SHIV GAUTAM ORATION AWARD
Year : 2022 | Volume
: 9 | Issue : 2 | Page : 75--78
Delirium in elderly: Battling a silent killer in the Indian context
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India
Abstract
Delirium is considered a manifestation of acute brain failure that usually has an acute onset, fluctuating course, and is often associated with multitude of negative outcomes. It is usually seen in medical-surgical patients, with very high prevalence rates among those on mechanical ventilation. It is often undiagnosed and undertreated. In developed countries, delirium is usually managed by multidisciplinary teams and the focus is on both prevention and management of delirium. In contrast to the developed countries, in India, physicians–surgeons have a negative attitude toward delirium and due to which not only it is underdiagnosed and undertreated but also mismanaged, and mental health professionals are not consulted. The research on delirium in India is also limited. The psychiatrists when involved in the care of patients with delirium also mainly focus on using pharmacological agents, with relatively lesser emphasis on the use of nonpharmacological measures. Further, in their encounter with specialists from other specialties, psychiatrists pay little attention to discussing the diagnosis of delirium and its management. There is a need to have an attitudinal change both at the level of the physicians–surgeons and psychiatrists in terms of clinical practice and research on delirium in the Indian context.
How to cite this article:
Grover S. Delirium in elderly: Battling a silent killer in the Indian context.J Geriatr Ment Health 2022;9:75-78
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How to cite this URL:
Grover S. Delirium in elderly: Battling a silent killer in the Indian context. J Geriatr Ment Health [serial online] 2022 [cited 2023 Jun 4 ];9:75-78
Available from: https://www.jgmh.org/text.asp?2022/9/2/75/368293 |
Full Text
Introduction
Delirium is one of the most common psychiatric morbidities in patients with acute medical and surgical illnesses. It involves a change in the patient's mental state that starts suddenly, has a fluctuating course, and is usually reversible. It is characterized by disturbance of attention, awareness, and other cognitive disturbances, along with sleep disruption. It is often associated with a multitude of negative clinical outcomes such as prolonged hospital stay, increased cost of treatment, higher risk of development of dementia after recovery, need for institutional care, functional decline, and a higher rate of mortality. The whole experience of delirium is also distressing for the patients and their caregivers.[1]
Although patients with delirium present with psychiatric manifestations, it is purely of organic etiology due to an underlying structural or physiological change influencing the brain. The prevalence of delirium is influenced by the study setting and study population, with higher prevalence reported for patients admitted to intensive care units (ICUs), those requiring mechanical ventilation, and the elderly. The prevalence is reported to be as high as 80% among elderly patients admitted to ICUs requiring mechanical ventilation. A systematic review and meta-analysis of 48 studies reported the pooled prevalence to be 31% (95% confidence interval: 24–41) in patients admitted to ICUs.[2]
In developed countries, delirium is often managed by a multidisciplinary team including physicians, anesthetists, psychiatrists, neurologists, geriatricians, nurses, occupational therapists, etc., and there is a significant focus on preventing delirium.[3] Despite the involvement of multidisciplinary teams, delirium is often underrecognized in developed countries.[3]
In India, too, delirium is often underrecognized and undertreated in medical and surgical settings. Many physicians, surgeons, and intensive care specialists prefer managing delirium independently rather than seeking help from mental health professionals. It is often considered an expected outcome, and the primary focus remains on addressing the primary illness. Due to this, delirium in severely ill patients is often neglected. In this oration article, I will discuss the current status of the management of delirium in India and what can be done to improve delirium care.
Practices of Management of Delirium in Indian Setting
In India, patients with delirium are often brought to emergency medical or surgical settings that are usually overburdened. A new-onset hospital emergent delirium is seen in various locations such as medical and surgical wards, ICUs, and high-dependency units, to name a few.
The recognition of delirium in the emergency setting is poor. A study that involved screening elderly patients presenting to the emergency showed that 34.1% of the patients have delirium.[4] In contrast, the psychiatry referral rates from the same setting have been <2.5%,[5] suggesting that many patients are often unrecognized and undertreated.
