Delirium and Other Organic Mental Disorders in a
General Hospital
Paula T. Trzepacz, M.D.
Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine,
Service, Western Psychiatric lnstitute and Clinic, Pittsburgh, Pennsylvania
Gregory B. Teague, Ph.D.
Assistant Professor of Clinical Psychiatry, Department
Hampshire
Z. J. Lipowski, M.D.
Professor of Psychiatry, Director, Psychosomatic Unit,, Clark lnstitute of Psychiatry,
Abstract: The authors analyze 233 cases of organic mental
disorders (OMDs) from a total of771 patients who were referred
for psychiatric consultation from a general hospital. The cases
represent a 2-year referral period which began July 1, 1980,
when DSM-Ill criteria were instituted. Delirium and dementia
are most commonly diagnosed and features of these, particularly
in the geriatric population, me described. Delirium was more
frequent in patients with multiple medical problems, was alz
indicator of poor prognosis having the highest mortality rate,
and was usually undiagnosed by the referring physician.
Introduction
There is a paucity of studies on organic mental
disorders (OMDs) in general hospital patient popu-
lations. Criteria for the diagnosis of these disorders
had not been available until the introduction of
DSM-III in July 1980 [ 11. DSM-III also offers a broad-
er range of diagnostic possibilities than previous
descriptions of OMD as either acute or chronic
organic brain syndromes, terms that roughly corre-
sponded to delirium and dementia. Both delirium
and dementia are disorders with global cognitive
deficits, and yet delirium also involves clouding of
consciousness, fluctuation, and more acute onset
than dementia.
GerreralHospital Psychiatry 7, 101-106, 1985
0 Elsevier Science Publishing Co., Inc. 1985
52 Vanderbilt Avenue, New York. NY 10017
Director, Consultation-Liaison
of PsychiatrJy, Dartmouth Medical School, Hanover, New
Toronto, Ontario, Canada
Delirium appears to be the most common organ-
ic brain syndrome (OBS) diagnosis [2,3]. The preva-
lence of OBSs other than delirium and dementia is
reported as being low. Lee described 130 cases of
OBS based upon modified Feighner’s criteria, with
7.6% intoxication/withdrawal, 6.9% organic per-
sonality, 3.8% organic delusional, and 2.3% each of
organic affective and hallucinosis syndromes [2].
He found delirium in about 60% and dementia in
14.5% of cases, the average age of his sample being
mid-forties. A sex difference was not reported, a
finding substantiated by other work [4].
The present study applied DSM-III criteria to
patients referred for psychiatric consultation from
medical and surgical wards in order to identify
relevant etiologic factors and patient characteris-
tics, and thus to provide factual basis for the needed
research on the pathophsiology of the organic brain
syndromes (OBS), especially in the aged.
Method
From July 1, 1980, through June 30, 1982, 771 pa-
tients were referred for psychiatric consultation
from the Dartmouth-Hitchcock Medical Center, a
420-bed, rural, tertiary care teaching hospital. Of
101
ISSN 0163-8343/85/$3.30
P. T. Trzepacz, G. B. Teague, and Z. J. Lipowski
these, 133 patients (17.3%) received a diagnosis of
an organic mental disorder based on DSM-III crite-
ria. In previous reports of psychiatric referrals from
this same medical center from 1971 to 1979, cases of
OBS accounted for about 15% of the diagnoses,
using DSM-II criteria [3,5]. Charts of these 133 cases
were retrospectively reviewed in detail by one of
the authors (P.T.T.) for information on demograph-
ic factors, reasons for referral, medical and psychi-
atric diagnoses, etiologic factors, mortality, and
consultee compliance with consultant recommen-
dations. All cases had been seen by a psychiatric
resident as well as by an attending consultation-
liaison psychiatrist who had made the final psychi-
atric diagnosis. The data were analyzed with com-
puter assistance.
Results
Demographic Data
Of the OMD cases, 55.6% were female and 44.4%
were male. Almost half (49%) were geriatric, that is,
65 years old or over. The mean age for the whole
sample was 60 years. Sex was fairly evenly dis-
tributed in each age category (above or below 65), as
well as in psychiatric diagnoses, except for alco-
holism, which was predominantly male (77%).
Referral Patterns
Internal medicine accounted for 53% of the 133
referrals, neurology 23%, surgery 15%, and all oth-
ers 8.3%. In only three cases did the stated reasons
for the referral include the correct diagnosis. In the
majority of the referrals (57%), consultation was
sought because of the presence of isolated psychi-
atric symptoms, including confusion, hallucina-
tions, agitation, bizarre or hysterical behavior, par-
anoia, combativeness, belligerence, forgetfulness,
or delusions. In 37% of referrals, an affective symp-
tom or diagnosis was cited in the referral, the pa-
tient being described as depressed, needing sup-
port, tearful, or suicidal. Need for management,
including evaluation for competency and refusal to
eat or cooperate with tests, was noted in 23%. Less
frequent reasons were a change in personality or
mental status (ll%), “nuisance” behavior” (7%),
and alcohol-related problems (5%). Most of the pa-
tients perceived by the consultee as being a “nui-
sance” or manipulative were, in fact, found by the
consultant to suffer from delirium (six out of nine
cases). Dementia cases were referred as needing
102
management twice as often as delirium (31% vs.
15%). Delirium was referred for consultation on the
basis of isolated symptoms 67% of the time and as
affective disturbance 35% of the time.
Diagnostic Characteristics
Delirium was the most common psychiatric diag-
nosis (58%), and about half of the cases (48%) were
in the geriatric group. Delirious patients had a
mean age of 59. Dementia was found in 34% of the
cases, two-thirds of whom were in the geriatric
group; demented patients had a mean age of 69.
The other OMD diagnoses accounted for 17% of the
cases (see Tables 1 and 2). Three cases were diag-
nosed as pseudo-OMD, two as pseudodementia,
and one as pseudodelirium.
There was a trend toward an increased incidence
of delirium as the number of medical diagnoses
increased. Patients with one or two diagnoses had a
49% incidence of delirium whereas those with three
or more had a 65% incidence.
The number of etiologic factors was also related
to the incidence of delirium. Examples of etiologic
factors included abnormal results of laboratory
tests, radiologic exams, and the like, or a phar-
macologic agent or an active medical problem that
could be established with a high index of clinical
probability as contributing to the altered mental
state. Cases with two or more etiologic factors had a
significantly greater incidence of delirium than did
cases with only one (x2=13.94, p<O.OOl, df=l).
Etiologic factors most commonly associated with
delirium were drugs (48%), metabolic (30%), neu-
rologic (20%), infectious (17%), and hypoxic (14%);
associated with dementia were neurologic (76%),
unknown (16%), metabolic (7%), and vitamin defi-
ciency (7%). Etiologic factors identified for other
organic brain syndromes are listed in Table 3.
Alcoholism affected 16.5% of our sample and
was judged to be an etiologic factor in a tenth of the
delirium cases.
Mortality
Twenty-three of I33 cases, or 17% of our sample,
died within 6 months of the consultation date (see
Table 4). Delirium was significantly related to mor-
tality in this sample (x2=6.97, df=l, p<O.Ol), with
delirious patients having the highest 6-month mqr-
tality rate of 25% (z=2.33, pcO.05). Only one out of
nine cases with alcoholism died-a patient who
had an associated alcoholic dementia. None of the
Table 1. Psychiatric diagnoses

