Join the Cause: Get Delirium on the Agenda by J. L. Rudolph and M. Shaughnessy

Here’s a guest post on delirium by a couple of leaders in the American Delirium Society (American Delirium Society) by James L. Rudolph, MD and Marianne Shaughnessy, PhD, CRNP. Dr. Rudolph and Dr. Shaughnessy are both on the American Delirium Society (ADS) Board of Directors.

James L Rudolph, MD

VA Boston Geriatric Research, Education, and Clinical Center Past President, American Delirium Society

Address:

VABHS GRECC

150 S. Huntington Ave

Boston MA 02130

Marianne Shaughnessy, PhD, CRNP

Baltimore VA Geriatric Research, Education, and Clinical Center

Secretary, American Delirium Society

Address:

Baltimore VAMC

10 N. Greene Street (BT/18/GR)

Baltimore, MD 21201

Evidence is rapidly building that delirium is associated with mortality, functional decline, and increased costs.  Despite the increased literature, delirium remains poorly recognized both clinically and as a research priority.  The American Delirium Society (ADS) formed to raise awareness, establish research collaborations, and develop educational initiatives.  In the following paper, we propose mechanisms to expand these domains.

In the 1980s, pioneering work in delirium found that physicians miss 33-66% of delirium in hospitalized adults. (1, 2) Later studies found that nurses also experience difficulty and recognize only 31% of patients with delirium.(3)  Additionally, the misnomers, (examples: sundowning, psychosis, dementia, encephalopathy, etc) continue in clinical practice among specialists.  Clearly, there is a strong need to increase delirium awareness among patients, healthcare professionals, and family members.  Additionally, the pending age wave, with its accompanying anticipated increase in the incidence of cognitive impairment, add to the imperative to answer some of the underlying questions about delirium.  Finally, changes in healthcare financing with the Affordable Care Act will demand that cost effective approaches to quality care take priority in research and clinical environments.

Prior work has found that research funding for delirium lags behind the funding of other, equally, morbid mental health disorders.  For example, 2011 NIH funding for delirium was $14.5M compared with funding for depression ($1,166M) , dementia/Alzheimer’s Disease ($819M), and schizophrenia ($577M).(4)  The lack of available  research funding  hampers efforts to identify a  defined pathophysiologic mechanism for delirium,  and effective pharmacological and  non-pharmacological treatments.  As a result, there is incredible need for increased research collaboration and innovation in delirium.  The ADS serves as a network to develop these collaborations, present and discuss preliminary research findings, and develop pathways for delirium drug approval, as well as, increasing awareness of drug development.

To achieve the clinical and research aims related to delirium, there is also a need for an educational strategy.  While the primary focus of such a strategy must be clinicians who provide front-line care, there is also a need to educate researchers, policy makers, and all healthcare providers about delirium.  The ADS is developing educational materials for health care professionals as well as for patients and families about the course and recovery of delirium by leveraging its multidisciplinary membership.  The Institute of Medicine (IOM) report on developing a geriatric workforce (2008) suggested that “geriatric competence needs to be improved through significant enhancements in educational curricula and training programs”. (5)   Capitalizing on opportunities to introduce delirium into pre-licensure curricula and post-licensure competencies would be critical for the ADS.

From a clinical standpoint, there is great need for quality improvement and models not only to improve detection but also to improve hands on clinical care.  Time effective strategies that improve the recognition, prevention, and treatment are vital.   Delirium currently takes a tremendous toll, both in healthcare and human costs in the form of poorer physical and functional outcomes and increased mortality.  The American Delirium Society has as its mission to promote and lead scientific inquiry, sharing knowledge about delirium: its presentation, prevention, and management, using research, education, quality improvement, advocacy, and implementation science in order to minimize the impact of delirium on patient’s short and long-term health and well being, and on the health care system.   Despite the fact that delirium has long been an identified phenomenon, remarkably little is understood in terms of mechanisms, effective preventions and treatments. 

The ADS welcomes membership from all healthcare disciplines to join the cause.

Check out our website at American Delirium Society.

