A survey of current practices in Management of Delirium in a Geriatric population

Introduction

Delirium is defined as a transient, commonly reversible, cause of fluctuations in mental function. This can occur at any age, but most commonly occurs in older adults or in those with pre-existing mental health issues..¹

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) defines delirium as fluctuating disturbance in attention and awareness which occurs over a short period of time, generally over a few hours to days. The change in cognition should not be explained by a pre-existing, established or evolving dementia. For delirium to occur there should be evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.² Management of delirium is dependent on the underlying organic cause of delirium. There are different types of delirium mainly hyperactive, hypoactive and mixed types.

Some of the assessment methods used to identify delirium include the Confusion Assessment Method (CAM), Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC) ³ and 4 ‘A’s Test (4AT) screening tool ³

The main aim of this study was to investigate current practices in the detection, investigation and management of older adults with delirium. This is of utmost importance because delirium is under recognised among older adults, leading to serious adverse health outcomes and death at times.³

Methodology

Approval was obtained from the research committees of Karin Grech Hospital (KGH) and Saint Vincent de Paul long term facility (SVP). An electronic survey was distributed to all foundation doctors, basic specialist trainees, higher specialist trainees, resident specialists, general practitioners and consultants working within the Department of Geriatric Medicine between 18th October 2021 and 16th January 2022. It included doctors working at KGH, SVP, orthogeriatric section at Mater Dei Hospital (MDH) and community. A total of 58 doctors were invited to participate. A second reminder was sent via electronic mail after three weeks.

The questionnaire was developed by the researchers based international literature as well as keeping in mind the local scenario. There were seventeen questions in all, some being close ended, while others allowed further comments from the participants.

Results

Fifty-eight doctors working within the Geriatric Medicine Department were asked to participate in the survey. Twenty-six doctors (44.8%) replied with the majority of whom ten (38.5%) were consultants and nine (34.6%) were higher specialist trainees. Unfortunately only one (3.8%) basic specialist trainee and two (7.7%) foundation doctors gave their input.

Twenty-four participants (41.4%) declared their work place as shown in Table 1. The majority work in KGH and SVP

Twenty-nine (50%) participants had more than 10 years’ experience as a medical doctor and twenty (34.6%) had been working for 6-10 years. Only one (1.7%) respondent had been working for 1-2 years.

Over fifty-two (90%) respondents admitted that they encounter delirium frequently or on a daily basis. This reflects the extent of the challenges delirium presents especially in the geriatric setting.

Mixed delirium was the commonest type of delirium encountered by the respondents with fourteen (53.8%) giving this answer. Nine (34.6%) participants stated that they most frequently encounter hyperactive delirium, with three (11.5%) stating that they commonly meet hypoactive delirium. This might reflect the fact that it is more difficult to pick up issues when a patient is more “quiet” than usual. Relatives or care-givers who know the patient well will easily identify “hypoactivity”, but this is more difficult to be picked up by others.

Over forty-six (80%) respondents admitted that they frequently or always screen for delirium in older adults. Just over thirty-two participants (55%) claim that the inter-disciplinary team is primed to detect delirium.

Figure 1 shows the commonest reasons for delirium, while drug classes which were mostly associated with delirium are shown in Figure 2.

Figure 1

Commonest causes of delirium

Figure 2

Drugs commonly associated with delirium

Seventeen (65.4%) participants admitted that they frequently encounter problems with drug prescription, with six (23.1%) claiming that they rarely encounter this issue. Furthermore nineteen (73.1%) state that they frequently notice issues with drug administration.

When it comes to environmental issues, unfamiliar place was named by fifty-three (88.5%) and chaotic environments by thirty-eight (65.4%) participants as being the main players which contribute to delirium. Lack of clock in the surrounding and lighting were mentioned to a much lesser extent, them being highlighted by eleven (19.2%) and twenty (34.6%) respectively.

4AT was used by twelve (46.1%) of the participants. Eight (30.8%) participants claimed that they used the Confusion Assessment Method (CAM). Five (19.2%) used orientation to time, place and person, while one (3.8%) participant claimed they used clinical examination, and another one (3.8%) used bloods and parameters mostly. One of the participants did not reply to this question.