Number % Number %
of of of of
cases total cases total

Dementia Delirium Amnestic

Senile dementia Substance-related delirium: Substance induced 1 0.8
Uncomplicated 3 2.3 Alcohol withdrawal 8 6.0 Syndrome 1 0.8
With delusions 1 0.8 Substance withdrawal 1 0.8
With delirium 8 6.00 Substance induced I.9 14.3
With depression 3 2.3 Total 28 21.1
Total 15 11.4 Affective
Delirium (syndrome) 38 28.6
Organic syndrome 1 0.8
Presenile dementia Delirium associated with 11 8.30
Uncomplicated 1 0.8 dementia
With delirium 1 0.8~ Total all categories delirium 77 58.0
With depression ._z 1.5
Personality
Total 4 3.1
Organic syndrome 6 4.5
Multiinfarct dementia
With delirium 2 1.5n
Delusional
With depression 6 4.5
Substance induced 1 0.8
Total 8 6.0 Atypical/mixed
Organic syndrome 1 0.8
Substance induced 2 1.5
Substance-related dementia
Atypical/mixed syndrome 2 1.5
Substance induced 2 1.5
Alcohol related _I 0.8
Total 3 2.4
Hallucinosis Other
Dementia (syndrome) 15 11.3
Substance induced 1 0.8 Bipolar, manic 1 0.8
Total all categories dementia 45 34.2 Organic syndrome 3 2.3 Pseudodementia 2 1.5

REleven patients met diagnostic criteria for both delirium and dementia
P. T. Trzepacz, G. B. Teague, and Z. J. Lipowski

Table 2. Psychiatric diagnoses and relationship to a geriatric population

Numbers of Psychiatric Diagnosesa

Age Any
in alcohol-related
years Delirium Dementia Other OBS Pseudo-OBS OBS Total

<65 40 15 13 1 9 78
265 37 30 6 2 0 75

aPossible multiple diagnoses/case.

