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Delirium as the Sixth Vital Sign

      We read with interest the editorial by Flaherty and colleagues recently published in the Journal of the American Medical Directors Association, indicating delirium as the sixth vital sign.
      • Flaherty J.H.
      • Rudolph J.
      • Shay K.
      • et al.
      Delirium is a serious and under-recognized problem: Why assessment of mental status should be the sixth vital sign.
      We strongly agree and provide at least 2 additional motivations to support the assessment of delirium as a routine procedure in the care of elderly people.
      • 1
        Delirium as the most specific vital sign. While fever does not always accompany infectious and other diseases frequently occurring in elderly people and the elevation of pulse and respiratory rates may be observed in uncritical medical conditions (such as anxiety disorders), delirium always marks the presence—or represents the prodrome—of a serious pathological condition occurring in frail subjects. In this perspective, delirium is more specific than the other 5 vital signs.
      • 2
        Monitoring the evolution of delirium allows one to evaluate the efficacy of clinical care. Because delirium in most cases is the result of an acute medical illness commonly superimposing on a chronic disease,
        American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders: DSM-IV.
        the structured and regular monitoring of delirium (for example assessing its persistence or resolution with the Confusion Assessment Method
        • Inouye S.K.
        • Van Dyck C.H.
        • Alessi C.A.
        • et al.
        Clarifying confusion: The Confusion Assessment Method.
        at brief time intervals) may allow physicians to modify their clinical approaches. For example, when a patient is admitted with delirium to a hospital or postacute medical ward, the staff immediately starts a plan of interventions for each potential “cause” of delirium. If delirium persists longer than expected, this indirectly suggests that somatic causes underlying delirium have not been identified (and/or removed) and simultaneously compels physicians to rediscuss the global processes of care. On the contrary, the resolution of delirium may be viewed as the result of an appropriate patient's management.
        • Bellelli G.
        • Trabucchi M.
        Outcomes of older people admitted to postacute facilities with delirium.
        Delirium can also be regarded as a marker of the global quality of care
        • Inouye S.K.
        • Schlesinger M.J.
        • Lydon T.J.
        Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care.
        in hospitals but also in long-term care settings when the low level of technological equipment gives a particularly important role to direct clinical observation.
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      References

        • Flaherty J.H.
        • Rudolph J.
        • Shay K.
        • et al.
        Delirium is a serious and under-recognized problem: Why assessment of mental status should be the sixth vital sign.
        J Am Med Dir Assoc. 2007; 5: 273-275
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders: DSM-IV.
        4th ed. American Psychiatric Publishing, Washington, DC1994
        • Inouye S.K.
        • Van Dyck C.H.
        • Alessi C.A.
        • et al.
        Clarifying confusion: The Confusion Assessment Method.
        Ann Intern Med. 1990; 113: 941-948
        • Bellelli G.
        • Trabucchi M.
        Outcomes of older people admitted to postacute facilities with delirium.
        J Am Geriatr Soc. 2006; 54: 380-381
        • Inouye S.K.
        • Schlesinger M.J.
        • Lydon T.J.
        Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care.
        Am J Med. 1999; 106: 565-573
        • Speciale S.
        • Bellelli G.
        • Trabucchi M.
        Staff training and use of specific protocols for delirium management.
        J Am Geriatr Soc. 2005; 53: 1445-1446

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