Cited by 660Intensive Care Unit Cognitive DisordersAnesthesia and Sedative AgentsAlcoholism and Thiamine Deficiency

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Delirium and Its Motoric Subtypes: A Study of 614 Critically Ill Patients

Peterson, Josh F., Pun, Brenda T., Dittus, Robert S., Thomason, Jason W. W., Jackson, James C., Shintani, Ayumi K., Ely, E. Wesley·2006·Journal of the American Geriatrics Society

DOI 10.1111/j.1532-5415.2005.00621.x

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Abstract

OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. DESIGN: Prospective cohort study. SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center. PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

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Fick, D. M., & Mion, L. C. (2008) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000304476.80530.7d · Cited by 49
Delirium Severity Trajectories and Outcomes in ICU Patients. Defining a Dynamic Symptom Phenotype
Lindroth, H. L., Khan, B. A., Carpenter, J. S., Gao, S., Perkins, A. J., Khan, S., Wang, S., Jones, R. N., & Boustani, M. A. (2020) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201910-764oc · Cited by 49
Managing ICU delirium
Schiemann, A., Hadzidiakos, D. A., & Spies, C. (2011) · Current Opinion in Critical Care · doi:10.1097/mcc.0b013e32834400b5 · Cited by 46
Emergency physician recognition of delirium
Suffoletto, B. P., Miller, T. H., Frisch, A., & Callaway, C. W. (2013) · Postgraduate Medical Journal · doi:10.1136/postgradmedj-2012-131608 · Cited by 46
Management of Delirium in Critically Ill Older Adults
Balas, M. C., Rice, M. J., Chaperon, C., Smith, H., Disbot, M., & Fuchs, B. D. (2012) · Critical Care Nurse · doi:10.4037/ccn2012480 · Cited by 45
Effect of delirium motoric subtypes on administrative documentation of delirium in the surgical intensive care unit
Bui, L. N., Pham, V. P., Shirkey, B. A., & Swan, J. T. (2016) · Journal of Clinical Monitoring and Computing · doi:10.1007/s10877-016-9873-1 · Cited by 47
“23%) is much lower than the prevalence of hypoactive (19% - 68%) and mixed subtypes (14% - 55%) [18,20-28].”
BackgroundMethodResultInfluential
The Incidence of Delirium at the Postoperative Intensive Care Unit in Adult Patients
Bilge, E. U., Kaya, M., Şenel, G., & Ünver, S. (2015) · Türk anesteziyoloji ve reanimasyon derneği dergisi · doi:10.5152/tjar.2015.93798 · Cited by 46
“(22) çalışmalarında 65 yaş üstü yoğun bakım hastalarında deliryum görülme oranının anlamlı olarak arttığını bulmuşlardır.”
Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice
Roberson, S. W., Patel, M. B., Dąbrowski, W., Ely, E. W., Pakulski, C., & Kotfis, K. (2021) · Current Neuropharmacology · doi:10.2174/1570159x19666210119153839 · Cited by 50
“Although hypoactive delirium is the most easily overlooked, this form combined with mixed delirium are the most common presentations in the ICU, accounting for 66-90% of cases [95, 96].”
Background
Top 10 Myths Regarding Sedation and Delirium in the ICU
Peitz, G. J., Balas, M. C., Olsen, K. M., Pun, B. T., & Ely, E. W. (2013) · Critical Care Medicine · doi:10.1097/ccm.0b013e3182a168f5 · Cited by 45
“Hypoactive delirium, which presents as inattentiveness or a disorganized thought process, is prevalent in 43–60% of all delirium cases and is associated with greater mortality than hyperactive delirium (67).”
Background
Impact of dexmedetomidine supplemented analgesia on delirium in patients recovering from orthopedic surgery: A randomized controlled trial
Hong, H., Zhang, D., Li, M., Wang, G., Zhu, S., Zhang, Y., Wang, D., & Sessler, D. I. (2021) · BMC Anesthesiology · doi:10.1186/s12871-021-01441-3 · Cited by 46
Electroconvulsive therapy as a treatment for protracted refractory delirium in the intensive care unit—Five cases and a review
Nielsen, R. M., Olsen, K. S., Lauritsen, A. O., & Boesen, H. C. (2014) · Journal of Critical Care · doi:10.1016/j.jcrc.2014.05.012 · Cited by 47
“6% of all cases in the ICU (Table 1) [13].”
Background
Comprehensive approaches to managing delirium in patients with advanced cancer
Kang, J. H., Shin, S. H., & Bruera, E. D. (2012) · Cancer Treatment Reviews · doi:10.1016/j.ctrv.2012.08.001 · Cited by 44
Effects of routine monitoring of delirium in a surgical/trauma intensive care unit
