Writing Disturbances: An Indicator for Postoperative Delirium

Abstract

Objective:

To study the writing ability pre- and postoperatively in patients undergoing major surgery.

Method:

In an open study twenty-four consecutive patients undergoing thoracotomy for pulmonary malignancy were monitored for postoperative delirium throughout their stay in the hospital. The writing ability was tested on a preoperative day and on the third day after the operation. Main outcome measures were delirium according to the DSM-III-R criteria and writing ability assessed on items such as reluctance to write and motor-, spatial-, syntactical- and spelling disorders.

Results:

Five patients (21%) developed delirium according to the DSM-III-R criteria. The writing of all patients with delirium was severely impaired with features like reluctance to write, motor disability and spatial disturbances. No patient without delirium developed these disturbances.

Conclusions:

These results suggest that testing of writing ability may be useful in the diagnosis of delirium. The Delirium Writing Test is proposed as a diagnostic tool.

Keywords

delirium detection postoperative writing disturbances surgical stress mental dysfunction

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References

Lipowski

Z. J.

, Delirium. Acute Confusional States, Oxford University Press, New York, pp. 47–53, 1990.

Wragg

R. E.

Dimsdale

J. E.

Moser

K. M.

Daily

P. O.

Dembitsky

W. P.

, and Archibald

Operative Predictors of Delirium after Pulmonary Thromboendarterectomy, Journal of Thoracic and Cardiovascular Surgery, 96: 524–529, 1988.

Williams-Russo

Urquhart

B. L.

Sharrock

N. E.

, and Charlson

M. E.

Post-operative Delirium: Predictors and Prognosis in Elderly Orthopedic Patients, Journal of the American Geriatrics Society, 40: 759–767, 1992.

Thomas

R. I.

Cameron

D. J.

, and Fahs

M. C.

A Prospective Study of Delirium and Prolonged Hospital Stay, Archives of General Psychiatry, 45: 937–940, 1988.

Wedington

W. W.

The Mortality of Delirium: An Underappreciated Problem?

Psychosomatics, 23: 1232–1235, 1982.

Berggren

Gustafson

Eriksson

Bucht

Hansson

Reiz

, and Winblad

Postoperative Confusion after Anesthesia in Elderly Patients with Femoral Neck Fractures, Anesthesia and Analgesia, 66: 497–504, 1987.

Lindesay

MacDonald

, and Starke

, Delirium in the Elderly, Oxford University Press, New York, 1990.

Levkoff

S. E.

Evans

D. A.

Liptzin

Cleary

P. D.

Lipsitz

L. A.

Wetle

T. T.

Reilly

C. H.

Pilgrim

D. M.

Schor

, and Rowe

Delirium: The Occurrence and Persistence of Symptoms among Elderly Hospitalized Patients, Archives of Internal Medicine, 152: 334–340, 1992.

Lipowski

J. C.

Delirium (Acute Confusional States), Journal of the American Medical Association, 258: 1789–1792, 1987.

10.

Perez

E. L.

and Silverman

Delirium: The Often Overlooked Diagnosis, International Journal of Psychiatry in Medicine, 14: 181–189, 1984.

11.

Trzepacz

P. T.

Teague

G. B.

, and Lipowski

Z. J.

Delirium and Other Organic Mental Disorders in a General Hospital, General Hospital Psychiatry, 7: 101–106, 1985.

12.

Lipowski

Z. J.

Transient Cognitive Disorders (Delirium, Acute Confusional States) in the Elderly, American Journal of Psychiatry, 140: 1426–1436, 1983.

13.

Tune

and Folstein

M. F.

Post-operative Delirium, Advances in Psychosomatic Medicine, 15: 51–68, 1986.

14.

Zbigniew

and Lipowski

J. C.

Delirium in the Elderly Patient, New England Journal of Medicine, 320: 578–584, 1989.

15.

Daniel

D. G.

and Rabin

P. L.

Disguises of Delirium, Southern Medical Journal, 78: 666–672, 1985.

16.

Golinger

R. C.

Delirium in the Surgical Patient, American Surgeon, 55: 549–551, 1989.

17.

Golinger

R. C.

Delirium at Surgical Patients Seen at Psychiatric Consultation, Surgery Gynecology & Obstetrics, 163: 104–106, 1986.

