Guidelines

Diagnosis, prevention, and management of delirium: summary of NICE guidance

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c3704 (Published 28 July 2010)
Cite this as: BMJ 2010;341:c3704

Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

Displaying 1-4 out of 4 published

28 September 2010

Sir,

We note with interest the recent publication of NICE guideline CG103:Delirium: diagnosis, prevention and management1, specifically the following phrase from the introduction; "...reporting of delirium is poor in the UK, indicating that awareness and reporting procedures need to be improved." Key priorities for implementation from the guidelines include ensuring that a diagnosis of delirium is documented in both secondary and primary care records.

We recently undertook a retrospective case note review of 100 consecutive admissions to a Department of Medicine for the Elderly (DME) ward. Using a previously validated chart based assay 2, we determined the prevalence of delirium during the admission. We then ascertained the proportion of these where the diagnosis of delirium was stated in the patient's discharge summary, which is sent to their general practitioner and a copy retained in both the hospital paper and electronic records.

14 cases were excluded due to missing documentation. Of the remaining 86 patients, 41 (48%) had, documented in their notes, convincing evidence of an episode of delirium. In only 18 of those 41 cases (44%) was there any mention of this episode in the discharge summary. 32 patients had a diagnosis of dementia which was documented in 19 (59%) discharge summaries.

Delirium is associated with higher rates of mortality, development of dementia, greater length of stay in hospital and an increased likelihood of being discharged to institutional care 3,4. Older age, previous cognitive impairment and medical illness are the most significant risk factors for development of delirium 5. Since by definition all admissions to a DME are adults with one risk factor for delirium (age > 65), we need to be able to better identify those at higher risk of delirium to concentrate specialist expertise. Simple measures, incorporated in good nursing care, can be taken to prevent delirium in patients with known risk factors 6.

Adherence to the diagnosis and management algorithm incorporated in the NICE guidelines should do much to improve the diagnosis and documentation of delirium. Unless previous diagnoses of delirium or dementia are clearly apparent on rapid review of "old notes", this vital information and opportunity to case manage the most vulnerable may be lost, with resultant potential detriment to the quality of their care and negative impact on health resource utilisation.

Joanna Taylor, 4th year medical student, Cambridge University Medical School

Martyn C Patel, ST5 Geriatric Medicine Registrar, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust

Duncan Forsyth, Consultant Geriatrician, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust

Fiona Thompson, Consultant Psychiatrist, Cambridgeshire and Peterborough NHS Foundation Trust & NIHR-CLAHRC

1. http://www.nice.org.uk/guidance/CG103 July 2010-09-03

2. Inouye S, Leo-Summers L, Zhang Y, Bogardus ST Jr, Leslie DL, Agostini JV. A Chart-based Method for Identification of Delirium: Validation Compared with Interviewer ratings Using the Confusion Assessment method. Journal of the American Geriatric Society 2005; 53:312- 318

3. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine 2000; 30: 921-929

4. Rockwood K, Cosway S, Carver D, Jarret P, Stadnyk K, Fisk J. The risk of dementia and death after delirium. Age and Ageing 1999; 28: 551- 556

5. Elie M, Cole M, Primeau F, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. Journal of General Internal Medicine 1998; 13: 204-212

6. Inouye S, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multi-component intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999; 340: 669-676

Competing interests: None declared

FIONA THOMPSON, Consultant Psychiatrist

Jo Taylor, Martyn Patel, Duncan Forsyth

Cambridgeshire and Peterborough NHS Foundation Trust and NIHR-CLAHRC

Click to like:

We note with interest the recent publication of NICE guideline CG103:Delirium: diagnosis, prevention and management1, specifically the following phrase from the introduction; "...reporting of delirium is poor in the UK, indicating that awareness and reporting procedures need to be improved." Key priorities for implementation from the guidelines include ensuring that a diagnosis of delirium is documented in both secondary and primary care records.

We recently undertook a retrospective case note review of 100 consecutive admissions to a Department of Medicine for the Elderly (DME) ward. Using a previously validated chart based assay 2, we determined the prevalence of delirium during the admission. We then ascertained the proportion of these where the diagnosis of delirium was stated in the patient's discharge summary, which is sent to their general practitioner and a copy retained in both the hospital paper and electronic records.

14 cases were excluded due to missing documentation. Of the remaining 86 patients, 41 (48%) had, documented in their notes, convincing evidence of an episode of delirium. In only 18 of those 41 cases (44%) was there any mention of this episode in the discharge summary. 32 patients had a diagnosis of dementia which was documented in 19 (59%) discharge summaries.

Delirium is associated with higher rates of mortality, development of dementia, greater length of stay in hospital and an increased likelihood of being discharged to institutional care 3,4. Older age, previous cognitive impairment and medical illness are the most significant risk factors for development of delirium 5. Since by definition all admissions to a DME are adults with one risk factor for delirium (age > 65), we need to be able to better identify those at higher risk of delirium to concentrate specialist expertise. Simple measures, incorporated in good nursing care, can be taken to prevent delirium in patients with known risk factors 6.