Bigatello, L. M., Amirfarzan, H., Kazem, A., Newhouse, B. J., Rio, J. M. D., Allen, K., Chang, A., Schmidt, U. H., & Razavi, M. (2013) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0b013e31827e1b69 · Cited by 44
Delirium and effect of circadian light in the intensive care unit: a retrospective cohort study
Estrup, S., Kjer, C. K. W., Poulsen, L. M., Gögenür, I., & Mathiesen, O. (2017) · Acta Anaesthesiologica Scandinavica · doi:10.1111/aas.13037 · Cited by 46
Volatile Versus Total Intravenous Anesthesia on Postoperative Delirium in Adult Patients Undergoing Cardiac Valve Surgery: A Randomized Clinical Trial
Jiang, J.-L., Zhang, L., He, L., Yu, H., Li, X., Dai, S.-H., & Yu, H. (2022) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000006257 · Cited by 43
Understanding terminology of delirium and long-term cognitive impairment in critically ill patients
Morandi, A., Pandharipande, P. P., Jackson, J. C., Bellelli, G., Trabucchi, M., & Ely, E. W. (2012) · Best practice & research. Clinical anaesthesiology · doi:10.1016/j.bpa.2012.08.001 · Cited by 42
Treatment of four psychiatric emergencies in the intensive care unit
Sevransky, J., Bienvenu, O. J., Neufeld, K. J., & Needham, D. M. (2012) · Critical Care Medicine · doi:10.1097/ccm.0b013e31825ae0f8 · Cited by 41
Postoperative delirium in elderly citizens and current practice
Reddy, S., Irkal, J. N., & Srinivasamurthy, A. (2017) · Journal of Anaesthesiology Clinical Pharmacology · doi:10.4103/joacp.joacp_180_16 · Cited by 42
“• The hypoactive type, in which patients are withdrawn and quiet, unaware, with prominent lethargy or apathy, decreased alertness, staring, psychomotor slowing, slowed movements, sparse, or slow speech • The hyperactive type, featuring prominent agitation, hyperarousal, hypervigilance, irritability, restlessness, comb…”
Background
Dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phosphorylated neurofilament heavy subunit
Mietani, K., Sumitani, M., Ogata, T., Shimojo, N., Inoue, R., Abe, H., Kawamura, G., & Yamada, Y. (2019) · PLoS ONE · doi:10.1371/journal.pone.0222721 · Cited by 42
Japanese guidelines for the management of Pain, Agitation, and Delirium in intensive care unit (J-PAD)
日本集中治療医学会J-PADガイドライン作成委員会 (2014) · Journal of the Japanese Society of Intensive Care Medicine · doi:10.3918/jsicm.21.539 · Cited by 41
Delirium in the Long-Term Care Setting: Clinical and Research Challenges
Eeles, E. M., & Rockwood, K. J. (2008) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2007.12.001 · Cited by 41
Delirium assessment in intensive care units: practices and perceptions of Turkish nurses
Özsaban, A., & Acaroğlu, R. (2015) · Nursing in Critical Care · doi:10.1111/nicc.12127 · Cited by 40
Differences in 90-day mortality of delirium subtypes in the intensive care unit: A retrospective cohort study
Rood, P. J. T., van de Schoor, F. R., van Tertholen, K., Pickkers, P., & van den Boogaard, M. (2019) · Journal of Critical Care · doi:10.1016/j.jcrc.2019.06.007 · Cited by 44
Remifentanil Reduces the Incidence of Post-Operative Delirium
Radtke, F. M., Franck, M., Lorenz, M., Luetz, A., Heymann, A., Wernecke, K.-D., & Spies, C. (2010) · Journal of International Medical Research · doi:10.1177/147323001003800403 · Cited by 41
Derivation and Validation of an Ensemble Model for the Prediction of Agitation in Mechanically Ventilated Patients Maintained Under Light Sedation
Zhang, Z., Liu, J., Xi, J., Gong, Y., Zeng, L., & Ma, P. (2021) · Critical Care Medicine · doi:10.1097/ccm.0000000000004821 · Cited by 39
Tryptophan Supplementation and Postoperative Delirium—A Randomized Controlled Trial
Robinson, T. N., Dunn, C. L., Adams, J. C., Hawkins, C. L., Tran, Z. V., Raeburn, C. D., & Moss, M. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12972 · Cited by 40
Delirium in Trauma Patients: Prevalence and Predictors
Rueden, K. T. V., Wallizer, B., Thurman, P., McQuillan, K., Andrews, T., Merenda, J., & Son, H. (2017) · Critical Care Nurse · doi:10.4037/ccn2017373 · Cited by 39
The Cognitive Consequences of Critical Illness: Practical Recommendations for Screening and Assessment
Gunther, M. L., Jackson, J. C., & Ely, E. W. (2007) · Critical Care Clinics · doi:10.1016/j.ccc.2007.07.001 · Cited by 38
