tests done in all included:

  • Complete blood count and erythrocyte sedimentation rate
  • Serum B12
  • Liver function tests
  • Lipid profile
  • Renal function tests
  • Chest X-ray
  • Blood glucose and ketones
  • Electrocardiogram
  • Electrolytes (sodium, potassium, magnesium, and calcium)
  • Urinalysis.


Tests done as per indication included thyroid function tests, culture studies, neuroimaging, electroencephalogram, and cerebrospinal fluid studies.

Patients were evaluated through their hospital course for various interventions required (surgery, assisted ventilation, inotropic support, etc.,) as well as final outcome.

Statistical method

All data were statistically analyzed using SPSS software SPSS Version 18 IBM USA. Parametric data were expressed as mean value ± standard deviation and categorical variables as percentage. The Chi-square test was used for the comparison of dichotomous variables and the Fisher's exact test for smaller variables. P < 0.05 was considered statistically significant [Flow chart 1].




  Results Top


The study was carried out on 180 elderly patients presenting with acute confusional state in tertiary hospital in western Rajasthan. There were 102 males (mean age: 70.21 ± 8.49 years) and 78 females (mean age: 72.03 ± 8.97 years). Predominantly affected group in both the genders was 60–70 years.

Patient characteristics are described in [Table 1]. One hundred and fifty-one patients had a history of comorbid illnesses, most common of which were diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease (COPD), CVA, and malignancy. 47.78' of the patients had a significant history of substance abuse, most of which were males. The most common addictions were smoking and alcohol. One hundred and thirty-seven (75 males and 62 females) out of 180 had psychosomatic disorders, most common of which were poor functional status and decreased oral intake. Around one-third of the study population was socially isolated.
Table 1: Patient demographics

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In our study, acute confusional state was accompanied with or preceded by a number of symptoms. The most common presenting complaints included shortness of breath (35.56') and fever (31.11'). The spectrum of symptoms also included seizures, vomiting, history of fall, chest pain, abdominal distension, slurring of speech, diarrhea, anasarca, difficulty in walking, gastrointestinal (GI) blood loss, decreased urine output, vision abnormalities, jaundice, and drug overdose.

[Table 2] describes the most common acute insults leading to confusion in the study population. Multiple causes were present in the same patient. Most common were metabolic encephalopathy (81.11'), infection (79.44'), and dehydration (73.88'). Other common precipitating factors included intensive care unit (ICU) setting, hypoxia, ischemia, urinary or stool retention, and sleep deprivation.
Table 2: Acute insult leading to confusion in the study population

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The most common metabolic encephalopathies [Figure 1] found were hyponatremia (25'), CO2 narcosis (21.11'), and hypoglycemia (20.56'). Other causes included hypernatremia, hypocalcemia, septic encephalopathy, uremia, hepatic encephalopathy, metabolic acidosis, and hypoxic encephalopathy.

The most common infections [Figure 2] were pneumonitis, urinary tract infection, and GI infection. Other infections included malaria, acute viral illness, central nervous system (CNS) infections, and abscess. Others included bed sores, pleural effusion, myocarditis, and hydronephrosis.

Analysis of CAM-S questionnaire [Table 3] revealed that majority (72.22') of the patients developed confusion on day 1 of admission while the rest developed on day 2. It was associated with inattention (67.22') and disorganized thinking (61.11') in most of the patients. Majority (68.33') of the patients were lethargic while 22.7' of the patients were hyperalert. Based on analysis of psychomotor activity [Figure 3], hypoactive delirium was found to be most common (72.77') followed by hyperactive delirium (22.7').
Figure 1: Metabolic encephalopathy in the study population

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Figure 2: Infections in study population

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Table 3: Analysis of Confusion Assessment Method questionnaire in the study population

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Figure 3: Type of delirium

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The most common primary causes of acute confusional state [Table 4] in males were CVA (15.6'), hypoglycemia (10.7'), COPD (10.7'), left ventricular failure (7.8'), and intracerebral hemorrhage (6.8'). The most common causes in females were CVA (17.74'), hypoglycemia (12.8'), urinary tract infection (7.6'), acute coronary syndrome (6.4'), and left ventricular failure (6.4').
Table 4: Primary cause of confusion in the study population (sex distribution)

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Almost half of the patients presenting with confusion (49.5') expired. Vasopressor and ventilator support were required in more than half of the patients presenting with acute confusional state with a significant associated mortality: 87.2' of the patients who needed ventilatory assistance and 85.4' of the patients who need vasopressor support eventually expired (P < 0.0001).