When a patient with delirium who is agitated is brought to the emergency medical or surgical setting, the primary aim of the resident in a multispecialty medical college is to assess whether the patient has a life-threatening illness that requires immediate attention, rather than delirium per se. If the patient is lucky to have a life-threatening medical condition, they would be admitted to the emergency to manage the medical surgical emergency. However, delirium may not receive adequate attention until and unless the patient is agitated and disruptive. In a small proportion of the patients, a psychiatrist may be consulted. In most patients, the primary physician or surgeon may administer antipsychotic medications such as haloperidol to calm them down. Some patients with a severe physical illness requiring immediate attention may be intubated and ventilated. The mental health needs of patients with hypoactive delirium are often neglected. If the patient with delirium presenting to the emergency does not have a life-threatening medical condition then the physician or surgeon may not entertain the patient and may send back the patient, asking them to consult the psychiatrist in the outpatient setting. Suppose, by chance, psychiatrists are consulted, despite being informed that the delirium is due to an underlying medical-surgical illness, the clinicians may refuse to manage the patient in the emergency and may ask the psychiatrist to admit the patient to the psychiatric ward.
Similarly, psychiatrists are often not consulted for patients experiencing hospital emergent delirium. A study from India showed that in an ICU where the prevalence and incidence of delirium were 68.2% and 59.6%, respectively, the psychiatry referral rates were only 1.71%.[6] This possibly suggests that the care of delirium is primarily shouldered by physicians or intensivists, who often consider delirium as an expected outcome in the background of severe physical illness, that will improve once a physical disease is treated. Until then, these patients are often sedated and physically restrained.
Further data from India also suggests that if the psychiatrists are consulted for delirium, this is often delayed, with a mean delay of slightly more than 2 days for hospital emergent delirium and those with delirium at the time of admission.[7] Studies from India also suggest that delirium is, at times, misdiagnosed as depression or other mental health conditions by physicians and surgeons. The diagnostic concordance for diagnosis of delirium between psychiatrists and the physicians–surgeons have been shown to have a kappa <0.19, indicating poor concordance.[8]
A web-based survey from India that included opinions of 659 physicians of the Indian Society of Critical Care Medicine and the Indian Society of Anesthesiologists evaluated the practices related to the assessment scales used for delirium, sedation, and pain, and management practices for these conditions showed that two-thirds of the physicians believed that the incidence of delirium in mechanically ventilated patients is <10% and only 2% of the participants reported the incidence of delirium to be >50% in mechanically ventilated patients. Most of the participants said they did not assess patients for delirium routinely, and only a tiny proportion of the participants reported using formal instruments to assess delirium. Among the various tools used, the confusion assessment measure for ICUs was the most preferred instrument, and the most preferred medication for managing delirium was haloperidol. Further, this survey showed that most physicians used midazolam and fentanyl for sedation and pain relief, respectively. This is in contradiction to the recommendation to use nonbenzodiazepine agents. The majority of the respondents were aware of the benefit of early mobilization. Still, a lack of support staff and safety concerns were the main obstacles to its implementation. Only 50% of the physicians responded when asked about having a written protocol in their ICU for sedation, pain, and delirium management.[9]
Based on all this evidence, it can be said that, in general, in India, delirium is often not diagnosed or misdiagnosed, usually patients with delirium are not referred to a psychiatrist, or when diagnosed a referral to a psychiatrist is often delayed, and it is often mismanaged. Overall, it can be said that physicians are often disinterested and do not recognize, evade it, leave it untreated, consider it inevitable, rely on the use of medications on their own, increase the cost of treatment, and contribute to the unexpected complications and mortality [Table 1].{Table 1}
Prevalence of Delirium in Consultation–Liaison Psychiatry Practice
Delirium is one of the most common psychiatric diagnoses among the patients seen in consultation–liaison psychiatry settings, with prevalence varying across different studies from 2.81% to 43.4%. The prevalence in emergency settings ranges from 4.6% to 34.1%.[10]
Involvement of Mental Health Professionals in Delirium Care
In India, most consultation–liaison psychiatry is practiced more or less as per the consultation model rather than the liaison model.[11] As a result, all medically ill patients are not screened by psychiatrists for delirium, and psychiatrists usually rely on referrals from other specialists. Due to this practice model, most patients with delirium are not referred to a psychiatrist. Further, there is a lack of geriatric psychiatrists and multidisciplinary old age services. These further contribute to the poor care of patients with delirium.
Research on Delirium From India
Despite being ubiquitous, delirium as a diagnostic entity has not received adequate research attention. A recent systematic review identified only 165 articles on delirium originating from India, with slightly more than half of these being original articles. However, these articles mainly focused on epidemiology (incidence, prevalence, outcome, etc.) and symptom profiles of delirium. Only a few studies focused on the effectiveness of various pharmacological interventions in managing delirium.[12] In less than one-third of the papers, nonpsychiatrists were authors, suggesting that psychiatrists conducted most of the research.