Impact of Quetiapine Treatment on Duration of Hypoactive Delirium in Critically Ill Adults: A Retrospective Analysis
Michaud, C. J., Bullard, H. M., Harris, S. A., & Thomas, W. L. (2015) · Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy · doi:10.1002/phar.1619 · Cited by 41
“55 Received dexmedetomidine during delirium course 14 (27) 14 (23) 0.”
Background
Risk and clinical-outcome indicators of delirium in an emergency department intermediate care unit (EDIMCU): an observational prospective study
Mariz, J. A., Santos, N. C., Afonso, H., Rodrigues, P., Faria, A., Sousa, N., & Teixeira, J. (2013) · BMC Emergency Medicine · doi:10.1186/1471-227x-13-2 · Cited by 37
“In patients who were CAM-ICU positive, the Richmond Agitation and Sedation Scale (RASS) was used to categorize the psychomotor subtype of delirium (RASS score between: +1 and +4, hyperactive delirium; 0 and -3, hypoactive delirium; with both positive and negative scores at 0 and 3 hrs, mixed type) [22,23].”
Method
The impact of psychomotor subtypes and duration of delirium on 6‐month mortality in hip‐fractured elderly patients
Bellelli, G., Carnevali, L., Corsi, M., Morandi, A., Zambon, A., Mazzola, P., Galeazzi, M., Bonfanti, A., Massariello, F., Szabó, H., et al. (2018) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.4914 · Cited by 37
Types of Brain Dysfunction in Critical Illness
Stevens, R. D., & Nyquist, P. (2008) · Neurologic Clinics · doi:10.1016/j.ncl.2008.02.004 · Cited by 36
“Recent data suggest that the hypoactive and mixed forms of delirium may be significantly more prevalent that the purely hyperactive type [78,79].”
Background
Treatment of delirium in supportive and palliative care
Gagnon, P. R. (2008) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0b013e3282f4ce05 · Cited by 36
Exploring Delirium's Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients
Han, J. H., Brummel, N. E., Chandrasekhar, R., Wilson, J. E., Liu, X., Vasilevskis, E. E., Girard, T. D., Carlo, M. E., Dittus, R. S., Schnelle, J. F., et al. (2016) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2016.05.016 · Cited by 36
“As part of the CAM-ICU, the RASS was also recorded to quantify level of arousal.(28,29) The RASS ranges from -5 (coma) to +4 (combative); RASS of 0 represent normal level of arousal (alert and calm), a RASS < 0 represents decreased arousal, and a RASS > 0 represents increased arousal.”
Effect of Sleep Disorder on Delirium in Post-Cardiac Surgery Patients
Wang, H., Zhang, L., Luo, Q., Li, Y., & Yan, F. (2020) · Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques · doi:10.1017/cjn.2020.62 · Cited by 36
“Additionally, delirium can be divided into three types according to RASS scores: (1) hypoactive type: when the RASS score is less than 0; (2) hyperactive type: when the RASS score is more than 0 and (3) mixed: hypoactive and hyperactive types alternately occuring.(21)”
Method
Development and validation of the Korean Nursing Delirium Scale
Kim, K.-N., Kim, C., Kim, K., Yoo, H.-J., Park, S.-Y., & Park, Y. (2012) · Journal of Korean Academy of Nursing · doi:10.4040/jkan.2012.42.3.414 · Cited by 36
“특히 노인에서는 활 동 과소형 섬망이 더 흔하기 때문에(Milisen, Steeman, & Foreman, 2004; Peterson et al., 2006), ‘졸려하는’과 같은 정신 운동 지연 징후를 잘 관찰하여 입원 노인의 섬망을 간과하지 않고 조기에 발견할 수 있도록 하는 것이 필요하다.”
Influential
Perceptions, attitudes, and current practices regards delirium in China
Xing, J., Sun, Y., Jie, Y., Yuan, Z., & Liu, W. (2017) · Medicine · doi:10.1097/md.0000000000008028 · Cited by 40
Temporal biomarker profiles and their association with ICU acquired delirium: a cohort study
Simons, K. S., van den Boogaard, M., Hendriksen, E., Gerretsen, J., van der Hoeven, J. G., Pickkers, P., & de Jager, C. P. C. (2018) · Critical Care · doi:10.1186/s13054-018-2054-5 · Cited by 35
“In all patients the subtype of delirium was defined by means of the RASS score according to the Peterson criteria [21]; if the RASS was persistently zero or less during the time that delirium was present, this was considered to be hypoactive delirium, if not directly related to the use of sedatives.”
Method
Perioperative prediction of agitated (hyperactive) delirium after cardiac surgery in adults – The development of a practical scorecard
Mufti, H. N., & Hirsch, G. M. (2017) · Journal of Critical Care · doi:10.1016/j.jcrc.2017.07.045 · Cited by 35

