Attitudes and priorities of training clinicians in diagnosing delirium in an academic hospital

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Corresponding author: M.kemal Kuşcu, MD,

Marmara University School of Medicine Department of Psychiatry Tophanelioglu Cad. No: 13-15 34034 Uskudar-Istanbul

E-mail: mkkuscu@marmara.edu.tr

Marmara Medical Journal 2004;17(3);99-104

ORIGINAL RESEARCH

ATTITUDES AND PRIORITIES OF TRAINING CLINICIANS IN DIAGNOSING DELIRIUM

IN AN ACADEMIC HOSPITAL

M.Kemal Kuşcu, Volkan Topçuoğlu, Aylan Gımzal Gönentür, Yasin Bez, Çağrı Yazgan,

Nurhan Fıstıkçı, Duygu Şahin Biçer, Ali Keyvan

Department of Psychiatry, School of Medicine, Marmara University, Istanbul, Turkey ABSTRACT

Objective: The aim of our study is to explore the attitudes and practices of residents on establishing a diagnosis of delirium and their clinical intervention in different clinical settings in Marmara University Hospital.

Methods: Seventy-five residents in different clinical settings in Marmara University Hospital completed a 14-item questionnaire which

focused on their priorities and attitudes concerning diagnosis and treatment of delirium.

Results: Orientation difficulties, clouding of consciousness and hallucinations were chosen as the most frequently encountered

symptoms of delirium. For the purpose of establishing the etiology of delirium the most frequently preferred method was biochemical screening. Metabolic imbalances were most frequently found while only less than 50% of participants could establish the etiology. Most of the participants indicated treatment of the specific etiology as the preferred treatment method of delirium. Haloperidol was the most frequently selected medication for symptom control.

Discussion: Delirium still remains an important clinical emergency in clinical practice. We hope this study will promote further insight

for daily clinical routines in Marmara University Hospital. We believe this effort will provide ground for developing new consensus guidelines for the management of delirium, which will improve the outcome and treatment process of this clinical condition.

Keywords: Delirium, Clinical practice

BİR EĞİTİM HASTANESİNDE ASİSTAN HEKİMLERİN DELİRYUM TANISINA

YÖNELİK TUTUM VE ÖNCELİKLERİ

ÖZET

Amaç: Çalışmanın amacı klinik eğitimleri sırasında hekimlerin delirium tanısını oluştururken tutumlarının ve buna eşlik eden

müdahalelerdeki önceliklerinin saptanmasıdır.

Yöntem: Marmara Üniversitesi Tıp Fakültesi Hastanesi’nin farklı kliniklerinde eğitimlerine devam eden yetmişbeş asistan hekim

delirium tanısına yönelik tutum ve tedavi önceliklerini sorgulayan 14 sorudan oluşan bir değerlendirmeyi tamamladılar.

Sonuçlar: Yönelim güçlükleri, bilinç bulanıklığı ve halüsinasyonlar en sık gözlenen delirium semptomları olarak saptandı. Deliryum

tanısına yönelik en sık başvurulan metodun biyokimyasal değerlendirme olduğu belirlendi. Genelde % 50 oranında etiyolojik faktörlerin saptanabildiği gözlemlenirken, en sık etiyolojik faktor olarak metabolik nedenler bildirildi. Katılımcıların çoğunluğu etiyolojiye yönelik tedaviyi tercih ederken (% 94.7), en sık kullanılan medikasyonun haloperidol olduğu saptandı.

Tartışma: Deliryum gündelik klinik pratiğin içerisinde önemli bir acil durumdur. Çalışmamızın Marmara Üniversitesi Tıp Fakültesi

Hastanesi genelinde delirium takip ve tanısında uygun klinik yaklaşım rehberlerinin oluşturulmasına ve sık gözlenen bu klinik durumun tedavi ve prognozuna katkıda bulunacağını umuyoruz.

Anahtar Kelimeler: Deliryum, Klinik pratik

INTRODUCTION

Delirium is an important clinical condition where disturbance in consciousness and cognition represent the common symptomatology based on different etiologies. The essential feature of delirium is a disturbance of consciousness, ranging from attention disturbances to total

inability to respond to environmental stimuli accompanied by a change in basic cognitive skills such as memory and language that cannot be better accounted for by a preexisting or evolving dementia. This clinical condition develops over a short period of time, usually from hours to days, and tends to fluctuate during the course of the day1_{. The fluctuating course causes an important}

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Marmara Medical Journal 2004;17(3);99-104 M.Kemal Kuşcu, et al.