Only twelve (20%) knew about the local guideline for delirium. Ten (83.3%) of those knowing about the guideline found it useful.

The respondents agreed that there needs to be more awareness about delirium. When asked what could be done to enhance this, over forty-six (80%) believed that educational activities would help. Thirty-eight (65.4%) claimed that staff education would enhance reporting patient behaviour changes to professional staff such as nurses and doctors. This would allow safer and more timely managements of patients in delirium.

Discussion

This study had a response rate of 44.8% which is deemed acceptable compared to usual response rates among medical doctors. International literature quotes 35% as an average response rate for most online surveys among doctors.⁴

The greatest strength of this study was that it the first such local study exploring the management of delirium in Malta. International research about this topic is also limited. In 2009, a group of researchers investigated the barriers to the management of delirium among junior doctors. It was clear that more awareness and education was required among these doctors.⁵ The first Italian multicentre study about the management of delirium was published in 2014. This study included nurses, physiotherapists, psychologists apart from medical doctors.⁶

Whereas studies abroad show that CAM is the commonest used tool for the detection of delirium, it seems that the 4AT (4-abbreviated mental test) is more commonly used in the Geriatric department in Malta. In fact, 46.1% used 4AT versus 30.8% who used CAM The CAM tool is based on the four core features of delirium and has a high sensitivity (94-100%) and specificity (90-95%). The 4AT tests knowledge about age, date of birth, place and year. A score of three of less would indicate a problem with cognition.⁷ Reasons for which 4AT is more commonly used in Malta need to be studied.

This first local study investigated the types of delirium the participants most commonly encountered and the commonest causes of delirium mostly identified by them. This had not been published in foreign studies. On the other hand, just like other published studies, this local study surely highlights the lacunae present in the teaching of the more junior staff about delirium. All the respondents felt that there need to be more awareness about delirium. This is also in light of the fact that 53.8% of doctors working within the Geriatric Department in Malta were not aware of a local guideline which had been published in 2020 on the local hospital intranet.

Just like foreign research, it is clear that there should be more education and awareness about delirium among doctors and other healthcare professionals.⁸ Ideally there should be more promotion of local available material such as delirium guideline and leaflets. These results are also seen in international literature.^5,6

The limitation of this study is that only doctors were invited to participate in the study. Should the study have included other healthcare professionals, the results would have been more robust. Ultimately all members of the interdisciplinary team are involved in the management of delirium with carers and nurses being at forefront in the detection of possible cues for delirium.

Conclusion

In conclusion, the results obtained in this survey reflect the need for more education among doctors for timely detection and management of delirium. Ideally there should be more promotion of local available material such as delirium guideline and leaflets. These results are also seen in international literature.^5,6 Another study about the management of delirium among other members of the interdisciplinary team would add more knowledge about the current situation in Malta.

References

1. https://emedicine.medscape.com/article/288890-overview
2. American Psychiatric Association 2013. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. 5th ed. Washington DC: American Psychiatric Association.
3. Grover S Assessment scales for delirium: A review. World Journal of Psychiatry. 2012;2:(4)58.
4. Cunningham C, Quan H, Hemmelgarn B, et al Exploring physician specialist response rates to web-based surveys. BMC Medical Research Methodology. 2015;15.(1)
5. Davis D & MacLullich A Understanding barriers to delirium care: a multicentre survey of knowledge and attitudes amongst UK junior doctors. Age and Ageing. 2009;38:(5)559-63.
6. Bellelli G, Morandi A, Zanetti E et al Recognition and management of delirium among doctors, nurses, physiotherapists, and psychologists: an Italian survey. International Psychogeriatrics. 2014;26:(12)2093-102.
7. Bellelli G, Morandi A, Davis DH et al Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43:(4)496-502.
8. Oh ES, Fong TG, Hshieh TT & Inouye SK Delirium in older persons. Journal of American Medical Association 2017;26; 318:(12) 1161–74.

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