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Authors' Response to Letter by Speciale et al.

Institute for Aging Research Hebrew SeniorLife Boston, Massachusetts
Division of General Medicine and Primary Care Beth Israel Deaconess Medical Center Boston, Massachusetts
Interdisciplinary Center on Aging Harvard Medical School Boston, Massachusetts

Address correspondence to Dan K. Kiely, MPH, MA, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St., Boston, MA 02131-1097. E-mail: kiely{at}hrca.harvard.edu

To the Editor:

We read with interest the letter to the editor by Speciale and colleagues presented in this issue. They report on data gathered from their experiences in detecting and managing delirium in their Rehabilitation and Aged Care Unit from June 1, 2004, through January 31, 2006. The authors state that their study supports our finding that later delirium resolution is associated with poor functional recovery. However, they further state that they were not convinced that early recognition and treatment of delirium necessarily results in good functional recovery among all individuals.

We have two responses to Speciale and colleagues' letter. First, we are pleased that their data supports our primary conclusion that persistent delirium is associated with worse functional recovery in the postacute setting. Second, in our Discussion section, we stated "our results highlight the importance of early recognition and treatment ... as well as good management ... of delirium." Interestingly, the results of Speciale and colleagues' study may in fact support this contention, given the likely excellent detection and management of delirium in their study and the remarkably high delirium resolution within 2 weeks (40/58 = 69%). However, we never stated that early recognition and treatment of delirium would ensure good functional recovery among all individuals, and our study was not designed to address this question. Whether improved delirium recognition and management can improve functional recovery in some individuals remains an important issue that is worthy of further investigation.

Finally, in reference to Speciale and colleagues' study, we wish to emphasize that without premorbid assessments of cognitive and functional performance, it is difficult to accurately assess "frailty" as it relates to the trajectory of delirium over time. Measures such as the Mini-Mental Status Examination and the Barthel index are inevitably affected by the severity of the ongoing delirium, and therefore assessment of patients' baseline functional and cognitive status requires proxy assessments, as were done in our study.

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