Attitudes and Priorities of Training Clinicians in Diagnosing Delirium in An Academic Hospital

burden in making a concrete diagnosis on daily basis. If the underlying etiological factors are found and corrected, recovery is more likely to be accomplished.

Delirium occurs in 15-18% of patients on surgical and medical wards, based mostly on referral numbers 2_{. Its prevalence is higher in specific}

conditions: 30% in post-coronary artery by-pass graft (CABG) surgery 3_{and 50% in post-hip}

surgery patients 4_{. A wide variety of physiological}

and central nervous system (CNS) insults produce delirium, which need extensive differential diagnose.

During the last years, systematic research into the prevalence, incidence, and risk factors for delirium has provided valuable insight into this disorder 5_{. The incidence of delirium depends on}

the different individual factors and specific etiologies involved. Patients who are at increased risk for developing delirium include the elderly, patients with CNS disorders, postsurgical patients, burn-patients, drug dependent patients, and cancer patients 2_.

Delirium is one of the leading clinical conditions which can cause an important burden in daily clinical routine 6. Delirium, a medical disorder that results in the morbidity and mortality of patients, is often misdiagnosed and inappropriately treated. Besides being a clinical emergency, delirium has a high mortality rate 7. Delirium remains a poorly managed clinical condition and specific guidelines fail to improve

the process and outcome of care 8_{. Early}

recognition of delirium might improve the quality of life and general outcome of the medical condition 9_{. One way of creating these guidelines}

is to understand the nature of daily routines/ practices in clinical settings. These routines / practices depend heavily on the priorities and attitudes of the medical staff.

Clinical decisions are the cornerstones of daily clinical routines in inpatient units. Despite the available clinical algorithms, most of the daily clinical decisions depend on the attitudes and priorities of the clinical staff 10_{. Despite the}

importance of the issue, the information on how clinicians assess a delirious patient is still limited. Also, the medical staff dominating the daily clinical routines have an important impact on clinical decisions. Furthermore, there is little

information on how the medical staff construct these daily priorities and translate their medical knowledge to practice. How they organize their clinical decisions in daily routine still remains a research area 11_.

The aim of our study is to explore the attitudes and practices of residents on establishing a diagnosis of delirium and their clinical intervention in different clinical settings in Marmara University Hospital. Sequences of clinical decision and priorities in examining and treating delirium are analyzed in order to understand the clinical and personal needs in managing such a clinical condition in an inpatient setting.

METHODS

Participants and procedure

Seventy-five residents from the internal and surgical wards in Marmara University Hospital participated in the study. Each clinician in surgical and internal medicine wards was visited in and a questionnaire about their daily practices concerning delirium was applied. The respondents participated in the study on voluntary basis.

The questionnaire was administered in an interview format. The semi-structured interview consisted of 14 questions focusing on 4 main areas in delirium diagnosis and treatment: (a) Priorities in diagnosing delirium: The participants gave a detailed account of their chosen prognostic symptoms and the course of the delirium, (b) pathway to establish clinical decision: Steps, paths for informations are shared and laboratory procedures are assessed, (c) possible clinical etiologies in delirium, (d) treatment priorities and clinical interventions.

RESULTS

All the participants were residents working in the Marmara University Hospital. Twenty two (29.3%) of them were male, and 53 (70.6%) of them were female. Fifty-one participants (68%) had been practicing as clinicians for 1-5 years, 21 participants (28%) had been practicing for 6-10 years, and 3 participants (4%) had been practicing for 11-15 years. Forty participants (53.3%) had been in residency for 1-2 years, 20 participants (26.7%) had been in residency for 3-4 years and 15 participants (20%) had been in residency for 5 years and longer.

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When the participants were asked about the main symptoms of delirium, they responded as follows: orientation difficulties (74 %), clouding of consciousness (57.3 %), hallucinations (57.3 %), anxiety (45.3 %), psychomotor activation (37.3 %), insomnia (30.7 %), memory deficit (28 %), attention deficit (21.3 %), somnolence (18.7 %), ideas of persecution (16 %), speech problems (12 %), psychomotor retardation (8 %) and depression (2.7 %) consequently.