Most of the patients had multiple causes for confusion, with only 10.5' of the patients having a single cause. As the number of causes increases, the proportion of patients discharged became less and those who expired became more although the result was not statistically significant [Figure 4].
Figure 4: Relation of number of causes with outcome

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[Figure 5] shows that the need for ventilator and vasopressor support increased with the number of causes although the result was not statistically significant. The difference is significant in patients with five or more causes.
Figure 5: Relation of number of causes with ventilator and vasopressor support

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As shown in [Table 5], sodium was deranged in 57.22' of the patients (hyponatremia –33.89' and hypernatremia – 23.33') while potassium was deranged in 43.33' of the patients (hypokalemia –35' and hyperkalemia – 8.33'). The proportion of patients requiring ventilatory and ventilator support when sodium was deranged was statistically significant (P = 0.008). The proportion of patients requiring ventilator and vasopressor support when potassium was deranged was more than when potassium was normal, but the difference is not statistically significant. The proportion of patients discharged when sodium or potassium was deranged lesser than when they were normal, but the difference was not statistically significant.
Table 5: Electrolyte analysis of the patients

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  Discussion Top


Our study investigated the clinical profile of acute confusional state in 180 elderly patients presenting either as a primary symptom or developing within 2 days as a consequence of some other insults.

There were 102 males (mean age: 70.21 ± 8.49 years) and 78 females (mean age: 72.03 ± 8.97 years). Khurana et al.[10] reported a male-to-female ratio of 1.27:1. Despite the higher proportion of females in the elderly population,[11] there were fewer females in both studies, probably reflecting lesser access to medical care for females due to various socioeconomic factors. Almost half of the patients had a history of substance abuse. Mundada et al.[12] found a prevalence of addiction among elderly males to be 68.34'. More than 80' of the patients had one or more comorbidities. In a study by Rai et al.,[13] comorbid conditions were present in 48.1' of the patients. Around three-fourths of the patients had preexisting psychosomatic conditions and around one-third were socially isolated. McCusker et al.[14] found that social isolation, absence of family member, and physical restraints were associated with increased delirium severity score. These findings are important because underlying physical and mental diseases and impaired ambulation are the major risk factors for delirium[15] and delay recovery, even from a simple infection.

In our study, the most common acute insults were metabolic encephalopathies, infection, and dehydration. In contrast, Khurana et al.[10] found infection to be the most common etiology, whereas Sumji et al.[16] found CVA to be the most common cause of delirium in the elderly. A study by Grover et al.[17] found common etiologies associated with the delirium referrals being infections, trauma, and metabolic/endocrine causes.

The most common metabolic abnormality in our study was hyponatremia. This result has been supported in various studies by Khurana et al.[10] and Zieschang et al.[18] The most common infections in our study were pneumonitis and urinary tract infection. Similar results were found by Khurana et al.,[10] and Sirisena and Wijesnghe,[19] Mariz et al.,[20] who found that age, SIRS (Systemic Inflammatory Response syndrome) criteria, renal function tests, and serum osmolality levels are indicators of delirium and should alert the clinician as it is also a predictor of inhospital mortality in elderly patients.[21]

In our analysis of CAM-S questionnaire, hypoactive delirium was most common. Our result was similar to Khurana et al.[10] and Kaur et al.,[22] but the results are varied in other similar studies. Sandberg et al.[23] reported mixed delirium to be most common, whereas Camus et al.[24] observed that the hyperactive subtype was more. This may be related to etiology of delirium as drug abuse presented with hyperactive features while metabolic disturbances presented commonly with hypoactive delirium and sepsis did not show any predilection to hypoactive or hyperactive delirium.

Despite confusion being a neurological symptom, CNS imaging with computed tomography (CT) and magnetic resonance imaging (MRI) was nonspecific. A study by Theisen-Toupal et al.[25] says that CT scans have a low diagnostic yield for delirium in the absence of new neurological deficit or history of recent fall. A cross-sectional study by Hasan et al.[26] found chronic microvascular ischemia to be the most common change on MRI, but no specific change was found to be diagnostic of delirium. This highlights the importance of being alert about development of delirium in routine patients as well.