Authors: Peterson, J. F., Pun, B. T., Dittus, R. S., Thomason, J. W. W., Jackson, J. C., Shintani, A. K., & Ely, E. W.
Affiliations: Vanderbilt University Medical Center (US)
VA Tennessee Valley Healthcare System (US)
Corresponding author: Peterson, Josh F.
Ely, E. Wesley
ORCID: Peterson, Josh F.
Jackson, James C.
Shintani, Ayumi K.
Ely, E. Wesley
Venue: Journal of the American Geriatrics Society
Publisher: Wiley
Published: 2006-03
Volume: 54
Issue: 3
Pages: 479-484
ISSN: 0002-8614 (ISSN-L)
1532-5415
DOI: 10.1111/j.1532-5415.2005.00621.x
OpenAlex: W1505808688
Cited by: 660
References: 31
Citations by year: 2026: 11 · 2025: 17 · 2024: 32 · 2023: 37 · 2022: 21 · 2021: 33 · 2020: 32 · 2019: 45 · 2018: 44 · 2017: 41 · 2016: 48 · 2015: 37 · 2014: 29 · 2013: 42 · 2012: 44
FWCI: 27.31
Type: journal article
Language: en
Open access: closed
Licence: onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations: Journal of the American Geriatrics Society (publishedVersion)
PubMed (publishedVersion)
Funders: Eli Lilly and Company
Pfizer
Topics: Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
Health Sciences › Medicine › Clinical Neurology › Alcoholism and Thiamine Deficiency
Keywords: delirium, hypoactive delirium, hyperactive delirium, mixed delirium, critically ill patients, older adults, intensive care unit, age as predictor, sedation, level of consciousness, delirium monitoring
MeSH terms: Age Factors, Aged, Critical Care, Delirium, Female, Follow-Up Studies, Humans, Male, Motor Activity, Prognosis, Prospective Studies, Severity of Illness Index, Incidence, Prevalence, Critical Illness

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Delirium and Its Motoric Subtypes: A Study of 614 Critically Ill Patients

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