Adherence to the diagnosis and management algorithm incorporated in the NICE guidelines should do much to improve the diagnosis and documentation of delirium. Unless previous diagnoses of delirium or dementia are clearly apparent on rapid review of "old notes", this vital information and opportunity to case manage the most vulnerable may be lost, with resultant potential detriment to the quality of their care and negative impact on health resource utilisation.

Joanna Taylor, 4th year medical student, Cambridge University Medical School

Martyn C Patel, ST5 Geriatric Medicine Registrar, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust

Duncan Forsyth, Consultant Geriatrician, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust

Fiona Thompson, Consultant Psychiatrist, Cambridgeshire and Peterborough NHS Foundation Trust & NIHR-CLAHRC

1. http://www.nice.org.uk/guidance/CG103 July 2010-09-03

2. Inouye S, Leo-Summers L, Zhang Y, Bogardus ST Jr, Leslie DL, Agostini JV. A Chart-based Method for Identification of Delirium: Validation Compared with Interviewer ratings Using the Confusion Assessment method. Journal of the American Geriatric Society 2005; 53:312- 318

3. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine 2000; 30: 921-929

4. Rockwood K, Cosway S, Carver D, Jarret P, Stadnyk K, Fisk J. The risk of dementia and death after delirium. Age and Ageing 1999; 28: 551- 556

5. Elie M, Cole M, Primeau F, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. Journal of General Internal Medicine 1998; 13: 204-212

6. Inouye S, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multi-component intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999; 340: 669-676

Competing interests: None declared

FIONA THOMPSON, Consultant Psychiatrist

Jo Taylor, , Martyn Patel, Duncan Forsyth

Cambridgeshire and Peterborough NHS Foundation Trust and NIHR-CLAHRC

Click to like:

There are ongoing interests in the study of phenomenology and management of delirious patients. In our daily practice we manage different cases who present with delirious states especially in medical wards. Delirium is known as an acute mental disturbance associated with physical illness, is well described in early medical literature, but it was not until Celsus coined the term ‘delirium’.

Although delirium has many synonyms that are applied in particular clinical settings, all acute disturbances of global cognitive functioning are now recognised as ‘delirium’, .. Delirium is a complex neuropsychiatric syndrome that typically involves a plethora of cognitive and non-cognitive symptoms, resulting in a broad differential diagnosis dominated by mental disorders.

Psychiatrists' skills in assessing cognitive function and psychopathology, coupled with their knowledge of psychotropic agents, make them well suited to improving detection, coordinating management and facilitating research into this understudied disorder. The symptoms of delirium include a constellation of physical, biological and psychological disturbances.

Impaired attention is considered the core cognitive disturbance. Delirium symptoms are non-specific, their pattern is highly characteristic: acute onset, fluctuant course (symptoms tend to wax and wane over any 24-hour period and typically worsen at night) and transient nature (in most cases, delirium resolves within days or weeks). Delirium is easily mistaken for dementia or functional psychiatric disorders. Rates of delirium are increasing in tandem with the rise in mean age of the general population.

The presentation of delirium can mimic functional psychiatric disorders. Emotional and behavioural changes of delirium are easily mistaken for adjustment reactions, particularly in patients who have experienced major trauma or have cancer. Delirium is frequently confused with depression, especially in females and those with hypoactive or lethargic delirium presentations. Most symptoms of major depression can occur in delirium (e.g. psychomotor slowing, sleep disturbances and irritability), but the onset of depressive illness is generally less acute and mood disturbance dominates the clinical picture. Moreover, cognitive impairment in depression typically resembles dementia more closely than delirium – ‘depressive pseudodementia’. Hyperactive presentations of delirium can mimic similar disturbances in patients with anxiety disorders, agitated depression or mania. Delirium involves both qualitative and quantitative alterations in consciousness, and in hypoactive patients can be associated with lethargy, but patients should be rousable. Explicit recognition of delirium is associated with better outcomes in the form of shorter in-patient stays and lower mortality. Psychiatrists can aid diagnosis by clarifying symptoms, assessing cognitive status and advising on supplementary investigation. Electroencephalography and a range of investigative tools that assess delirium symptoms can be useful in distinguishing delirium from dementia and functional psychiatric disorders. Psychiatric consultation facilitates identification of predisposing and precipitating factors for delirium.

