Delirium
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7365.644 (Published 21 September 2002) Cite this as: BMJ 2002;325:644
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Dear Sir
Further to the recent series on psychological medicine, we would wish
to comment on an important omission from the section covering delirium 1
and also provide some data from a small related pilot study. In Scotland,
the Adults with Incapacity (Scotland) 2000 Act is now in force and
legislates in a number of dimensions, including that relating to the
provision of a consent for medical treatment 2. The Act states that
prior to any treatment an adult’s capacity to consent to that treatment
must be assessed by the doctor who is primarily responsible for the
patient. If capacity to consent is deemed to be absent the doctor can
then issue a certificate of incapacity detailing the treatment required,
including the reason capacity is felt to be absent. The Act does not apply
in cases of life or death where common law still holds sway but could
clearly be taken to affect adults suffering from delirium.
We sought to investigate some of the implications of this Act in our
working practice. Over a four week period 33 emergency admissions to two
elderly assessment wards were assessed by two of the authors (a doctor and
neuro-psychologist). These assessments, which included an MMSE, were time
consuming, taking the doctor a mean of 24.2 minutes (range 10 – 60
minutes). Those who were clearly capable or clearly incapable were
quicker to assess than those for whom there was doubt. The time required
for assessment is likely to be an underestimate given that the Act
requires discussion with relatives. The more detailed neuro-psychological
assessments took longer (45 – 115 minutes) but identified a greater
number of older people who were definitely or probably incapable of giving
consent. The doctor’s assessment of this group indicated that 18 % were
definitely or probably incapable, whereas the neuro-psychologist
identified a larger proportion (33 %) ; this indicating a relatively low
level of agreement (kappa = 0.11) .
There are moves to introduce similar legislation to cover the rest of
the United Kingdom 3 and it is clear that further guidance will be
required to clarify the law in this area. Implementation of such law is
not without difficulty however and we have highlighted problems relating
to the time and accuracy of assessments of capacity. Furthermore our
small study only looked at hospitalised patients- the impact on general
practice is already leading to difficulties 4.
References
1. Brown TM, Boyle M F. ABC of psychological medicine: Delirium. BMJ
2002;325:644–7
2. Adults with Incapacity (Scotland) 2000 Act, The Stationary Office
3. Lord Chancellor’s Department. Consultation Paper: Making Decisions
- Helping people who have difficulty deciding for themselves. April 2002
(www.lcd.gov.uk/consult/family/leaf2.htm)
4. ‘GP’s set to break law over protest.’ Douglas Fraser Sunday
Herald 6th October 2002 (www.sundayherald.com/28288)
Competing interests: No competing interests
Sir
Brown and Boyle (1), in their article on delirium, miss the
opportunity to clarify legal aspects of the management of this condition
that are often confusing to inexperienced junior medical staff in all
specialities, who are usually the first to be called on to assess and
manage it.
Delirium is a mental disorder within the meaning of the Mental Health
Act and as such use of the Act may need to be considered if the patient
decides they wish to leave the hospital.
If the patient cannot be persuaded to stay then the use of the
“doctor’s holding power” (Section 5(2)) of the Act may have to be
considered, followed by further assessment as to the appropriateness of
other Sections, depending on the nature and course of the disorder. If the
patient is not under the care of a Consultant Psychiatrist then the non-
psychiatric Consultant's junior doctor is technically their nominated
deputy under the Act, and should complete the relevant form and ensure it
is delivered to the hospital managers (out of routine hours this is
normally a senior member of nursing staff). Physical treatment in such
instances would remain possible only under the common law doctrine of
necessity. Prompt liaison with psychiatric specialists is also recommended
by the Mental Health Act Code of Practice (2). The Mental Health Act
Commission has issued guidance in relation to the use of the Act in
general hospitals without a psychiatric unit (3).
While often in a patient with an acute physical illness who lacks
capacity the Act might not be considered appropriate, and treatment under
common law might be pursued, it can be argued that this allows for less
protection of a patient’s rights. The Mental Health Act has often been
held to represent a formalisation of prejudice against the mentally ill.
Delirium is perhaps an example that counters this idea, suggesting the
Mental Health Act, or a capacity based act not confined to mental illness,
could offer protection to all without capacity. The Richardson Committee
on the reform of the Mental Health Act4 considered these issues in detail,
although the present Draft Mental Health Bill (5) illustrates how risk has
become the preoccupation of present legislators, rather than capacity.
