Chapter 10: Education about delirium

Emerging themes

The failure of guidelines?

There are now several sets of guideline for the recognition and management of delirium in medical settings. A guideline-driven intervention in British geriatric wards by Young and George (2003) failed to show any response, although the cluster design was clearly underpowered. A similar “disconnect” between appreciation of the importance of delirium and actual practice is also manifest in Ely et al’s study of intensive care staff (2004). One problem might be that apparent consensus may be illusory; in all such endeavour it is easier to retain something favoured by a colleague that you actually think is unimportant to ensure that something you think important is included without demur. Michaud has presented a study of expert views on the appropriateness of over 200 statements on risk factors, prevention, screening and diagnosis of delirium, using a formal method of iterative grading (Michaud (2005). He found that 84 percent of the statements achieve significant agreement, but he found a lower rate of agreement about the feasibility of interventions to prevent delirium than about the appropriateness of these intervention. The usefulness of screening and the role of physical restraints in the development of delirium emerged as the most contentious. His full report has been submitted for publication but preliminary results support those of Carnes, Howell, Rosenberg et al (2003). Variation in the management of delirium by 282 American physicians (including 14 psychiatrists) who are members of the American Geriatrics Society emerged from a vignette-based study of “best practice” in delirium after hip fracture surgery. Acknowledging the lack of an evidence base for the latter, the authors found wide variation in choice and dose of medications suggested. Interestingly, 15% of male respondents favoured the use of restraints (vest or wrist or both) compared with 3% of female ones. It is not clear how generalisable these results are- particularly to the surgeons who actually manage patients epitomised in the vignettes.

Mayo Smith and colleagues from the American Society Of Addiction Medicine have proposed a practice guideline on the management of alcohol withdrawal delirium in which they favour sedative-hypnotic agents over neuroleptic agents, based on a meta-analysis of nine prospective controlled trials (2004). However Klijn and van der Mast (2005) in a thoughtful letter have challenged the established view the benzodiazepines are the first line of treatment for alcohol withdrawal delirium, pointing out that the Dutch guidelines (van der Mast, Huyse, & Rosier (2005) developed by themselves and colleagues determined that haloperidol should be the first line of treatment for suspected alcohol withdrawal delirium. They suggest that there is a danger that once alcohol withdrawal has been diagnosed, other additional causes of delirium in acute older medical in patients are ignored

The British Association of Critical Care Nurses has issued guidance on the use of restraint in adult critical care units (intensive care units) (Bray, Hill, Robson et al (2004). They do not confine their advice to physical restraints but include pharmacological and psychological methods. Their recommendations seem very reasonable and sensible, but interestingly they do not tackle the problem of capacity and consent in fluctuating states like delirium.

Preconceptions of nursing staff

Low rates of recognition of delirium - especially of hypoactive symptoms, have been reported by Milisen, Foreman, Wouters et al (2002) in a study of case-note recording by nurses in post-hip-fracture patients. Possible reasons behind this and other similar findings have been explored by McCarthy in an important qualitative analysis of nurse interviews (2003a). She found two main attitudinal perspectives on older medical and surgical patients, and an intermediary one. In the first, the “decline perspective”, nurses expected all older people to be “confused”, did not distinguish between acute and chronic cognitive decrement, and were most interested in the impact that patients with “confusion” would have on their working day or night. It is this attitude which Segatore and Adams so indignantly refuted: “Delirium is never a “normal” or an acceptable response to acute surgical stress” (2001). In the opposite “healthful perspective” nurses saw any cognitive impairment as unexpected and worthy of interest, distinguished between different causes, and were most interested in remediation or palliation. The intermediate perspective, which McCarthy called the “vulnerable perspective” nurses were unsure or vacillated between the other perspectives. She has refined this approach in a participant observation study and added that context was also important (2003b). She suggests 4 approaches to maximise the benefit to delirious patients: first, know the perspective of the nursing staff assigned to care for them, second, do not assign nurses with the “decline perspective” to this work, third, institute protocols that mitigate against this perspective, and only finally, education. If these findings could be developed, perhaps in a quantitative way if this was possible, it could lead to much better focussed management and educational interventions that could be validated against outcomes for patients..

Footnotes

The documentation of mental status in emergency department patients has been found deficient by Hustey and Meldon (2002). suggesting yet another area for educational activity. The same team have later shown a very low rate of recognition of delirium in this setting (2003). They studied delirium in 271 emergency department attenders. Recognition rates by the physicians showed a sensitivity of 16% and a specificity of 98.4%. Over half the 19 delirious patients, of whom 3 were recognised, were planned to be discharged home. When CAM scores were revealed to physicians, no change in management plan resulted. The study was of a small proportion of attenders and was not a probability sample but the results are worrying.

Rockwood has criticised the tendency for teaching to be over-complex or remote and this may affect its efficacy (2004). We have recently shown that a simple educational package for staff on one ward was associated with a lower prevalence of delirium on that ward compared with the control ward (Tabet, Hudson, Sweeney et al (2005). No causal connection can be made, but it does raise an issue about how complex interventions are evaluated- context is extremely important (Pawson and Tulley (1997).

Mnemonics for teaching in delirium are offered by Flaherty and Morley (2004) and Crausman (2004).

The American Medical Association has produced a patient information leaflet about delirium (Torpy, Lynm, & Glass (2004). It is not clear when it is to be used, but the language is clearly inaccessible to anyone with delirium, and most without.

Pun, Gordon, Peterson et al (2005) have shown that with modest training it is possible to achieve very high rates of use of the CAM-ICU and compliance rates of 90 percent are possible. In addition, they were able to show agreement between the CAM-ICU and independent assessment could be sustained in routine use. This bodes well for all delirious patients if the results can be generalised to general medical and surgical settings older people, but, as Riker and Fraser (2005) have said, the benefits for all improved detection have to be judged against improved outcome for delirious patients in all settings.

Reference List Chapter 10

 

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