|
 
 |
| EDITORIAL |
|
| Year : 2014 | Volume
: 1
| Issue : 2 | Page : 57-59 |
|
Delirium-most prevalent mental disorder: Still a clinical orphan?
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Web Publication | 3-Mar-2015 |
Correspondence Address:
Dr. Sandeep Grover
Associate Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2348-9995.152423
How to cite this article:
Grover S. Delirium-most prevalent mental disorder: Still a clinical orphan?. J Geriatr Ment Health 2014;1:57-9 |
Delirium is the most common neuropsychiatric condition encountered in medically ill patients admitted to the hospital with incidence rates varying from 3% to 42%, and the prevalence rates varying from 5% to 44% in hospitalized patients. [1] However, these rates are much higher for people admitted to various Intensive Care Units (ICUs), with prevalence rates reported to be as high as 82%. [2],[3] While delirium is associated with medical morbidity across ages, it is the elderly and the cognitively impaired who are at increased risk of development of the disorder. Data from various parts of the globe now suggest that development of delirium is independently associated with a significant increase in the length of hospital stay, requirement for institutional care, functional decline, inpatient mortality, and long-term mortality. [4],[5],[6],[7],[8] Delirium has also been shown to be associated with increased health care costs. [9] Contrary to the earlier view that delirium is just an acute condition with no long-term deficits, recent research has demonstrated its adverse effects on long-term cognitive functions with increase in the risk of development of dementia. [10] A recent meta-analysis which included seven studies with about 700 elderly subjects with history of delirium showed a significant increase in the risk of postdischarge mortality (hazard ratio - 1.95), institutionalization (odds ratio - 2.41), and future dementia (odds ratio - 12.52) after adjusting for the effect of age, gender, comorbid illnesses. [11] Recent data also suggest that the whole experience of delirium is considered as distressing by a significant proportion of the patients and their accompanying relatives too. [12],[13],[14] However, despite this high prevalence and significant negative consequences, the disorder remains orphan as this is mostly seen in nonpsychiatric set-ups.
In a resource poor country like India, where a major proportion of the health care cost is spent out of the pocket by patient and the family, prolonged stay in the hospital and other negative consequences impose a significant financial and caregiving burden on the family unit. Further, there is scarcity of the ICU beds as these facilities are available only in few centers. Hence, it is desirable that the ICU stay of all the patients is kept to a minimum so that the other needy patients can avail the facilities as per their requirement.
These negative consequences of delirium call for prevention, early identification, and appropriate management of delirium. Unfortunately, delirium is often underdiagnosed and undertreated in medicosurgical and ICU settings. Studies suggest that the rates of under diagnosis for delirium vary from 33% to 72% and the common diagnostic errors include misattribution of symptoms to dementia or depression. [15],[16] Further, on many occasions if the psychiatric help is taken, there is often a lag period between the onset of delirium and psychiatric consultation. [17]
| Why is this Problem? | |  |
When a patient develops a psychiatric illness like depression or schizophrenia, the patient themselves or their family members feel the need for a psychiatric consultation and often the patient is brought to the attention of a psychiatrist, either directly or through other pathways of care. Further, all the symptoms at the time of presentation are considered to be part of mental disorder until and unless there is a clear evidence for a physical illness. Resultantly, the psychiatrist becomes the primary professional who takes care of mental and physical health issues of the patient with consultation with other specialists as per the requirement. In contrast, delirium is seen in the presence of a physical illness, which is often life-threatening, for example, myocardial infarction and requires more clinical attention. Thankfully, with the current level of sophistication, many life threatening conditions like renal failure, pulmonary dysfunction or cardiac dysfunction can be managed successfully. In contrast, if at all the physicians know that the patient has delirium, they may not be aware of what they can offer or may not give it its due importance. Next is the problem with the clinical picture. For example if a patient has hypoactive delirium and becomes quiet (but is not comatose), this state is considered to a blessing in disguise, both by the family caregivers and the treating team, as patient appears to be stable as he/she is not disturbing anyone. If the patient develops hyperactive delirium, especially with florid delusions and hallucinations and creates a ruckus, the patient is considered to be having a psychiatric illness, and the underlying physical illness has nothing to do with it. For example, if a surgeon has operated on the patient 3 days back and patient was showing improvement but suddenly develops hyperactive delirium, the psychiatry team is consulted to shift the patient to the psychiatry ward. Often, it becomes very difficult for the psychiatrist to convince the physicians that although the symptoms are of a mental illness, but these are due to the underlying physical illness, that is, in this case due to surgery or complications of surgery. All this suggests that the basic problem lies in the knowledge among other medical professionals about delirium. In addition, because of the shortage of manpower, it is not possible for psychiatrists to screen all medically ill patients for delirium. As a result, many patients with delirium are not diagnosed and treated. Finally, comes the issue of managing delirium. For example, if a psychiatrist is called for consultation and diagnosis of delirium is made-what next? Is it sufficient just to prescribe antipsychotics? If reorientation cues are suggested to the family caregivers or nursing staff, who monitors that the same is being followed? How seriously do the nursing staff and family caregivers take the advice of the psychiatrists as he/she is not the primary physician? This is of relevance as if the same instructions came from the primary physician to his/her junior colleagues, nursing staff or family caregivers; there is a greater chance that these instructions would be followed with more diligence and regularity.
Hence, despite its significant prevalence and impact, delirium is not the baby of anyone and remains an orphan. We all know what the fate of an orphan child is. As mental health professionals, most of us do not like this scenario. Hence, we need to consider what need to be changed.