Table 3. Etiologic factors for OBS other than Table 4. Mortality within 6 months of
delirium or dementia consultation date

Number of Psychiatric diagnosesa

OBS diagnosis Etiologic factor cases
Delirium Dementia Other Total
Delusional Alcohol 1
Unknown 1 No. of deaths/ 19177 3145 2124 231133
Hallucinosis Carbamazepine 1 No. of cases
Epilepsy/ (%) (25) (6.7) (8.3) (17.3)
polypharmacy 1
Remote effects of Vossible multiple diagnoses/case.
cancer 1
Pituitary adenoma/
right parietotem-
Causes on death certificate for 19 delirious cases
poral abscess 1
Amnestic Falx meningioma 1
Respiratory Renal Cardiovascular
Cerebral multiple
Cancer Failure Failure Failure Unknown
sclerosis 1
Affective Epilepsy 1
13 2 2 1 1
Personality Alcohol 2
Left frontotemporal
meningioma 1
CNS hypoxia second- cases with alcohol withdrawal delirium died. Thir-
ary to pulmonary teen (68%) of the delirium deaths occurred during
disease 1
the index admission. The mean number of etiologic
Epilepsy 1
factors (2.1) for delirious patients who died was
Cerebrovascular
significantly larger than the mean number (1.6) for
accident 1
Atypical/mixed CNS hypoxia second-
those who did not (t=2.18, df=27, ~4.05).
ary to cardiac
disease 1
Recommendations and Compliance
CNS hypoxia second-
ary to cardiac ar- Recommendations by the consultants for various
rest/hypoglycemia 1 tests, procedures, or interventions were complied
ICU/paralysis second- with by the consultees in 91% of the cases, and were
ary to Guillain- partially followed in 3.8%. Recommendations usu-
Barre 1
ally included performing laboratory tests, EEGs,
Unknown 1
ECGs, radiologic studies, adjusting drug regimens,
Pseudodelirium Mania 1
or adding medications such as neuroleptics or ben-
Pseudodementia Depression 2
zodiazepines. Transfer to a psychiatric inpatient

