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General Hospital Psychiatry 33 (2011) 637–639

Distress due to delirium experience☆,☆☆

Sandeep Grover, M.D.⁎, Ruchita Shah, M.D.Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India

Received 6 July 2011; accepted 29 July 2011

Abstract

Background: Very few studies have evaluated the level of distress due to the experience of delirium in patients who have recoveredfrom delirium.Methodology: Fifty-three patients were rated on Delirium Rating Scale-Revised-98 at baseline and were again evaluated on DeliriumExperience Questionnaire after recovery for level of distress due to the experience of delirium.Results: The mean age of patients was 45.58 (S.D. 19.06) years. Only 15 patients (28.3%) remembered themselves to be confused and resthad no recollection of the same. Those who could remember their experience had moderate (n = 4; 26.7%), severe (n = 6; 40.0%) and verysevere (n = 5; 33.3%) level of distress. Of those who could not remember their delirium experience, most of them had moderate (n = 17;44.7%) to severe (n = 10; 26.3%) distress. Those who remembered their experience in general described it as a state of fearfulness (n = 8),anxiety (n = 4) confusion and feeling strange (n = 7). Other experiences which were recollected were those of visual hallucinationsand illusions.Conclusion: Overall experience of delirium is distressing for the patients. Most of the patients (those who remembered or who were not ableto remember) experienced at least moderate level of distress.© 2011 Elsevier Inc. All rights reserved.

Keywords: Delirium; Distress; Psychological impact

1. Introduction

Few studies have evaluated the psychological conse-quences of experience of delirium [1]. Many patients areunable to remember their experience of delirium, and thosewho are able to recollect it describe it to be an unpleasantexperience with dominant emotions of fear, anxiety andfeeling threatened [1]. In general, these studies suggest that asignificant proportion of patients with delirium or confu-sional states who do remember their delirium experiencetend to recall the experience as distressing and disturbing[2–7]. Majority of the patients remember perceptualdisturbance like illusions and hallucinations and short verbalcommands from nurses during these periods of alteredperception [8], and others described their delirium asincomprehensible experience for them. The present study

☆ Funding: None.☆☆ Conflict of interest: None.⁎ Corresponding author. Tel.: +91 172 2756807(O); fax: +91 172

2744401; 2745078.E-mail address: drsandeepg2002@yahoo.com (S. Grover).

0163-8343/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2011.07.009

attempted to study the patient's experience of delirium interms of recollection and distress.

2. Methodology

Fifty-three cases of delirium diagnosed as perDSM-IV-TRby a qualified psychiatrist, selected by convenience sam-pling, were evaluated on Delirium Experience questionnaire(DEQ) after recovery from delirium after obtaining properwritten informed consent. The study was approved by theDepartmental Research committee. DEQ has six questionsevaluating the experience of delirium in patients who haverecovered from delirium and includes the following: (1) Doyou remember being confused? Yes or No; (2) If no, are youdistressed that you can't remember? Yes or No; (3) Howdistressed? 0–4 numerical rating scale (NRS) with 0 equal to“not at all” and 4 equal to “extremely”; (4) If you doremember being confused, was the experience distressing?Yes or No; (5) How distressing? 0–4 NRS; and (6) Can youdescribe the experience? This final question allows for aqualitative assessment of the delirium experience through the

able 2atient's description of the experience

Themes of qualitative description Level of distress

Could see frightening things and can't describethe full experience

Very severe

Fearful, was able to see ghost of a female, feltthat she was beating me. My brother used to say

Very severe

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verbatim transcription of patients' description of theexperience [9]. This instrument is reported to have facevalidity for assessment of recall of the delirium experienceand the degree of distress related to the delirium episode inpatients, spouses/ caregivers and nurses [9].

All the patients were also assessed on Delirium RatingScale-Revised-98 (DRS-R-98) [10].

that I am undergoing treatment.Things around were strange and different(akin to derealization)

Moderate

Was feeling anxious, was not able to understandas to what was happening around

Moderate

Was seeing ants on the body and bed; was fearful,felt that somebody is going to kill me; atthat time, everything appeared real and true

Severe

I was not able to understand as to what washappening; was feeling strange

Moderate

I was confused, was not able to see thingsclearly; things would appear strange;was fearful and would have lot of anxiety

Moderate

I was very anxious. SevereWas not able to sleep, was restless and wouldfeel strange; was fearful as to something isgoing to break, something is going to fall

Severe

0 I was confused, was fearful, would see ropesas snakes, the clock on the wall would appearstrange; was not aware about the surroundings

Very severe

1 Was able to see snakes, there were snakesevery where; was very much fearful

Very severe

2 Was very fearful; I was speaking excessively,without an understanding of the same

Very severe

3 Was very much anxious and fearful Severe4 Was fearful, was seeing strange things, don't

remember the restSevere

5 Was anxious Very severe

3. Results

The age range of the sample was 18–83 years, and themean age was 45.58 (SD 19.06) years. The years ofeducation range was 0–17 years, with mean number ofyears of education being 9.07 (SD 5.31). Most of the patientswere males (N = 38; 71.7%). The mean total duration ofdelirium (prior to baseline assessment to recovery) was8.60 days (SD 6.82; range 1–37).The follow-up assessmentwas done 1.60 days (SD 0.96; range 1–6 days) after recoveryfrom delirium. Other clinical details are provided in Table 1.