Where Does the Diagnosis of Delirium Stand?
Taken together, despite high prevalence, delirium remains an orphan because it occurs in a setting where people are not prepared to recognize and manage it, and those who can handle it appropriately are not involved or do not have enough time and workforce resources to focus on the same.
What is the Need of the Hour?
There is a need to improve the focus on delirium. This can be done at the level of professional organizations, psychiatrists, and individual clinicians. In addition, there is a need to improve research on delirium to understand the contextual factors that may be more relevant to identify and manage delirium in the Indian context.
At the professional association level, there is a need for liaison between psychiatric associations and other professional organizations to improve awareness about delirium. These liaisons can lead to the formation of multidisciplinary teams that can facilitate care, education, training, and research in delirium. Many Western countries have multidisciplinary delirium associations, such as the American Delirium Society and the European Delirium Society. There is also a need to form such an association in India to facilitate interaction among various specialists involved in caring for patients with delirium.
Professional organizations such as the Indian Association for Geriatric Mental Health, the Indian Academic for Geriatrics, and the Geriatric Society of India should strive to develop educational material for the patients, their caregivers, clinicians, and trainees so that they have readily available material to refer to when they are faced with a patient with delirium. The availability of these materials in local languages can also help to institute prevention measures at the earliest by making the caregivers aware of the possible risk factors and preventive strategies.
There is also a need to have more continuing medical education programs and conferences, primarily focusing on delirium. Professional organizations should also attempt to develop clinical practice guidelines for managing delirium.
Psychiatrists should also take the initiative to improve the knowledge and awareness of physicians, surgeons, and intensivists about delirium. When called to see a patient, they should utilize this opportunity to interact with specialists and inform them about the diagnosis of delirium and its management. They should also attempt to answer all the queries of the specialists concerning delirium. It is here that the psychiatrist should learn to speak the language that physicians will be able to understand, as this can positively impact the attitude toward delirium and possibly change it to a more positive attitude and practice in recognizing and managing delirium [Table 1].
It is often helpful to tell physicians that delirium is a form of acute brain failures, like a failure of other organs, such as the heart, kidney, and liver. Further, psychiatrists can also emphasize that delirium manifests as multiorgan failure (i.e., understood as a failure of two or more organs). Hence, as clinicians focus on specific organ failure while managing a patient with any organ failure, they should also focus on brain failure. Similarly, it can be stated that as they consider kidney or hepatic functions while starting any medications or intervention, acute brain failure needs to be considered while choosing various interventions. When delirium occurs superimposed on dementia, it can be emphasized that dementia is like a chronic organ failure, and like the occurrence of acute renal failure over chronic renal failure, delirium is a superimposed acute brain failure over chronic brain failure. Psychiatrists should also emphasize that delirium is associated with poor outcomes, irrespective of the severity of the physical illness. The specialists can also be informed that studies have shown that despite controlling for all possible confounding variables, delirium is associated with poor outcomes in the form of mortality in both medically and surgically ill patients. This can have better impact on surgeons, who do not like to have a poor outcomes of patients on whom they have operated. They should be told to look for delirium actively, try to prevent it, intervene at the earliest, and educate the patient and family about delirium. They should try to mobilize the patient at the earliest.
The psychiatrists, as clinicians/teachers, should make themselves more knowledgeable and competent in assessing and managing delirium. They should also understand that the management of delirium does not involve the use of antipsychotics only, but nonpharmacological measures are the first line of management of delirium.[1]
There is a need to improve research on delirium in India. Research should focus on contextual factors responsible for the higher prevalence and poor outcomes of delirium. Till now, most of the research on delirium has focused on the clinical picture and effectiveness of antipsychotics. There is no national-level data on the epidemiology and impact of delirium. Similarly, there needs to be more data on biomarkers of delirium from India. Hence, the research should now move forward from just descriptive studies to evaluate the biomarkers, factors that impede delirium care, and those that improve the outcome of delirium.
Conclusions
Delirium is a substantial, unrecognized, and undertreated psychiatric morbidity among the elderly in India. Currently, clinicians in India are far behind their counterparts from developing countries in assessing and managing delirium, and research on delirium is meager. Hence, there is a need for an attitudinal change at the level of clinicians and professional organizations to improve clinical care, training, and research on delirium. It is hoped that these attitudinal changes will lead to reduction in the mortality associated with delirium.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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