Background Whether postoperative subsyndromal delirium (SSD) is a separate syndrome from delirium and has clinical relevance is not well understood. Objectives We sought to investigate SSD in older surgical patients and to determine its prognostic significance. Methods We performed a prospective cohort study of patients aged ≥65 years of age scheduled for noncardiac surgery. Postoperative delirium was determined using the Confusion Assessment Method. SSD was defined as the presence of at least one out of a possible 10 symptoms of delirium, as defined by the Confusion Assessment Method, but not meeting criteria for delirium. Results The number of features of SSD on the first postoperative day was associated with the subsequent development of delirium on the next day, after controlling for other risk factors. Compared to a patient with no SSD features, a patient with one SSD feature was 1.07 times more likely to have delirium on the next day (95% CI 0.42, 2.53), 2 features – 3.32 times more likely (95% CI 1.42. 7.57), and ≥ 2 features - 8.37 times more likely (95% CI 4.98, 14.53). Furthermore, there was a significant relationship between the number of features of SSD and increased length of hospital stay, and worsened functional status at one month after surgery. Conclusions SSD is prevalent in at risk surgical patients and has prognostic significance. Only one symptom of SSD was sufficient to cause a significant increase in hospital length of stay and further decline in functional status. These results suggest that monitoring for SSD is indicated in at risk patients.

Case Presentation"Ms. V," a 60-year-old college-educated woman, was brought by her daughter to the emergency department at a teaching hospital for the evaluation of heart palpitations. Ms. V had personality changes and mood swings with aggressive verbal and physical behaviors that had progressively worsened over the past year. A psychiatric consultation was requested to evaluate these emotional outbursts. On the day of admission, Ms. V had had a court hearing for assaulting her brother, who is disabled due to mental retardation. One month before presentation, she had held a pillow over his face in front of the brother's social worker, who then called the police. After this event, her brother, who has been dependent on others for self-care since childhood, disappeared for several days. She was unconcerned about her legal situation and appeared cold and indifferent. She did not report that she did anything more than throw a pillow at her brother's face, and she laughed when she heard that he was missing. Ms. V's daughter reported that her mother had become increasingly irritable, with episodes of unprovoked shouting of profanities at strangers and family members. These behaviors were uncharacteristic of the patient's personality at baseline. She had had an increase in goal-directed activities, cleaning the house constantly, checking the locks, and checking the stove. Two years before, Ms. V was fired from her job as a school administrative assistant because of difficulties managing her relationships with the students' parents. Since then, she had not made any attempts to seek other employment. There was no history of head trauma, loss of consciousness, seizures, or previous contact with mental health providers.Ms. V reported no new stressors but did report some "moodiness" over the last 6 months. She reported no angry outbursts or violence but endorsed a decreased need for sleep (now 6 hours, down from 8, per night). Although she did not report feeling euphoric, she reported increased irritability, daytime energy, task-oriented behavior, impulsivity, distractibility, racing thoughts, and pressured speech. Ms. V did not report feeling depressed or experiencing anhedonia. She reported no anxiety or psychotic symptoms, substance use, or recent changes in medications. Ms. V did not report any specific memory complaints, word-finding difficulties, misplacing or losing objects, or problems using transportation, following directions, or navigating. Her family history was notable for a brother with mental retardation and a sister with unipolar depression. Ms. V's vital signs were within normal limits, and complete physical and neurologic examinations were unremarkable. A CBC, a Chem 10 (basic chemistries), liver function tests, tests of thyroid-stimulating hormone, free thyroxine, rapid plasma reagin, B 12 , and folate, an ECG, a chest X-ray, and a head computerized tomography with and without contrast showed no abnormalities. Mental Status ExaminationMs. V appeared a well-dressed and well-groomed woman with mild psychomot...

Objectives: Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care.Methods: This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED.Results: A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = À60 to 5.9 visits per month) in the postintervention phase.Conclusions: A comanagement model was associated with a marked reduction in the LOS for this patient population.ACADEMIC EMERGENCY MEDICINE 2013; 20:338-343

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