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Olov Sandberg


New Series No. 687 ____ ISSN 0346-6612 ____ ISBN 91-7191-893-0


Clinical studies in institutional care and in stroke rehabilitation

Olov Sandberg, MD. Geriatric Medicine, Department of Community Medicine and Rehabilitation, Umeå University, SE-901 87 Umeå, Sweden


Delirium and psychiatric and behavior symptoms are common in old age and delirium causes much suffering for the affected person and increased workload for the nursing staff. Delirious patients also have higher mortality rates and greater morbidity leading to prolonged hospital stay.

The purpose of this study was to examine the prevalence of delirium, psychiatric and behavior symptoms, delirium subtypes, diurnal variation and cognitive functioning in different patient populations. Another aim was to investigate whether delirium, psychiatric and behavior symptoms, cognitive functioning and ability to perform personal ADL could be improved by nasal Continuous Positive Airway Pressure (nCPAP) treatment in stroke patients with sleep apnea.

The patients were examined using the Organic Brain Syndrome Scale for delirium, delirium subtypes, diurnal variation of delirium and psychiatric and behavior symptoms. Cognitive functioning was assessed with Mini Mental State Examination and symptoms of depression with Montgomery-Åsberg Depression Rating Scale. Personal activities of daily living were assessed using the Barthel-ADL index. Delirium was diagnosed according to DSM-III-R and DSM-IV. Sleep apnea in a consecutive sample of stroke patients was diagnosed inhospital using a portable overnight respiratory sleep-recording equipment and sleep apnea was defined at an apnea-hypopnea index of 10 or more.

The prevalence of delirium and psychiatric and behavior symptoms is high in all types of care settings for the elderly. Delirium was most common in the morning. Twenty-six percent of the delirious patients had a hypoactive delirium, 22 % a hyperactive delirium and 42 % experienced a combination of both types. Seventy-seven percent of the delirious patients had a delirium with pronounced emotional symptoms and 43 % had pronounced psychotic symptoms. Fifty-nine percent of the stroke patients had sleep apnea and 66 % were delirious. More patients with sleep apnea than without were delirious, depressed and more ADL-dependent. Severity of hypoxemia was independently associated with delirium and depressed mood with sleep apnea in multivariate analysis. Depressed mood improved significantly after 28 nights on nCPAP treatment in the treatment group compared with the control group (p=0.006). Delirium did not improve which might be explained by low tolerance to nCPAP treatment among delirious patients. A sub-analysis in patients using nCPAP for a mean of more than four hours per night showed that these patients also experienced an improvement in personal ADL compared with those who had no or insufficient nCPAP treatment (p=0.020). Multivariate analysis showed that patients treated with nCPAP for seven nights besides showing improvement in depressed mood (p<0.004) also improved significantly with regard to anxiety (p<0.002), restlessness/agitation (p<0.006) and irritability (p<0.007), and the improvement was related to the tolerance of nCPAP.

This study shows that the prevalence of delirium is high in stroke patients and in all types of care settings for the elderly. The study also shows that different treatment strategies for patients with different types of delirium might be indicated, and it demonstrates the need for psychiatric medical and nursing competence in all types of care for the elderly. Furthermore, stroke patients should be examined for the presence of sleep apnea, since nCPAP treatment significantly reduces depressive illness and improves personal ADL, which is of great importance for the rehabilitation process.

Keywords: activities of daily living; aged; cerebrovascular disorders; cerebral hemorrhage; cognition; delirium; dementia; geriatric psychiatry; home care services; homes for the aged; hospitalized; mental disorders; mood disorders; nursing homes; prevalence; randomised controlled trials; sleep apnea syndromes.

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