Although there is similarity in primary cause of confusion in both the genders in our study, various studies have shown differences in rates of development of confusion after a similar procedure and differences in their response to medication, mortality after delirium has developed. In a study by Serpytis et al.,[27] female patients who experienced delirium demonstrated a higher prevalence of hypertension, hyponatremia, heart failure, cardiac rhythm and conduction disorders, myocardial infarction, and dementia.

Half of the patients who developed confusion expired. This is significantly higher than Khurana et al.[10] who reported a mortality of 27', whereas Rai et al.[13] reported a mortality of 44.6'. In a meta-analysis[28] of 42 studies, it was found that delirium in ICU was associated with higher mortality, longer ICU stay, greater need for vasopressor and mechanical ventilation, and subsequent cognitive impairment postdischarge.

In our study, only 10.5' of the patients had a single cause of confusion. Camus et al.[24] found that 84' had two or more etiologies. Webster and Holroyd[29] in their study observed that 49.3' of the delirium cases had multiple etiologies. Grover et al.[17] in their study on psychiatric referral found two or more etiologies in 20.7'. Our study clearly shows that the increasing number of etiologies is associated with greater morbidity, earlier requirement of vasopressor and ventilator support, longer ICU stay, and poorer outcome.

Our study demonstrated that the need of vasopressor and ventilator increased in electrolyte disturbance, and the result was significant for sodium. There has not been any study we could compare our result with. Sodium abnormalities are associated with cognitive impairment, and low potassium is associated with psychosis, metabolic alkalosis, and cardiac arrhythmias Impaired cognition and cardiac arrhythmia induced failire are both associated with increased need for ventilator. Sodium abnormalities are common in infections while potassium disorders cause cardiac arrhythmias, both increasing the requirement of vasopressor requirement.


  Conclusion Top


This is the first study on clinical profile of acute confusional state in elderly indoor medical patients in western Rajasthan. Confusion is often considered to be a part of age-related dementia, but as our study showed, acute confusion in the elderly can be a symptom of a sinister underlying problem, which if undiagnosed can have a significant impact on prognosis. Hence, greater awareness is required so as not to miss it.

Limitations

  • CAM-S questionnaire was used for classification of acute confusional state. It is not possible to assess the severity of confusion with this questionnaire
  • The patients were followed till the end. However, the study cannot correlate mortality with number of days in delirium and severity of the disease. Further studies are required for that.


Compliance with ethical standards

Ethical Approval and informed consent: This was an observational study conducted in compliance with ethical standards of the institution after taking informed consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perez EL, Silverman M. Delirium: The often overlooked diagnosis. IntJ Psychiatry M 1984;14:181-9.  Back to cited text no. 1
    
2.
Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med 1995;25:751-5.  Back to cited text no. 2
    
3.
Roche V. Southwestern Internal Medicine Conference. Etiology and management of delirium. Am J Med Sci 2003;325:20-30.  Back to cited text no. 3
    
4.
Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998;13:234-42.  Back to cited text no. 4
    
5.
Rahkonen T, Eloniemi-Sulkava U, Paanila S, Halonen P, Sivenius J, Sulkava R. Systematic intervention for supporting community care of elderly people after a delirium episode. Int Psychogeriatr 2001;13:37-49.  Back to cited text no. 5
    
6.
Inouye SK. Delirium in older persons. N Engl J Med 2006;354:1157-65.  Back to cited text no. 6
    
7.
Australian Society for Geriatric Medicine Position Statement No. 13. Delirium in Older People. Australasian Journal on Ageing, 2015;34: 68-73. Doi.org/10.1111/ajag.12195.  Back to cited text no. 7
    
8.
Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age Ageing 2009;38:19-26.  Back to cited text no. 8
    
9.
Arokiasamy P, Shekher TV, Lhungdim H, Dhar M, Roy A. India: Study on global AGEing and adult health (SAGE) Wave 1 National Report; 2015: 6.  Back to cited text no. 9
    
10.
Khurana V, Gambhir IS, Kishore D. Evaluation of delirium in elderly: A hospital-based study. Geriatr Gerontol Int 2011;11:467-73.  Back to cited text no. 10
    
11.
Population Census. Primary Census Abstracts, Registrar General of India, Ministry of Home Affairs, Government of India; 2011. Available from: http://www. censusindia.gov.in/2011census/PCA/pca_highlights/pe_data.html. [Last accessed on 20 August 2020].  Back to cited text no. 11
    
12.
Mundada V, Jadhav V, Gaikwad AV. Study of addiction problems and morbidity among geriatric population in rural area of Aurangabad district. J Midlife Health 2013;4:172-5.  Back to cited text no. 12
    
13.
Rai D, Garg RK, Malhotra HS, Verma R, Jain A, Tiwari SC, Singh MK. Acute confusional state/delirium: An etiological and prognostic evaluation. Ann Indian Acad Neurol 2014;17:30-4.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
McCusker J, Cole M, Abrahamowicz M, Han L, Podoba JE, Ramman-Haddad L. Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 2001;49:1327-34.  Back to cited text no. 14
    
15.
Lipowski ZJ. Delirium: Acute Brain Failure in Man. Vol. 23. Springfield, III: Charles C Thomas; 1980. p. 42-5.  Back to cited text no. 15
    
16.
Sumji S, Wani MI, Mohi-ud-Din M. Prevalence and etiological profile of patients with acute confusional state. Int J Sci Stud 2018;6:24-9.  Back to cited text no. 16
    
17.
Grover S, Subodh BN, Avasthi A, Chakrabarti S, Kumar S, Sharan P, et al. Prevalence and clinical profile of delirium: A study from a tertiary-care hospital in north India. Gen Hosp Psychiatry 2009;31:25-9.  Back to cited text no. 17
    
18.
Zieschang T, Wolf M, Vellappallil T, Uhlmann L, Oster P, Kopf D. The association of hyponatremia, risk of confusional state, and mortality. Deutsch Arztebl Int 2018;113:855-62.  Back to cited text no. 18
    
19.
Sirisena T, Wijesnghe CJ. Acute confusional state in hospitalised older adults; a preliminary study of the causes and associated factors. Galle Med J 2017;22:1.  Back to cited text no. 19
    
20.
Mariz J, Santos NC, Afonso H, Rodrigues P, Faria A, Sousa N, et al. Risk and clinical-outcome indicators of delirium in an emergency department intermediate care unit (EDIMCU): An observational prospective study. BMC Emerg Med 2013;13:2.  Back to cited text no. 20
    
21.
Pieralli F, Vannucchi V, Mancini A, Grazzini M, Paolacci G, Morettini A, et al. Delirium is a predictor of in-hospital mortality in elderly patients with community acquired pneumonia. Intern Emerg Med 2014;9:195-200.  Back to cited text no. 21
    
22.
Kaur J, Mohan G, Nayyar S.B, Kaur R. A study of etiological profile of acute confusional state. IJAM 2920;7:1.  Back to cited text no. 22
    
23.
Sandberg O, Gustafson Y, Benny Brannstrom RN, Bucht G. Clinical profile of delirium in older patients. J Am Geriatr Soc 2015;47:11-5.  Back to cited text no. 23
    
24.
Camus V, Gonthier R, Dubos G, Schwed P, Simeone I. Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J Geriatr Psychiatry Neurol 2000;13:38-42.  Back to cited text no. 24
    
25.
Theisen-Toupal J, Breu A, Mattison M, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium. J Hosp Med 2014;9:497-501.  Back to cited text no. 25
    
26.
Hasan LM, Khan A, Singh M, Malone ML. Brain imaging in older patients with delirium. J Patient Cent Res Rev 2017;4:261.  Back to cited text no. 26
    
27.
Serpytis P, Navickas P, Navickas A, Serpytis R, Navickas G, Glaveckaite S. Age- and gender-related peculiarities of patients with delirium in the cardiac intensive care unit. Kardiol Pol 2017;75:1041-50.  Back to cited text no. 27
    
28.
Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al. Outcome of delirium in critically ill patients: Systematic review and meta-analysis. BMJ 2015;350:h2538.  Back to cited text no. 28
    
29.
Webster R, Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics 2000;41:519-22.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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