References:

1.         Levkoff SE, Besdine RW, Wetle T. Acute confusional states (delirium) in the hospitalized elderly. Annu Rev Gerontol Geriatr. 1986;6:1-26.

2.         Inouye SK. Delirium in hospitalized older patients: risk factors and recognition. J Geriatr Psychiatry Neurol. 1998;11(Fall):118-25.

3.         Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM, Jr. Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med. 2001 Nov 12;161(20):2467-73.

4.         NIH RePORT: Estimates of Funding for Various Research, Condition, and Disease Categories.  Bethesda, MD: National Institutes of Health; 2011 [cited 2012 June 15]; Available from: http://report.nih.gov/rcdc/categories/.

5.         Retooling for an aging America: building the healthcare workforce. In: Medicine Io, editor. Washington, DC: National Academies Press; 2008.

 

 

Advertisements

Comments

  1. Sharon Van Fleet, MS, RN, PMHCNS-BC says:

    I am new to an institution where I am surrounded by physicians, including two veteran C-L psychiatrists, who prefer the term”encephalopathy” to “delirium.” I am told that it is a coding issue, although I have twenty years of inpatient C-L experience and have never worked with psychiatrists who routinely used “encephalopathy.” A neurologist added that avoiding “delirium” helped reduce the tendency on the part of uninformed clinicians to confuse delirium and dementia; I hope that through my educational efforts everyone will come to know the difference. I now work mostly with nurses and I strongly prefer “delirium” but fear I will be accused of muddying the waters if I don’t relent. Any suggestions to help a shift to “delirium”?

    Like

    • Hi Sharon,

      Great question. I’m also working with physicians here who still prefer the term “encephalopathy” when delirium occurs in certain conditions such as liver failure, i.e., “hepatic encephalopathy”. I’ve posted about this issue before. I wonder if it would help to cite a chapter from a book written by a couple of savvy intensivists, E. Wesley Ely and Valerie Page. Wes Ely represents the peerless ICU delirium group at Vanderbilt and Valerie Page is a critical care doctor in the UK. The book is Delirium in Critical Care: Core Critical Care, published in 2011 by Cambridge University Press. In the first chapter there’s a section on terminology. It begins, “In 1990, over 30 terms used to refer to delirium were identified in the medical literature…” I’m paraphrasing, but they say using words other than delirium would be “unlikely” to encourage intensivists to take delirium more seriously. This is the exact opposite of what some of your colleagues are saying, and it’s coming from non-psychiatrists. Ely and Page go on to say, “The failure to standardize terminology may be one reason why delirium has not been given to date the scientific consideration it deserves, even if the multiplicity of terms and descriptions suggests a high prevalence.” The authors speculate that the many different names including “encephalopathy” might have been attempts to get clinicians to take delirium seriously or maybe that it’s a reflection of how common delirium is in different patient populations. In any case, dementia and delirium can be distinguished as we all know, without resorting to a plethora of terms that tend to obscure rather than highlight the importance of delirium.

      I suspect that persuading clinicians to adopt a more standardized terminology regarding delirium has a lot more to do with culture change than education. They’re not exactly the same animal. Here’s what I’ve been trying to do. We have an electronic health record (EHR) here and I try to remember to enter the diagnosis “Delirium” in the problem list of every patient I encounter who’s delirious, either on the Medical-Psychiatry Unit (MPU) or in the general hospital. I see “acute confusion” or even worse, “AMS” (“Altered Mental Status”) everywhere I look. Dr. Sharon Inouye of Yale who delivered the keynote address at the 2nd annual American Delirium Society (ADS) meeting in Indianapolis, IN in June 2012 urged everyone to start doing this. Often, now that we’ve switched to our new EHR, which is Epic, it would be impossible to come up with accurate occurrence rates for delirium unless we do something like this. So when my colleagues in medicine and surgery don’t put “Delirium” in the problem list when it’s appropriate–I do. Of course, that doesn’t stop them from deleting it or substituting something else, like “AMS”, since we all have equal access to the EHR problem list. But that’s more about culture. It can feel kind of like a whack-a-mole game.

      I’d welcome any ideas that others have.

      Best wishes,

      Jim Amos, MD

      Like

%d bloggers like this: