Preventing Delirium: Not Us vs Them But Us vs Delirium

I ran across an interesting open access article by Teodorczuk the other day about the problems health professionals and hospital administrators have in recognizing delirium as a problem to overcome [1]. The cultural barrier caught my eye:

There was considerable debate relating to the fact that delirium was not seen as belonging to a specific specialty. Consequently, it is perceived as an orphan condition managed haphazardly by a number of specialties and all too often falling between the gaps. This was underscored by the differing opinion, even among delegates, as to whether delirium should best be managed by general hospital staff or mental health professionals. This division in roles was articulated by expressions of “them and us” scenarios.–Teodorczuk et al, BMC Geriatr 2012.

The authors’ recommendations were in a table, reproduced below:

Call for Action on Delirium Teodorczuk et al BMC Geriatrics 2012

I’m reminded of a short passage from the book “Delirium in Critical Care” by Ely and Page [2]:

Should we, or should we not, call the psychiatrist? Can we replace them with a screening tool, and then use haloperidol freely? Psychiatrists and intensivists may have different opinions on the matter, but we would advocate that a psychiatrist should be consulted for patients already under the care of a psychiatrist or on antipsychotic medications.

A psychiatrist is often helpful for patients whose agitation cannot be controlled with the usual measures, for patients with dementia when the diagnosis of delirium is proving uncertain, and in patients with persistent delirium.

Psychiatrists might be useful at a later stage, when patients are followed up and ICU-related post-traumatic stress disorder suspected.

The recommendations are humorous because:

  • Delirium is a medical emergency that mimics primary psychiatric disorders.
  • Haldol is not the treatment for delirium.
  • Most patients who develop delirium don’t have preexisting primary psychiatric disorders and would therefore not be under the treatment of a psychiatrist in the community and already taking antipsychotic.
  • Because research has repeatedly demonstrated that the best way to manage delirium is to prevent it and because delirium responds so poorly to interventions after it gets started, psychiatrists typically are poorly positioned to do much about delirium after it’s established, and we’re especially helpless (just as are other physicians) after delirium has been present for a prolonged period of time.
  • The research literature on PTSD related to delirium, especially in the ICU, is encouraging but still in its infancy. Most of the work on ICU diaries for preventing delirium-associated PTSD is being pursued by non-psychiatrists, such as nurses.

The bottom line is that psychiatrists and non-psychiatric physicians can, in fact, work collaboratively on recognizing, treating, and preventing delirium. I think internists, intensivists, and surgeons need to simply lower their expectations about what psychiatrists can and cannot do about delirium in hospitalized patients. To the extent that delirium is produced by psychotropic polypharmacy (a distressingly common occurrence which I deplore), our role is to peel away unnecessary anticholinergic and sedative-hypnotic psychiatric drugs that some of us are all too liberal in prescribing. Psychiatrists are probably better-equipped than many at distinguishing between delirium and the many primary psychiatric disorders which it mimics, including dementia and depression amongst many others. In short, we can tell internists and intensivists what delirium is not so as to avoid chasing red herrings. After that, non-psychiatrists’ skills at differential diagnosis and treatment of the myriad medical problems that cause delirium will capitalize on their scope of practice in helping patients recover– keeping the end in mind.

Carrying the team-based model even further, nurses are probably best equipped at detecting delirium by using validated rating scales, the best one being the Confusion Assessment Method (CAM) on the general medical wards and the CAM-ICU in critical care units. Clinical pharmacists are essential for monitoring the medication lists which all too often contain too many drugs, compounding the intoxication delirium problem. Social workers fill a critically important role in furthering the education of families about delirium. Occupational and physical therapists are the best trained to assess and manage cognitive, functional, and physical challenges from which delirious patients invariably suffer. Neuropsychologists provide the expertise at testing to assess risk for and cognitive recovery from delirium. Administrators can promote the value of delirium detection, assessment, and treatment by communicating clearly their knowledge of the facts about delirium as a safety issue in hospitals and not standing in the way of systems development that will operationalize in practical ways what everyone needs to do to prevent delirium.

One of the biggest challenges I see is enculturating health professionals, families, and administrators to see themselves as members of a team. In the end, implementation of delirium prevention programs may be more about culture change than changing almost any other single equipment or process-related factor.

Organizations with a specific orientation to the goal of delirium research and management are also very important. The European Delirium Association (EDA) and the American Delirium Society are organizations dedicated to improving the recognition and prevention of delirium. The EDA has a superb video for public viewing about the patient’s experience of delirium, European Delirium Association | Health Professionals > Patient Experience of Delirium- Teaching Video.

ADS upcoming annual meeting in June of 2013 will feature presentations on the research and practical applications of that research into preventing and managing delirium, http://americandeliriumsociety.org/.

It doesn’t have to be about us versus them. It should be about us versus delirium.

1. Teodorczuk, A., E. Reynish, et al. (2012). “Improving recognition of delirium in clinical practice: a call for action.” BMC Geriatr 12: 55. (geezernote: open access article)

BACKGROUND: The purpose of this correspondence article is to report opinion amongst experts in the delirium field as to why, despite on-going training for all health professionals, delirium continues to be under recognised. Consensus was obtained by means of two conference workshops and an online survey of members of the European Delirium Association.Major barriers to recognition at an individual level include ignorance about the benefit of treating delirium. At an organisational level, reflecting socio-cultural attitudes, barriers include a low strategic and financial priority and the fact that delirium is an orphan condition falling between specialties. http://www.biomedcentral.com/content/pdf/1471-2318-12-55.pdf. http://www.biomedcentral.com/1471-2318/12/55

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

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