According to the responses of the participants the most prominent symptoms of delirium were anxiety, orientation difficulties and clouding of consciousness, and these were stated significantly higher than the other symptoms of delirium [χ2_(8,

N=72)=60.75, p=0.000]. The follow-up analysis revealed that frequency of the statement of these symptoms by the participants did not differ from each other [χ2_{(2,N=52)=4.3, p=0.13].}

Participants were asked to rate the number of delirium cases they had encountered in one year in a multiple choice format (a-0-10,b-11-20,c-21-30,d-31-40,e-41 and more). Most of the participants (N=61) indicated encountering less than 10 delirium cases. Seven participants encountered 11-20, 2 participants encountered 21-30, 3 participants encountered 41 and more cases and there were no participants who encountered 31-40 cases. The analysis revealed that there were significant differences between the groups [χ2(3,N=73)=134.28, p=0.000]. In order to carry out follow-up analysis these categories were regrouped as a = 0-10, and b = 11 and more. According to this regrouping, there were 61 participants indicating that they had encountered 0-10 cases, 12 participants indicating 11 and more cases. The results revealed that the number of clinicians who had encountered 0-10 delirium cases (N=61) was significantly greater than the number of clinicians who had encountered 11 and

more cases (N=12) [χ2_{(1, N=73) = 32.89,}

p=0.000].

When the participants were asked about the person who recognized delirium in clinical settings, 76.3% stated residents, 68 % family members, 57.3% nurses, 16% interns and 16% specialists. The result of the McNemar test revealed that a significantly greater number of participants stated nurses as the person who recognized delirium without stating specialists (N=38) than the participants who stated specialists without stating the nurses (N=7) (p=0.000). Similarly, the difference between the number of participants who stated residents as the person who recognized delirium without stating the specialists (N=45) and the number of residents who stated specialists without stating the residents (N=0) was statistically significant (p=0.000). Participants were asked to select one or more of the laboratory methods and clinical interventions which they used to diagnose delirium. Results are shown in table I. The participants were also asked to indicate their preferred method in an open ended format. There was a significant difference between the frequency of application of these methods as their preferred diagnostic method [χ2(8,N=70)=273.8, p=0.000]. While 51 clinicians indicated biochemical screening, chest X ray, urinalysis, electroencephalogram, ultrasonography of the abdomen were not indicated by any of the participants. Because these numbers were too small with which to carry out a meaningful analysis, the number of clinicians indicating methods other than biochemical screening were summed up (N=19). The difference between indicating biochemical screening (N=51) and indicating all other methods (N=19) were found to be significant, showing that biochemical screening was the most frequently preferred diagnostic method [χ2_{(1,N=70)=14.62, p=0.000].}

Table I: Laboratory methods and clinical interventions used by the residents to diagnose delirium Biochemical screening 90.7%

Psychiatric consultation 69.3% Arterial blood gases screening 54.7% Neurological consultation 41.3%

CT scan 14.7%

Urinalysis 13.3%

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Biochemical screening 90.7%

Medication 12%

Cranial MRI 9.3%

Electrocardiogram 8%

Electroencephalogram 6.7%

Participants were asked to indicate the percentage of cases in which they were able to find an etiology in a multiple choice format (a. 0-25%, b. 26-50%, c. 51-75%, d. 76-100%). A one-sample chi-square test was conducted to assess the differences between these choices. The result was significant [χ2_{(3, N=70)=14.34, p=0.002]. Follow}

up analyses were conducted. The proportion of participants who found etiology in 0-25% of cases (N=23) was not significantly different than the proportion of participants who found etiology in 26-50% of the cases (N = 27), and the proportion of participants who found etiology in 51-75% of the cases (N = 13) [in order χ2_{(1, N=50) = .32, p =}

.572; χ2_{(1, N=36) = 2,78, p = .096]. However, the}

proportion of participants who found etiology in 26-50% of cases (N=27) was significantly greater than both the proportion of participants who found etiology in 51-75% of cases (N=13), and the proportion of participants who found etiology in 76-100% of cases (N=7) [in order χ2 (1, N=40) = 4,9, p = .027; χ2 (1, N=34) = 11,77, p = .001}. Finally, the proportion of participants who found etiology in 0-25% of cases (N=23) was significantly greater than the proportion of

participants who found etiology in 76-100% of cases (N=7) [χ2_{(1, N=30) = 8,53, p = .003].}

Overall, the analysis revealed that most of the participants found etiology in less than 50% of the cases.

Etiologies of delirium as indicated by the participants are shown in table II. The participants were also asked to indicate the etiology which they most frequently found, in an open-ended format. There was a significant difference between the frequency of indicating these methods [χ2_{(10, N=73) = 229.73, p=0.000]. While}

43 clinicians indicated metabolic imbalances, 10 participants indicated long-term stay in intensive care unit as the most frequently found etiology. All other etiologies were indicated by 5 or less participants each. A one-sample chi square analysis was conducted to compare the proportion of participants who indicated metabolic imbalances with those who indicated long-term stay in an intensive care unit. The result was significant, showing that the most frequently found etiology by the participants was metabolic imbalance [χ2(1,N=53)=20.55 p=0.000].

