Psychiatry Engagement in The Management of Delirium in General Hospital Patients
Background: Delirium is a common and serious problem in patients with medical illness. The overall prevalence rate of delirium was 10~31% in hospital general medical in-patient settings. The purpose of this study is to examine the characteristics of patients with delirium encountered during the consultation of psychiatric departments in other departments of general hospitals, the benefit of consultation. Methods: We reviewed the medical records to collect relevant information. The Confusion Assessment Method-Short (CAM-Short) scale was used to evaluate the severities. Results: Twenty patients were recruited. The average age was 73.9-year-old. All the participants presented with hyperactive delirium. The average initial CAM score was 4.5 and then decreased to 2 after the follow-up. Almost all teams applying for consultation arranged treatment (19 in 20) or examinations (18 in 20) as the suggestion.. Conclusion: In our study, the psychiatric department's consultation services have specific assistance to patients with delirium. The consulting physician should still track the follow-up status of the case and discuss the treatment of delirium with other physicians at an appropriate time.
Keywords: Delirium, psychiatric consultation, CAM-S
Introduction
Delirium is a common and serious problem in patients with medical illness. Delirium is caused by a series of complicated pathophysiological mechanisms, and its core feature is a change in consciousness. According to the diagnostic cri- teria from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the main characteristics of delirium include (1) atten- tion and perception are disturbed; (2) this distur- bance is acute in a short period of time; (3) the disturbance fluctuates easily during the day; and
(4) cognitive distress is accompanied.[1]There are 3 recognized motor subtypes: hyperactivity, hypoactivity, and mixed[2].
Due to difficulties in performing studies in pa- tients with cognitive impairment, high-level evi- dence of management of delirium is still limited. Prevention strategies remain the most important management. Basic principles include (1) avoid- ing factors known to cause or aggravate delirium,
(2) identifying the underlying acute illness and providing appropriate treatments, (3) preventing further cognitive and physical decline with sup- portive and restorative care, and (4) low-dose, short-acting pharmacologic agents used only to control disruptive and risky behaviors[3]–[6].
Although delirium may be associated with a higher mortality rate[7], it is still often undiag- nosed. The overall prevalence rate of delirium was 10~31% in hospital general medical in-pa- tient settings[8]. A local study revealed lower rates of detection (44.9%) and treatment despite a high prevalence (46.9%) among terminal can- cer inpatients. The same study also mentioned that hypoactive subtype delirium was significant- ly underdiagnosed compared to the hyperactive/ mixed subtype, with detection rates of 20.5% and 95.7-100% (P < 0.0001)[9].
Efforts have been made to identify risk factors for delirium. The risk factors mainly included age, chronic pathology such as dementia, acute illness especially involving the central brain sys- tem such as coma, and poor physical conditions such as conditions needing emergent surgeries or mechanical ventilation[4]–[6],[10].
Past research on delirium has aroused. Many ex- perts in internal medicine and surgery are also in- volved in research in Taiwan[11]–[13]. Howev- er, delirium is the most common condition why psychiatrists were consulted. Although there is consensus to manage delirium by treating under-
lying diseases, disturbing behaviors and derived risks (e.g. falling) often require additional man- agement (e.g. psychotropic agents). Therefore, it is necessary to re-examine the clinical situation to understand the difference between the man- agement of delirium in the past and the current ward. The purpose of this study is to understand the characteristics of patients with delirium en- countered during the consultation of psychiatric departments in other departments of general hos- pitals, the changes in treatment after the consul- tation, and the prognosis of treatment.
Method
The study period of this study is from March 2021 to June 2021. The recruiting site is Chi Mei Medical Center, with a total of 1288 beds in this hospital. The period of acceptance is from 2021/3/18 to 2021/5/18, investigating all the pa- tients consulted to the psychiatric department with a diagnosis of delirium.
We reviewed the medical history and recorded the patient information to compare with prior tri- als: the patient’s gender and age; risk factors in- cluding chronic neurological diseases and under- lying psychiatric disorders; predisposing factors including acute brain lesions (central nervous system infection, hemorrhage, epilepsy), other site infections, metabolic disorders, indwelling pipelines, whether there was organ failure; type of delirium(hyperactive or hypoactive); admis- sion route(from emergency room or outpatient department); and the unit applying consulta- tion(ordinary ward, intensive care unit or emer- gency room). To compare the management of the original team and consulting psychiatrist, we also reviewed prescribed psychotropic agents before consultation.
We did a clinical interview to diagnose de- lirium according to DSM-5 criteria. For con- venience, we used the Confusion Assessment Method-Short (CAM-S) scale to evaluate the severities, in which higher scores indicate high- er disease severity. The Confusion Assessment Method (CAM) is now suggested as a standard- ized evidence-based tool for either psychiatri- cally or non-psychiatrically trained clinicians to effectively assess delirium in both research and clinical settings. Adapted from CAM, the Confu- sion Assessment Method for the Intensive Care Unit (CAM-ICU) is also widely used to detect de- lirium and assess severity in clinical settings. In
our hospital, CAM-ICU was routinely performed among ICU patients. The validity and specificity of CAM-S were examined and proven[14].
We replied the consultation with standard forms for treatment suggestions including (1) laborato- ry test such as electroencephalography or brain image; (2) pharmacological treatment including adjusting doses of psychotropic agents and did tapering drugs such as benzodiazepines(BZD) or anticholinergic agents, which may worsen delirium; (3) non-pharmacological management such as maintaining circadian rhythms, adequate environmental stimulus; (4) further disposition such as psychiatric outpatient clinic follow-up or psychiatric ward admission. We then contacted the original team for follow-up after 3 days of the consultation. The number of days of contin- uous treatment with psychiatric drugs after the psychiatric consultation, and whether the psy- chiatric administration recommendations and arrangements for inspections and hospital stays were also followed. We arranged our data with counting statistics. This study was approved by the IRB ethics review of Chi Mei Medical Center (IRB number: 11008-006).
Result
A total of 22 patients were recruited, and 2 of them were excluded due to incomplete informa- tion. Participant characteristics are summarized inTable 1.. There
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