Medication exposure, visual and hearing impairments, sleep deprivation, uncontrolled pain, dehydration, malnutrition, catheterisation and use of restraints are all factors that can be modified with substantial clinical benefit. Current delirium pharmacotherapies have evolved from use in the treatment of mainstream psychiatric disorders and hence psychiatrists are well acquainted with the practicalities of their use. Medications are implicated as significant contributing factors in over one-third of cases and can act as either protective or risk factors for delirium. The principles of good ward management of delirious patients include ensuring the safety of the patient and their immediate surroundings, achieving optimal levels of environmental stimulation and minimising the effects of any sensory impediments. Psychiatrists can advise regarding the appropriateness and dosing of drug treatment and help monitor treatment response. Medication use in delirium often represents a response to problem behaviours rather than the severity of actual delirium symptoms.

The available evidence suggests that antipsychotics are effective in alleviating a range of delirium symptoms in patients with either hyperactive or hypoactive clinical profiles. Moreover, their therapeutic impact is not merely due to their sedative effects and may reflect a specific antidelirium effect, perhaps mediated by effects on the dopamine–acetylcholine balance. Benzodiazepine use in delirium requires careful consideration as they are less effective than antipsychotics except in substance/alcohol-related deliria and have the disadvantage of operating as potential aggravating factors in delirium . Psychiatrists have the necessary skills to provide supportive psychotherapeutic input and interaction with relatives and carers that is fundamental to good management of delirium. Relatives can play an integral role in efforts to support and reorientate delirious patients, but ill-informed, critical or anxious carers can add to the burden of a delirious patient. In our daily practice I found that Involvement of psychiatry services tends to occur late in treatment efforts and frequently reflects a desire for advice on placement issues rather than acute treatment. Earlier intervention has many advocates and can positively influence outcome.

Moreover, the efficacy of antipsychotics in the treatment of patients with both hypoactive and hyperactive profiles is poorly appreciated, with much lower utilisation of antipsychotic agents in hypoactive patients. Psychiatry services therefore need to be more proactive in identifying hypoactive patients.

In summery Delirium is a complex neuropsychiatric syndrome that is common in all health care settings. The field of delirium is hampered by poor detection – a problem that psychiatrists can assist in reducing both through consultation in complex cases and educational interventions focusing on recognition of key diagnostic indicators and the varying clinical presentations of delirium in clinical practice.

References

Albert, M. S., Levkoff, S. E., Reilly, C., et al (1992) The Delirium Symptom Interview: an interview for the detection of delirium symptoms in hospitalised patients. Journal of Geriatric Psychiatry and Neurology, 5, 14–21.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). Washington DC: APA.

Competing interests: None declared

Competing interests: None declared

Dr Osama Hammer, Psychiatrist

Sussexpartnership Trust

Click to like:

The latest NICE guidelines on Delirium (1) are a timely addition to our clinical practice, and have finally addressed the impact of one of the most common syndromes affecting the elderly and their carers.

Since Delirium guidelines are notoriously difficult to implement (2), the Guideline Development group draws attention to barriers to delivery. Helpfully, they recommend improving implementation by raising awareness of delirium, adopting a new culture of delirium prevention and greater collaboration with patients and carers in care processes and system design.

As educational researchers working within the field of delirium we welcome these suggestions, however wish to supplement the implementation guidance with two further points:

Firstly, we suggest integrating NICE Guidance with an assessment of the individual learning needs of ward staff. From our work we have found learning needs are a dynamic construct and firmly rooted in clinical contexts. In contrast to our expectations, educational content focuses on “owning and joining up” existing tacit knowledge in relation to the patient, rather than knowledge or skill gaps regarding the disease process (3).

Secondly, given that in the work place the majority of learning happens on an informal opportunistic basis, we recommend that considerable attention is paid to creating “expansive” rather than “restrictive” ward learning environments (4). An expansive environment is one in which learning opportunities are maximised and participation in learning activities by all team members encouraged.

Finally, we wish to highlight the importance of education in preventing delirium and the central role of Liaison Old Age Psychiatry teams in facilitating this process (5). Once adopted within a community of practice, Liaison teams are ideally positioned to identify learning needs, create expansive ward learning environments and develop delirium practice at all levels.

References

1. Young J, Murthy L, Westby M, Akunne A, O'Mahony R. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ. 2010;341:c3704.

2. Young LJ, George J. Do guidelines improve the process and outcomes of care in delirium? Age Ageing. 2003 Sep;32(5):525-8.

3. Teodorczuk A. Developing educational interventions for Liaison Teams: findings from a grounded theory study. ASME Scientific conference; 2010 July; Cambridge.

4. Evans K, Hodkinson P, Rainbird H, Unwin L. Improving workplace learning. Oxford: Routledge; 2006.

5. Teodorczuk A, Welfare M, Corbett S, Mukaetova-Ladinska E. Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient. Int Psychogeriatrics 2010 Sep;22(6):874-85.

Competing interests: None declared

Competing interests: None declared

Andrew Teodorczuk, Teaching Research Fellow

Elizabeta Mukaetova-Ladinska, Sally Corbett, Mark Welfare

North Tyneside Hospital, Rake Lane, North Shields NE29 8NH

Click to like:

THIS WEEK'S POLL