Quiz Results On The Psychiatrist’s Role In Delirium

Quiz on Psych Role in Delirium

As promised, today I closed the quiz on the psychiatrist’s role in delirium in the intensive care unit and I’ll explain my answers. The questions were adapted from the book on ICU delirium by Valerie Page and E. Wesley Ely [1]. The answers were variable, but tended to indicate a little too much confidence in psychiatrists as experts on delirium. The correct answers are all “False,” and here’s why:

1. A psychiatrist should be consulted for delirious patients if they’re already under the care of a psychiatrist or on antipsychotic medications.

I said this is false and I admit the question is worded poorly, though I did say it was “adapted.” On the face of it, the answer would obviously be true, which should beg the question of why I included it. However, in the book, my sense of the authors’ point is that a psychiatrist should be called only if the patient is already under the care of a psychiatrist or on antipsychotic medications. I didn’t put the word “only” in the question because it’s not specifically stated in the book. But in my opinion, this is implied in the text. I suggest you buy the book and read it carefully yourselves. Many, if not most, patients who get delirious don’t have a psychiatrist and are usually not on psychotropic drugs. Frequently, delirium in the ICU happens to those without a psychiatric history of any kind. As I’ve always recommended, the first thing an internist should do for a patient who’s delirious is to look for and treat the underlying medical causes and to examine closely and simplify the medications the patient is being given–not request psychiatric consultation.

2. A psychiatrist is often helpful for patients whose agitation can’t be controlled with the usual measures.

This one I think is false because I’ve frequently been consulted for help controlling the agitation of delirious patients who couldn’t be controlled with antipsychotics and benzodiazepines, which are the “usual” agents doctors employ. I have few alternatives, but occasionally suggest the intensivists try dexmedetomidine–which is not a psychiatric drug and which intensivists know much more about than I ever will [2]. Ages ago, we used to recommend intravenous haloperidol infusions, but this intervention is nowadays frowned upon in our hospital and probably in many others.

3. A psychiatrist is often helpful for patients with dementia when the diagnosis of delirium is proving uncertain.

I may be selling psychiatrists short here but I called this false because the vast majority of cases I see in which a medically ill elderly demented patient is in hospital, it’s really not that easy to distinguish dementia from delirium, especially in patients suffer from Lewy Body Dementia–which resembles delirium in many instances. Getting a history of previous cognitive decline over an extended time period and whether or not there’s been an acute change in mental status can be helpful along with noting any fluctuations in the level of consciousness. But this skill is not specific to psychiatry.

4. A psychiatrist is often helpful in patients with persistent delirium.

I think this is false based on my experience as well. And part of the reason patients become “persistently” delirious is doctors “persistently” administer drugs to them which cause delirium. There are lists of these drugs available to all medical specialists–not just psychiatrists. I’ve been faced with countless cases of persistent delirium in which the intensivists have not found a medical cause or cannot reverse the diseases which caused the delirium, or have not had good luck with treatment response to antipsychotics. I’ve not been very helpful and the recent literature bears out my clinical impression that once delirium has started (whether or not it’s become persistent) we’re far less successful at reversing it . Persistent delirium, besides not being a primary psychiatric disorder per se, is extremely difficult for any medical professional to manage.

The point I’m trying to make is that the skill of assessing and managing delirium is not necessarily unique to psychiatrists. Of course there are many psychiatrists who are experts about delirium, and Dr. David Meagher is only one. You can see that in the list of board of directors of the American Delirium Society. However, the president of the European Delirium Association is Dr Alasdair MacLullich, who is a brilliant and wise geriatrician.

And you can read an erudite yet accessible educational piece about delirium here. The experts are Dr. James Rudolph and Dr. Sharon Inouye. Neither of them are psychiatrists.

Sometimes I think there is an unwarranted dependence on psychiatrists, which concerns me because there will never be enough consulting psychiatrists.

"Relegating this work entirely 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."--George W. Henry, MD, 1929

“Relegating this work entirely 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.”–George W. Henry, MD, 1929

 

It reminds me of a recent consultation request which got turned upside down while we were in the patient’s room. We were doing the best we could to help a patient who was demoralized by many medical conditions. The internist and his team popped their heads in and were going to excuse themselves and round on other patients as soon as they saw us in there.

I didn’t let them get away.

We watched, spellbound, while the faculty conducted a brief interview and physical exam, dispelled all of the anticipatory anxiety and fears the patient expressed–and just generally rendered our services completely unnecessary. Nothing more was needed than for the internist, who knew more about the patient’s medical problems than we ever could, to provide the reassurance that we could not. Some medical specialists are afraid of losing what they view as an expert on “psychiatric” issues. Maybe it’s because they think they lost some kind of humanistic quality or communication skill somewhere in their medical training. Maybe they’re afraid they never learned it. They never lost it. It doesn’t belong just to psychiatrists.

 

 References:

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

2. Reade, M. C., K. O’Sullivan, S. Bates, D. Goldsmith, W. R. Ainslie and R. Bellomo (2009). “Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial.” Crit Care 13(3): R75.

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Comments

  1. Jim – To your point number 4, I would add that health plan and managed care companies in general no longer provide the services necessary to manage chronic delirium or dementia from an outpatient clinic. Practically all psychiatric services are contingent upon the mythical “medical management” visit that assumes everything that a patient needs and all of their problems can be resolved by the prescription of a pill. Many psychiatric services are dumbed down to the point that the providers in the clinic will numbly recite that mantra. I used to run a clinic where we diagnosed and treated dementias and deliriums. We had a fair success rate with recognizing the deliriums and successfully managing them, but we were shut down because we spent too much time on the phone coordinating care and too much nursing time gathering collateral history.

    We couldn’t put all of that into a pill and so we were shut down. I would believe you that more docs are capable of recognizing and treating delirium if I ever saw them order an EEG. The “poor man’s PET scan” is often the best window into disordered brain metabolism irrespective of the cause.

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