Considering the shortage of mental health professionals, it will never be possible, at least in the near future, to have mental health professionals to screen all medically ill patients for delirium. Hence, to improve screening, it is important that the knowledge of the primary treating medical professionals must be enhanced. In terms of improving the knowledge, there is a need to emphasize the role of identification of the risk factors, daily screening, usefulness of antipsychotics, and reorientation cues and so on. However, it is important to remember that many of these things will not appeal to a physician and surgeon till this information is provided in such a way that they understand that all this will lead to improvement in the outcome of their patients. For example, importance of delirium would be more appreciated by a surgeon if he is told that despite your best efforts, 5-6 of your 100 patients die and this can reduced to 2-4 if delirium is identified and treated. This sharing of knowledge can be done at various levels. This can be done at one to one level between the psychiatrists and the other medical professionals while dealing with individual cases or as part of the joint educational sessions where specialists from both the specialties are present. Further, in the ICU setup and also for the general wards, there is a need to train the nurses to screen the patients for delirium as part of their evaluation of the patient. Research clearly shows that this can be beneficial and cost-effective. Over the years, considering the importance of identification and management of delirium, the professionals from various specialties have joined together to form the American Delirium Society and the European Delirium Association. On similar lines, formation of this kind of focused professional group involving professionals from various medical specialties in India can help in mutual enhancement of the knowledge about delirium. This will also help in sharing research on delirium and also enhance inter-specialty collaborations.
Recently, in a consensus statement, the European Delirium Association concluded that it is essential to incorporate "elements of modeling and opportunistic learning to showcase good clinical practice." [18] The consensus further suggests that there is a need to offer the educational innovations like e-learning, to all health care professionals before and after the qualifying exams, and this should be freely available online. The European Delirium Association suggests that developing resource materials in the form of videos of the patients and the caretakers can be developed and used as teaching material. [18]
The Indian Association of Geriatric Mental Health is attempting to achieve such a goal for geriatric mental health by developing online Continuing Medical Education (CME), which can be assessed freely by anyone at the Association's website. The Association can include delirium as one of the key areas in the online CME program. Further, this can be made interactive so that the queries of other medical professionals can be addressed.
Besides the educational activities, there is a need for the mental health professionals to take up the issue of delirium with hospital administrators. If the mental health professionals can impress the administration with respect to the improved outcome, shorter hospital stay, reduced short- and long-term mortality and overall outcome by improving delirium care, then the people at these positions can play a vital role in change in the practice with respect to screening, liaison and management of delirium.
It is expected that all these measures will help in improving the knowledge of all medical professionals toward the delirium and improve the practice with respect to prevention, identification, and management of delirium. It is hoped that all these measures will place the orphan baby to a joint family, where although the baby has a particular set of parents, but others are around to substitute for the parents, either for a short duration or a long duration.
| References | | |
| 1. | Fann JR. The epidemiology of delirium: A review of studies and methodological issues. Semin Clin Neuropsychiatry 2000;5:64-74.  |
| 2. | Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the Intensive Care Unit. JAMA 2004;291:1753-62. |
| 3. | Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, et al. Current opinions regarding the importance, diagnosis, and management of delirium in the Intensive Care Unit: A survey of 912 healthcare professionals. Crit Care Med 2004;32:106-12. |
| 4. | Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age Ageing 2006;35:350-64. |
| 5. | Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998;13:234-42. |
| 6. | McCusker J, Kakuma R, Abrahamowicz M. Predictors of functional decline in hospitalized elderly patients: A systematic review. J Gerontol A Biol Sci Med Sci 2002;57:M569-77. |
| 7. | Tennen GB, Rundell JR, Stevens SR. Mortality in medical-surgical inpatients referred for psychiatric consultation. Gen Hosp Psychiatry 2009;31:341-6. |
| 8. | Grover S, Shah R, Kr A. The mortality rate among patients with delirium 6 months after diagnosis by a consultation-liaison psychiatric team. Turk Psikiyatri Derg 2012;23:189-92. |
| 9. | Leslie DL, Inouye SK. The importance of delirium: Economic and societal costs. J Am Geriatr Soc 2011;59 Suppl 2:S241-3. |
| 10. | Popp J. Delirium and cognitive decline: More than a coincidence. Curr Opin Neurol 2013;26:634-9. |
| 11. | Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA 2010;304:443-51. |
| 12. | Grover S, Shah R. Distress due to delirium experience. Gen Hosp Psychiatry 2011;33:637-9. |
| 13. | Grover S, Shah R. Delirium-related distress in caregivers: A study from a tertiary care centre in India. Perspect Psychiatr Care 2013;49:21-9. |
| 14. | Grover S, Ghosh A, Ghormode D. Experience in Delirium: Is It Distressing? J Neuropsychiatry Clin Neurosci 2015 (in press). |
| 15. | Fick D, Foreman M. Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. J Gerontol Nurs 2000;26:30-40. |
| 16. | Kales HC, Kamholz BA, Visnic SG, Blow FC. Recorded delirium in a national sample of elderly inpatients: Potential implications for recognition. J Geriatr Psychiatry Neurol 2003;16:32-8. |
| 17. | Grover S, Kate N, Mattoo SK, Chakrabarti S, Malhotra S, Avasthi A, et al. Delirium: Predictors of delay in referral to consultation liaison psychiatry services. Indian J Psychiatry 2014;56:171-5. [ PUBMED]  |
| 18. | Teodorczuk A, Reynish E, Milisen K. Improving recognition of delirium in clinical practice: A call for action. BMC Geriatr 2012;12:55. |
|
Search Pubmed for