Of the 53 patients, only 15 (28.3%) of them rememberedthemselves to be confused, and the rest had no recollection ofthe same. Those who could remember their experience hadmoderate (n = 4; 26.7%), severe (n = 6; 40.0%) and verysevere (n = 5; 33.3%) level of distress. Of those who couldnot remember their delirium experience, most of them hadmoderate (n = 17; 44.7%) to severe (n = 10; 26.3%) distress.Only very few patients had no distress (n = 2; 5.3%), and therest had mild level of distress (n = 9; 23.7%).

The qualitative descriptions on Q-6 of DEQ are shown inTable 2. The general themes were that of fearfulness (n = 8),anxiety (n = 4), confusion and feeling strange (n = 7). Otherexperiences which were recollected were those of visualhallucinations and illusions. Those who remembered theirexperience were much younger [mean age 33.26 (SD 15.07)]than those who did not remember [mean age 50.44 (SD17.93)] and the difference between the two groups wassignificant (t value = 3.27, P = .002). However, there was nodifference in the number of years of education and gender.

Table 1Clinical details of the sample

Variables Mean (SD)f/n (%)

Mean duration of delirium at the timeof baseline assessment

3.88 days (SD 5.02)

Source of patientsMedical wards 33 (62.3%)Surgical wards 20 (37.7%)

Emergence of deliriumHospital emergent 39 (71.7%)Delirium present prior to admission 14 (28.3%)

Mean DRS-R-98 severity score at baseline assessment 23.05 (SD 5.17)Total DRS-R-98 score at baseline assessment 29.77 (SD 5.35)Mean DRS-R-98 score at the time of

follow-up assessment1.39 (SD 1.41)

TP

1

2

3

4

5

6

7

89

1

1

1

11

1

There was no difference in total duration of delirum andduration of recovery at the time of assessment.

4. Discussion

Delirium forms the largest diagnostic category among allthe cases seen in Psychiatry consultation–liaison services inour setting [11]. Hence, it is important to study thepsychological impact of the same on the patients.

Most of the previous studies of psychological impact ofdelirium on patients have been from the West, mostlyfocusing on the cancer patients [9,12] or patients admittedto the intensive or critical care units [2–4,7]. In contrast,we evaluated the heterogeneous group of patients whowere suffering from delirium and not necessary terminallyill. Hence, our findings can be more generalizable topatients admitted in medical and surgical wards, whoexperience delirium but not necessarily are suffering from aterminal illness.

Studies from the West have reported variable rates (53.5–94%) of ability to recall the delirium experience [9,12]. Inour sample, only 15 out of 53 (28.30%) could remembertheir experience. This could be possibly due to high

639S. Grover, R. Shah / General Hospital Psychiatry 33 (2011) 637–639

prevalence of cognitive symptoms like memory deficits orlack of psychological sophistication in the participants of thecurrent study.

Studies from the West have reported that the dominantemotions are that of fear, anxiety and of feeling threatened[1], and findings of the present study support the same.Studies also suggest that among the various symptomsremembered [8], perceptual disturbance like illusions andhallucinations are more frequently remembered. Participantsof the present study also remembered the perceptualdisturbances quite frequently, besides the other symptoms.

In the study by Breitbart et al. [9], presence of delusionswas the most significant predictor of patient distress andthere was no difference in the distress level among those withhypoactive or hyperactive delirium. Lack of relationshipwith delusions in the present study can be due to lowprevalence of delusions in the participants of the presentstudy. In our study, high level of distress was also reportedby those who were able to recollect their perceptualdisturbances, which is similar to the findings reported byCohen et al. [12].

However, the important finding of the present study isthat those who could remember their experience had severe(40.0%) to very severe (33.3%) level of distress. Further-more, those who could not remember also had moderate(44.7%) to severe (26.3%) distress. These findings suggestthat overall experience of delirium is extremely distressingto the patients. Hence, appropriate measures should betaken to prevent delirium in medically ill patients and reducethe distress.

Although we assessed both the qualitative and quantita-tive level of distress in delirium, our study was limited bysmall sample size. Further, although the qualitative de-scriptions which were obtained were informative, furtherdetailed interview with leading questions could have beenmore informative. We assessed the patients shortly after therecovery this could have possibly affected the patientsresponse, as some of them may still be having residual

cognitive features of delirium. The questionnaire used, i.e.,DEQ is a brief questionnaire and has inherent limitations andcould have impacted the findings of the study both in theform of reporting of symptoms and associated distress.Future studies should evaluate the distress in larger sampleand should evaluate the relationship of distress withphenomenology, etiology, socio-demographics and otherclinical parameters.

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