Great New Article on Decision Support Tools for Delirium Detection—and Some Thoughts

Quick and Dirty Comparison Table of Delirium Screening Scales

A colleague just sent me a copy of an article via our university interlibrary loan system on using a decision support tool for detecting delirium in patients with dementia. The authors describe the feasibility pilot using the electronic medical record (EMR) to assist in nursing assessment and detection of delirium in patients with dementia. The article contains screenshots from the EMR of potential medical causes of delirium, and interventions as well. This echoes what our own delirium prevention project is trying to accomplish. The only thing missing were screenshots of the Confusion Assessment Method (CAM), the delirium screening scale they chose to use. The cognitive assessment piece they used in order to increase the sensitivity of the CAM was the copyrighted Mini-Mental State Examination (MMSE) which, by the way, is not available in the public domain nowaday [1].

The exciting thing about this pilot is the 100% adherence by nursing staff on the delirium assessment decision support screens and 75% adherence on the delirium management screens using the EMR. Part of the protocol about which there was very little detail was just how the delirium assessment results were conveyed to physicians and how they responded.

I thought some of the nurses’ comments about the protocol were telling:

“The hardest part will be not medicating patients….It is all we have.”

“It will be nice to have strategies besides calling psychiatry to medicate patients.”

Notably only a little over half of the nurses attended the preliminary educational component of the protocol, which may in part explain the comments. However, I think they could also be illustrative of the organizational culture in patient care units in hospitals and the importance of keeping that in mind when trying to implement delirium prevention programs. I wonder if requiring doctors as well as nurses to attend might have made a
difference by sending a clear message that delirium prevention requires a team-building paradigm with a spirit of collaboration under a multidisciplinary umbrella.

The comment about drugs being “…all we have” is definitely not true and the best example of what is most frequently recommended for prevention and management of delirium is Dr. Sharon Inouye’s Hospital Elder Life Program (HELP), the leader in non pharmacologic multicomponent delirium prevention and management strategies. Please see the link to HELP in the sidebar for more information about this vital piece in the multicomponent repertoire for preventing delirium. While we can’t expect every hospital to duplicate this stellar example of high-quality medical care which has generated abundant evidence for its effectiveness in reducing many negative outcomes of delirium, there are enough studies of similar efforts to encourage wide-spread adoption of the model—and to ensure adherence.

I think the comment about calling the consulting psychiatrist is very interesting. If my only role is to advise the inpatient medical team on which drugs to use or not use for medicating delirious patients, then we’re all in serious trouble, especially the patients. A pharmacist could fill that role and if the pharmacist is viewed as a critically important member of an integrated delirium prevention team, then the assignment makes perfect sense. The authors of the just-published book about the assessment and treatment of delirium the intensive care unit, “Delirium in Critical Care” gave very little space to the section on the role of the psychiatrist in this area—something less  than 110 words. My comments from an earlier blog about this:

The authors say, while acknowledging that the opinions of psychiatrists and intensivists might differ, “…we would advocate that a psychiatrist should be consulted for patients already under the care of a psychiatrist or on antipsychotic medications”[2]. Usually, in most medical centers in the U.S.A. a Psychosomatic Medicine specialist (formerly called a general hospital consultation-liaison psychiatrist) sees the delirious inpatient rather than the patient’s outpatient psychiatrist. And many delirious patients don’t have a previous formal history of psychiatric illness and so would not have been seeing an outpatient psychiatrist in the first place.

The authors also believe psychiatrists might be helpful if there is trouble distinguishing
between dementia and delirium, in cases of delirium in which the usual pharmacologic strategies are ineffective in controlling agitation, and in cases of persisting delirium or when the diagnosis of delirium is uncertain. We “might be useful at a later stage” to evaluate and treat intensive care unit-related post-traumatic stress disorder. The section concludes with the very sensible “recipe” for treating delirium, which begins with treating all possible underlying medical conditions and only then administering Haldol provided it can be safely given as long as cardiac conduction times are not prolonged.

I think redefining the roles of the team in delirium prevention is long overdue. I think psychiatrists still have a role to play and that’s evident in the persisting tendency to validate the growing number of delirium screening scales for non-psychiatric nurses working in general medical units and intensive care unit against the Diagnostic and Statistical Manual for Mental Disorders (DSM) diagnostic criteria for delirium[3]. One role consulting psychiatrists can play is to help internists and intensivists and the nurses who work with them discriminate delirium from the many other psychiatric disorders which it can mimic.

However, I also believe that both non-psychiatric clinicians and psychiatrists can work together at being accountable for preventing delirium, because as George W. Henry pointed out in the first published paper on consultation psychiatry:

Relegating this work to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods[4].

Is delirium prevention an issue for “psychiatric methods”? Delirium prevention is an issue for both medicine and psychiatry.

1.            Fick, D.M., et al., Computerized decision support for delirium superimposed on dementia in older adults. J Gerontol Nurs, 2011. 37(4): p. 39-47.

2.            Page, V. and E.W. Ely, Delirium in Critical Care. Core Critical Care, ed. A. Vuylsteke. 2011, New York: Cambridge University Press.

3.            American Psychiatric Association. and American Psychiatric Association. Task Force on DSM-IV., Diagnostic and statistical manual of mental disorders : DSM-IV-TR. 4th ed. 2000, Washington, DC: American Psychiatric Association. xxxvii, 943 p.

4.            Henry, G.W., SOME MODERN ASPECTS OF PSYCHIATRY IN GENERAL HOSPITAL PRACTICE. Am J Psychiatry, 1929. 86(3): p. 481-499.