Clinical recognition of delirium.

Sir,

The development of delirium often initiates a cascade of events, which lead to functional impairment, increased risk of morbidity and mortality, and higher health care costs. Obviously, any delay in diagnosis can worsen the course and outcome of delirium. Grover et al.[1] identified factors contributing to the delay in referral to psychiatry in a group of patients with delirium in a teaching hospital. They found factors such as older age, presence of sleep wake cycle disturbance and motor retardation associated with delay in referral. It appears that many subjects who were referred late, probably had hypoactive delirium. Behavioral symptoms are often less remarkable in these patients and that could have delayed the identification of delirium. Physicians and internal medicine text books often designate this clinical condition as “acute confusional state” instead of “delirium.” Lack of uniform definitions and assessment methods had contributed to the prevailing low levels of understanding about delirium among medical professionals.[2]

There could be other reasons for the delay in seeking psychiatric help in a general hospital settings. The treating clinician might recognize the condition as delirium, institute interventions, but may seek the opinion from psychiatry only when faced with difficulties in management. Alternatively, some clinicians have a problem in identifying the clinical syndrome of delirium itself. They often miss the diagnosis, especially when it is hypoactive delirium. Misdiagnosis of delirium as acute psychosis happens when delusions and or hallucinations are part of the syndrome of delirium. Nonrecognition and delayed diagnosis of delirium, both are costly clinical errors which need to be prevented. Let us think of some measures to overcome this.

Let us begin with medical education. Under graduate medical training should enable clinicians to recognize delirium early and initiate management. Skills to delineate the clinical features of delirium include the clinician's ability to elicit relevant history and carry out appropriate bedside examination. Adequate practice is needed to attain a reasonable level of competence in the evaluation of cognitive functions, a fact often overlooked in training. The 2 weeks internship period in psychiatry is the best time to build this skill. Discussion and demonstration of clinical features of delirium could be done in the 1st or 2nd day of psychiatry posting. Psychiatry interns should be encouraged to take an active role in the assessment and management of patients with delirium tremens in psychiatry wards. They can also participate in the evaluation of cases of delirium referred to the liaison psychiatry services. Ideally every intern should have the opportunity to work up at least one case of delirium in detail as part of their psychiatric posting.[3] This will allow trainee clinicians to develop a better understanding of delirium, a difficult to comprehend neuropsychiatric syndrome, with variable clinical manifestations and fluctuating symptoms.

Management of behavioral and other disturbances during delirium requires close collaboration and communication between psychiatry and the referring unit. This offers opportunities to deliberate and make informed decisions, especially about the use of pharmacological and or nonpharmacological interventions. Management of delirium is best served by this liaison between the treating clinician and the consultant from psychiatry. Proper communication with the patient and the carers is also important. Well informed carers and health professionals can shorten the course and improve the outcome of delirium. We need to begin by strengthening the undergraduate training program. Concerted attempts are often needed to bring about changes in physicians and nurses to improve early recognition and management of delirium.[4] Constant efforts in this direction can lead to better identification and effective management of delirium.