Delirium is also the disorder that illustrates the folly of those who
wish to create clear distinctions between physical and mental disorders:
its is clearly both.
References
1 Brown TM, Boyle MF. ABC of Psychological Medicine: Delirium. BMJ
2002;325 644-7
2 Department of Health and Welsh Office. Mental Health Act 1983 Code of
Practice, London: The Stationary Office, 1999
3 Mental Health Act Commission. Guidance Note: Use of the Mental Health
Act 1983 in General Hospitals without a Psychiatric Unit,
2001(www.mhac.trent.nhs.uk)
4 Department of Health. Report of the Expert Scoping Committee: Review of
the Mental Health Act 1983 (“the Richardson Committee”), London:
Stationary Office, 1999
5 Department of Health. Draft Mental Health Bill, London, HMSO, 2002
(www.doh.gov.uk/mentalhealth/draftbill2002)
Competing interests: No competing interests
As this article points out the elderly are at particular risk of
developing delirium. However administering 10mg/day of haloperidol, a
"Low dose", to a confused elderly patient will, in my experience, cause
additional confusion, over-sedation, poor mobility or falls. Smaller
doses, e.g. 0.5mg, may still have a sedative effect with much less side
effects.
Competing interests: No competing interests
In requesting a psychiatric opinion for patients with delirum
developing after surgery, as I did on occasions as a houseman and
registrar, the response I invariably got was "call me if you need me when
you have sorted out the metabolic problems". Rarely if ever did I find it
necessary to call the psychiatrists again and very quickly abandoned the
practice of calling them in the first place.
I now think that delirium may simply be the product of an
intracerebral energy deficit even in patients who are substance abusers.
An energy deficit is an inadequacy of mitochondrial oxidative
phosphorylation with its accompany tissue acidosis caused by unreversed
ATP hydrolysis. If my hypothesis is valid then drugs that stimulate cAMP
should compound the problem for cAMP is derived from ATP and ATP stores
will be depleted especially in circumstances in which ATP resynthesis is
already compromised. Furthermore drugs, such as haloperidol, that may
compromise mitochondrial function should also compound the severity of the
energy deficit.
If so then the therapeutic effect of drugs may be misleading
clinicans, the disappearance of the clinical features of delirium being
indeed no more than the product of a further compromise of cerebral
function or a chemical cosh as some have called their effects.
In the event that an intracerebral energy defict is the cause of
delirium then treatment should be directed at reversing that defect by
addressing both the oxygen and the nutrient needs as presently done in
cases of hypoxaemia and hypoglycaemia respectively. The putative
consequences of free radical release and accompanying cerebral damage
should also be addressed with inhibitors and/or scavengers.
Competing interests: No competing interests
Hip fractures in elderly and delirium
Sir,
Two thousand years after the description of delirium by
Hippocrates and Celsus [1] it is inevitable to presume that neither of
them would be pleased to see that our knowledge of the pathogenetic
mechanisms of delirium remains rather poor [especially if we take into
account the great progress in almost every field of medicine]. Our
ignorance in a medical emergency that carries high rates of morbidity and
mortality may easily be considered to be a combination of both
professional malpractice and unwillingness for deep estimation of the
problem. This becomes more overt when applied in surgical patients and
postoperative delirium, especially after hip fracture treatment.
Hip
fractures constitute a major proportion of non elective geriatric surgical
conditions, especially after 75 years of age [2]. The fact that the
surgical candidates are of progressively increasing age rates, bearing
in mind the many commorbid situations and the prescribed medications,
not to mention the increased surgical stress, should have pointed our
attention to the prevention and treatment of delirium in these patients.
Instead of that it is commonly accepted that hip fracture prevention and
treatment, as well as the creation of orthogeriatric departments, have
made much progress in the last decades. Pyrrhic victory: what is the point
of healing just a few of the faces of Ianos leaving the others sick?
1.Kyziridis TC: Post-operative delirium after hip fracture treatment. GMS
Psychosoc Med 2006; 3:Doc01 (20060208)
2. Kyziridis TC: Epidemiology of hip fractures: a study of 52 cases.
Presented at the Greek National Nurses Association Congress, Thessaloniki
2005
Competing interests:
None declared
Competing interests: No competing interests