Psychiatrists Can Help Prevent Delirium

I teach doctors and nurses how to assess, treat, and prevent delirium-an acute confusional disorder caused by multiple medical problems that mimics mental illness-but is actually a medical emergency. Patients with delirium may be slow to respond, withdrawn, have attitude changes, and have mood symptoms. Delirium worsens concentration and can lead to hallucinations, withdrawal, changes in appetite, reduced mobility, and sleep disturbance.

Physicians and nurses in hospital settings have to work harder to treat delirious patients with serious medical disorders. That’s because the patients are too cognitively impaired to cooperate with treatment, too disorganized to consent for them, and too agitated and restless to sit still for necessary tests. Medical personnel want and need to learn how to use assessment skills and tools to prevent delirium. This vital educational resource allows them to provide the best health care for older patients. When doctors and nurses have the skills and tools to prevent delirium, they ultimately do less work yet provide safer and more effective care for their patients, thereby promoting healing.

Delirium leads to higher death rates, longer lengths of hospital stay, and persisting cognitive impairment. Nurses work harder to take care of these patients because confusion makes them less cooperative, emotionally volatile, harder to communicate with, and sometimes even violent. Nurses want and need to know how to prevent delirium. Delirium is often temporary but can cause longer hospital stays, or the need for long-term care, and raises the risk for falls and bed sores. Those at risk are over age 65 years, often already have memory problems or dementia, have a broken hip, or several serious medical illnesses.

The earlier doctors in training learn about delirium, the better the care patients will get. Delirium has average prevalence of about 20% in the general hospital and between 70% to 80% in the intensive care unit. It is misdiagnosed or undiagnosed in over 60% of patients in our health care system. According to the American Delirium Society, facts and figures about delirium include:

•More than 7 million hospitalized Americans suffer from delirium each year.
•Among hospitalized patients who survived their delirium episode, the rates of persistent delirium at discharge, 1, 3, and 6 months are 45%, 33%, 26%, and 21% respectively.
•Compared with hospitalized patients with no delirium and after adjusting for age, gender, race, and comorbidity, delirious patients experience:

–Higher mortality rates at 1 month (14% vs. 5%), at 6 months (22% vs. 11%), and 23 months (38% vs. 28%);
–Longer hospital stays (21 days versus 9 days); Receive more care in long-term care setting at discharge (47% versus 18%), at 6 months (43% versus 8%) and at 15 months (33% vs. 11%); and
–Higher probability of developing dementia at 48 months (63% versus 8%).

The goal is to detect delirium early and prevent it. What’s the best way to do that? The main multicomponent nonpharmacologic strategies, adapted from Inouye’s Hospital Elder Life Program (HELP) program, are the following:
1. Ensure that sensory aids, such as eyeglasses and hearing aids, are available and used.
2. Correct dehydration.
3. Remove immobilizing devices such as restraints and catheters and mobilize patients as soon as possible.
4. Reduce exposure to anticholinergic and sedative-hypnotic drugs.
5. Use non-pharmacologic ways to normalize the sleep-wake cycle.
6. Frequently reorient patients using clocks and calendars.
7. Educate staff about the importance of delirium prevention and how they can work as a team.
[See more about the HELP program at http://hospitalelderlifeprogram.org/public/public-main.php.]

Some studies show that using antipsychotics prophylactically can also be helpful.^1,2 We should also be looking for delirium using validated, sensitive screening tools. For example, one such tool would be the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) in critically ill patients.³ It follows that doctors should listen to nurses who are screening patients as positive for confusion or delirium-listen and act by working diligently to remove any reversible or modifiable medical causes of delirium. We’re all on the same team.

We don’t yet have perfect delirium screening scales for the general medical unit and there is no simple method in addition to education for inculcating a culture of vigilance for delirium.

The gold standard for diagnosing delirium is a psychiatric evaluation, using the Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) criteria:

A. Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention.
B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.⁴

It’s ironic that we depend on psychiatrists to diagnose delirium or base screening evaluations on the DSM criteria because ultimately delirium is a medical emergency, not a psychiatric problem per se. Hey, we’re all in this together.

References1. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:1658-1666.
2. Larsen KA, Kelly SE, Stern TA, et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics, 2010;51:409-418.
3. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29:1370-1379.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC: American Psychiatric Association; 1994: 886.