104

unit was necessary in only ten cases; three of these
patients had an affective component and three
were substance abusers.
Discussion
Our findings generally concur with previous re-
ports on the prevalence of OBS in psychiatric refer-
rals from a general hospital [2,3,5]. Our study
found a preponderance of delirium and dementia
diagnoses, with other OBS cases comprising only
17% of our sample.
Three of our cases, eventually diagnosed as af-
fective disorders, imitated an organic brain syn-
drome on initial presentation. Our case of pseudo-
delirium associated with a manic episode was con-
sistent with the diagnosis of delirious mania, first
described by Bell in 1849 [6]. Features of that variant
of mania include acute onset of confusion, disorien-
tation, visual and auditory hallucinations, delu-
sions, and severe agitation [6]. Pseudodelirium
may be induced by other psychiatric disorders as
well [7,8]. Lipowski proposes that the term “pseu-
dodelirium,” analogous to pseudodementia, be
used until the proper nosologic status of this appar-
ently “functional” yet deliriumlike syndrome has
been elucidated [8]. Our two cases of pseudode-
mentia were depression related. We agree with
McAllister, who has suggested that the cognitive
impairment associated with depression be more
appropriately viewed as a depression-induced OBS
[91*
The finding that half of our sample was elderly
underscores the growing need for attention to this
population’s medical and psychiatric needs in the
general hospital setting [lo]. Unexpectedly, our el-
derly group did not have a greater representation of
delirium than the younger group despite being af-
fected twice as often by dementia. The delirious
elderly patients had a higher mean number of med-
ical problems [3,5] than the younger ones [2,3]
(1=4.51, df=74, p<O.OOl), and were significantly
more affected by pulmonary, renal, endocrine (p-
cO.05) and cardiovascular illnesses (p<O.Ol). In the
younger group, alcohol intoxication or withdrawal
was a more common etiologic factor in delirium
than in the elderly group QKO.01). However, geri-
atric patients were relatively more often affected by
metabolic and neurologic factors (~~0.05). Drug-
related factors were equally common in both age
groups. The drugs implicated in causing an organic
brain syndrome included prednisone, opioids,
anticholinergics, benzodiazepines, cimetidine,
Organic Mental Disorders in a General Hospital
lithium, digoxin, barbiturates, cancer chemothera-
peutics, antidepressants, levodopa, phenytoin,
and carbamazepine.
The most common medical diagnosis in dement-
ed patients was neurologic in both age groups, and
included cerebrovascular diseases, CNS tumors,
epilepsy, meningitis/encephalitis, cerebral multi-
ple sclerosis, Alzheimer’s disease, and lipid storage
disease. The demented elderly patients were signif-
icantly more likely to have multiple medical diag-
noses (mean 3.1) compared to the younger group
(2.1) (t=2.1, df=22, ~~0.05) and were significantly
more affected by cardiovascular illness (~~0.05).
Etiologic factors for dementias were generally at-
tributed to the presenting neurologic illness, except
that an etiology could not be elucidated in 20% of
our elderly group despite extensive investigation.
Ten of eleven patients who exhibited symptoms
of both delirium and dementia were elderly (mean
age of 76). Such cases present difficult diagnostic
problems and are at risk of having delirium over-
looked.
Levine et al. reported that 65% of organic brain
syndrome referrals were misdiagnosed as de-
pressed [ll]. In Lee’s study, only 17% of referrals
were correctly diagnosed by the referring physi-
cian, while two-thirds of the cases were diagnosed
incorrectly as suffering from a functional psychi-
atric disorder [2]. Diagnosis or suspicion of an
OMD by the referring physician was even rarer in
our study, in which the majority of consultees cited
various isolated psychiatric symptoms as a reason
for the referral. This could indicate an ability to
accurately detect certain symptoms associated with
OMD, despite a lack of diagnostic expertise. How-
ever, a substantial number of patients were viewed
as being depressed, purposefully noncompliant, or
“problem” cases rather than as cognitively im-
paired.
Lack of recognition of delirium implies an insuf-
ficient pursuit of underlying medical etiologic fac-
tors. The need for prompt diagnosis is underscored
by the high mortality associated with delirium
[4,12] as well as by the psychologic morbidity per-
ceived by the patients. One-fourth of our patients
with delirium died within 6 months of consultation,
and two-thirds of those deaths occurred during the
index admission. Weddington reviewed charts of
116 psychiatric referrals and reported a 33% 3-
month mortality of patients with delirium [12].
Rabins and Folstein compared delirious and de-
mented patients and found a significant difference
in mortality rates, with 23% of the delirious patients
105
I’. T. Trzepacz, G. B. Teague, and Z. J. Lipowski
and only 4% of the demented patients dying during
the index admission [4].
Of the 15 cancer deaths in our sample, 13 (87%)
were also diagnosed as being delirious. In addition,
cancer was the most common reason for the high
mortality rate noted in our delirious cases. Levine et
al. assessed 100 cancer patients consecutively re-
ferred for psychiatric consultation and, using DSM-
II criteria, diagnosed 40% as having an organic
brain syndrome [ll]. In a study of 19 terminally ill
cancer patients, Massie et al. [13] found 85% (11 of
13) to be delirious and moribund, usually with mul-
tifactorial etiologies. We found that polypharmacy
and physiologic imbalances encountered as com-
plicating features to the cancer were often the
etiologic factors implicated as deliriogenic.
Compliance with recommendations made by our
service was gratifyingly high, in agreement with
the findings of Popkin et al. [14]. Those authors
reported an 84% concordance with recommenda-
tions concerning patients with OMD, versus only
53% for psychiatric consultations overall. They pro-
posed that nonpsychiatric physicians may prefer
management of OMD because of the more obvious
medical and physiologic nature underlying these
disorders.
Conclusions
Our study highlights the relatively high frequency
of the organic brain syndromes among medical and
surgical inpatients referred for psychiatric consulta-
tions, Delirium and dementia were the most fre-
quently encountered OBSs, especially among the
elderly, who are vulnerable to being affected by
both simultaneously. Other organic brain syn-
dromes comprised only 17% of our sample. Non-
recognition of OBS, particularly of delirium, may
result in increased morbidity and mortality.
106
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Direct reprint requests to:
Paula T. Trzepacz, M.D.
University of Pittsburgh School of Medicine
Director, Consultation-Liaison Service
Western Psychiatric Institute and Clinic
3811 O’Hara Street
Pittsburgh, PA 15213