Just Call Me…Rango

I was very honored to have been invited to give my first (and probably only) Internal Medicine grand rounds presentation on delirium August 4, 2011. I was pretty nervous, even after many years of giving similar presentations, only in my own department of Psychiatry. I really didn’t know what to expect. Many members of the audience were internal medicine residents I recognized, which helped. Several faculty members were also there, which surprised me just a little. They were very nice to me, not a tough crowd at all, even after I told them, in so many words, that a psychiatrist is not the first person they should call when they suspect one of their patients is delirious.

In other words, I spilled the beans. For years I and my colleagues have acted sort of as heroes, me more of an outlaw anti-hero more or less. I would ride in when called and act like a gunslinger. They asked me to evaluate depression, anxiety, psychosis, and mania–and I showed them the Clock Drawing Task of the Mini-Cog which I always do as part of my quick and dirty delirium assessment. The Clock Drawing Task almost invariably was what I intended it to be, a graphic piece of evidence that delirium was the problem, not a primary psychiatric disorder. Most of the residents laughed when I reminded them of the pretty wild clocks I’ve seen and shown them. Most of them laughed…not all but you can’t be all things to all people.

I talked of what delirium is and what it is not. It’s a mimic and often under the mask of mental illness, an ugly killer. And I spoke of what I think a psychiatrist’s role should be on a multidisciplinary team of hospital caregivers trying to prevent the mortal danger that delirium always is to the patient, especially the older person. I told them what I could do, which is to tell them what the strange malady gripping the patient is not–and it is not a primary psychiatric disorder but a medical emergency.

I did some clowning, like I always do when I’m on hospital rounds. The people in this audience, even though I’m the psychiatrist and they are the internists (the “real doctors”), are my friends and we respect each other. But I did more than just clown. I told them, again, about delirium screening instruments like the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) and the original CAM, the inventions of geniuses, real heroes, at Yale and Vanderbilt  who are not psychiatrists [1, 2]. I even read them the very short passage in Delirium in Critical Care, an outstanding book just published in the spring of 2011 (and which you can purchase by following the link in the menu on this blog site). This passage essentially asks the question whether we need psychiatrists to help manage delirium [3]. The answer is no.

Just like Rango, I plucked the tin Sheriff’s badge from my skinny chest and exposed the consulting psychiatrist for what he really is in the face of the scourge of delirium in the hospitalized patient–a fraud trumped-up by his peers who think they  must depend on him. What we are is a band of warriors who depend on each other in the face of a dangerous, complex reptile like delirium, which we don’t fully understand yet must battle every day on behalf of our patients. I thank them from the bottom of my heart.

Just call me…Rango.

1. Ely, E. W., M. D. Siegel, et al. (2001). “Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction.” Semin Respir Crit Care Med 22(2): 115-126.

The intensivist should think of delirium, or acute central nervous system dysfunction, as the brain’s form of “organ dysfunction.” Delirium is extremely common in intensive care unit (ICU) patients due to factors such as comorbidity, critical illness, and iatrogenesis. This complication of hospital stay is extremely hazardous in older persons and is associated with prolonged hospital stays, institutionalization, and death. Neurologic dysfunction compromises patients’ ability to be removed from mechanical ventilation or achieve full recovery and independence. Yet ICU nurses and physicians are usually unaware of the presence of hypoactive delirium and only recognize this disturbance in agitated patients (hyperactive delirium). More importantly, there are few studies that have included ICU patients in the assessment or prevention of delirium. This article reviews the definition and salient features of delirium, its primary risk factors, a newly validated instrument for delirium assessment that is being developed for ICU nurses and physicians, and pharmacological agents associated with the development of delirium and used in its management.

2. Inouye, S. K., C. H. van Dyck, et al. (1990). “Clarifying confusion: the confusion assessment method. A new method for detection of delirium.” Ann Intern Med 113(12): 941-948.

OBJECTIVE: To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. DESIGN: Prospective validation study. SETTING: Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). PATIENTS: The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. MEASUREMENTS AND MAIN RESULTS: An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 – 1.0). CONCLUSIONS: The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

3. Page, V. and E. W. Ely (2011). Delirium in Critical Care. New York, Cambridge University Press.

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Comments

  1. Set in a surreally off-kilter version of the Wild West populated entirely by animals, computer-animated Western Rango is both a witty spoof and loving homage to the genre. Good Review!

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    • I can’t thank you enough for a compliment I don’t deserve! This was a really funny, clever, and even poignant movie which just happens to echo my circumstances as a general hospital psychiatric consultant.

      Best wishes,

      Jim Amos, MD

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