18.

Tune

L. E.

Postoperative Delirium, International Psychogeriatrics, 3: 325–332, 1991.

19.

Mesulam

M.-M.

and Geschwind

Disordered Mental States in the Postoperative Period, Urologic Clinics of North America, 3: 199–215, 1976.

20.

Francis

Martin

, and Kapoor

W. N.

A Prospective Study of Delirium in Hospitalized Elderly, Journal of the American Medical Association, 263: 1097–1101, 1990.

21.

Anderson

S. W.

Damasio

A. R.

, and Damasio

Troubled Letters but Not Numbers. Domain Specific Cognitive Impairments Following Focal Damage in Frontal Cortex, Brain, 113: 749–766, 1990.

22.

Trillet

Croisile

, and Laurent

Pure Agraphia: Two Cases, Revuew Neurologique, 145: 720–745, 1989.

23.

Parker

D. M.

Besson

J. A. O.

, and McFadyen

Intermittent Alexia, Cortex, 26: 657–660, 1990.

24.

Ardila

, and Rosselli

Spatial Agraphia, Brain and Cognition, 22: 137–147, 1993.

25.

Chedru

and Geschwind

Writing Disturbances in Acute Confusional States, Neuropsychologia, 10: 343–353, 1972.

26.

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis- orders, (3rd Edition), American Psychiatric Association, Washington, pp. 10–20, 1987.

27.

Innouye

S. K.

Dyck

C. H. V.

Alessi

C. A.

Balkin

Siegal

A. P.

, and Horwitz

R. I.

Clarifying Confusion: The Confusion Assessment Method, Annals of Internal Medicine, 113: 941–948, 1990.

28.

Rosati

and Bastiani

Pure Agraphia: A Discrete Form of Aphasia, Journal of Neurology Neurosurgery and Psychiatry, 42: 266–269, 1979.

29.

Friedland

Development and Breakdown of Language, Journal of Communication Disorders, 23: 171–186, 1990.

30.

Gersh

and Damasio

Praxis and Writing of the Left Hand may be Served by Different Callosal Pathways, Archives of Neurology, 38: 634–636, 1981.

31.

Rothi

Roeltgen

, and Kooistra

Isolated Lexical Agraphia in a Right-handed Patient with a Posterior Lesion of the Right Cerebral Hemisphere, Brain and Language, 30: 188–190, 1987.

32.

Sugishita

Toyokura

Yoshioka

, and Yamada

Unilateral Agraphia after Section of the Posterior Half of the Truncus of the Corpus Callosum, Brain and Language, 9: 215–225, 1980.

33.

Benson

D. F.

and Cummings

J. L.

, Agraphia, in Handbook of Clinical Neurology, 1, Frederiks

J. A. M.

(ed.), Elsevier Science Publishers, London, pp. 457–472, 1985

34.

Kitselman

, Language Impairment in Aphasia, Delirium, Dementia, and Schizophrenia, in Speech Evaluation in Medicine, Darby

J. K.

Jr. (ed.), Grune and Stratton, New York, pp. 199–214, 1981.

35.

Golinger

R. C.

Peet

, and Tune

L. E.

Association of Elevated Plasma Anticholinergic Activity with Delirium in Surgical Patients, American Journal of Psychiatry, 144, pp. 1218–1220, 1987.

36.

Itil

and Fink

Anticholinergic Drug-induced Delirium: Experimental Modification, Quantitative EEG and Behavioral Correlations, The Journal of Nervous and Mental Disease, 143: 492–507, 1966.

37.

Kehlet

, General vs. Regional Anesthesia, in Principles and Practice of Anesthesiology, Rogers

M. C.

Tinker

J. H.

Covino

B. G.

, and Longnecker

D. E.

(eds.), Mosby Year Book, St. Louis, pp. 1218–1234, 1993.

38.

Weissmann

The Metabolic Response to Stress: An Overview and Update, Anesthesiology, 73: 308–327, 1990.

39.

Douglas

R. G.

and Shaw

J. H. F.

Metabolic Response to Sepsis and Trauma, British Journal of Surgery, 76: 115–122, 1989.

40.

Bryan

R. M.

Cerebral Blood Flow and Energy Metabolism During Stress, American Journal of Physiology, 259: H269–H280, 1990.