Table II: Etiologies of delirium as indicated by the residents

Metabolic imbalances 86.7%

Delirium tremens 40%

Long period of hospitalization 32% Long-term stay in an intensive care unit 30.7% Respiratory pathologies 26.7%

Infections 24%

Intracranial pathologies 24%

The participants were also asked to indicate the treatment which they most frequently preferred in an open ended format. Treatment of the specific etiology (94.7%), pharmacotherapy (90.7%), observation of the patients (54.7%) and psychotherapy/psychosocial interventions (20%) were stated as options for treatment in delirium patients. There was a significant difference between the frequency of indicating these

methods [χ2_{(3,N=71)=108.1, p=0.000]. Fifty-five}

of the clinicians indicated treatment of the specific etiology as the most frequently preferred treatment option. Because the numbers were too small to carry out a meaningful analysis the number of clinicians indicating treatment options other than treatment of the etiology were summed up (N=16). The difference between indicating treatment of the etiology (N=55) and indicating all

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the other treatment options (N=16) were found significant [χ2_{(1,N=71)=21.42, p=0.000].}

Medication alternatives used by the participants for the control of delirium symptoms are shown in table III. When they were asked to indicate their first medication choice in an open ended format, alprazolam, haloperidol, risperidone, quetiapine and diazepam were indicated. Forty-two participants indicated haloperidol as their first choice. Alprazolam, diazepam risperidone and quetiapine were chosen by 15, 9, 1 and 1 of the participants, respectively. These numbers were summed up (N=26). The results revealed that, even though all other medications were considered together, the choice of haloperidol (N=42) was greater than the choice of all the other medications (N=26); and this effect was marginally significant [χ2_{(1,N=68)=3.77, p=.052].}

Table III: Medications used by the the residents

for the control of delirium symptoms

Haloperidol 85.3% Lorazepam, olanzapine, diazepam 41.3%

Alprazolam 38.7% Risperidone 16%

Quetiapine 6.7%

Midazolam 6.7%

DISCUSSION

In our study, we observed that most of the diagnose of delirium and decision-making processes were limited to the hyperactive form of the delirium. Often, the silent or hypoactive forms of delirious states where lethargy and psychomotor retardation are the main symptoms, were not properly recognized in hospital settings. In an earlier study conducted in a sample of 38 inpatients, the hyperactive delirium rate was 80.45% and hypoactive delirium rate was 16.12%

12_{. This figure seems to represent a far lower}

delirium rate than expected and should therefore be revised. These result represented a retrospective analysis of the delirium patients and only covered the hyperactive forms. One of the leading causes might be the underdiagnosis of delirium or the lack of interdisciplinary collaboration during its management.

In an earlier case study, two major problems associated with the lack of recognition of delirium

were underlined as lack of knowledge on the part of the nurses about the criteria and methods for detecting delirium and the ineffective communication between staff members in relaying symptoms of the onset of the clinical condition 6_{. Our results confirm both findings. We}

believe that nurses and residents in daily care needed to be more careful about the correct diagnosis. Delirium or an acute confusional state, which, most of the time, is a result of hospital-related complications or hospital care, can be seen as a marker of the quality of hospital care. Failure to recognize delirium in its early stages is one of the leading pathways leading to an increase in the incidence of delirium 9_{. Examining delirium can}

also provide an opportunity to improve the quality of hospital care and associated services. Nursing staff play an important role in supporting the clinical decision process in this sense.

Unlike other studies, family members seem to participate in the daily clinical routine as one of the main sources of clinical information in Turkey. Despite their impact on daily routine, they are often neglected in terms of sharing clinical information. Short training sessions or information cards might improve their participation and better recognition and follow-up of delirium.

Situated clinical reasoning, incorporating decision support research might support ‘best practice’ clinical pathways and clinical reasoning in the treatment of delirium. Studies on teaching critical clinical decision skills showed that undergraduate interventions were more effective than resident interventions 13_{. These results also show that}

delirium should be an important curriculum item in internship training in medical schools. Delirium has only a limited coverage in the medical curriculum and most of the clinical priorities develop in medical practice. This result is also reflected in our findings: most of the priorities of clinical decisions and treatment focused mainly on clinical experience. Overall, the clinicians responded parallel to delirium guidelines concerning the clinical diagnosis and treatment. Current information on delirium has limited space in clinical practice. For example, the effect of medication was little covered in our study. In our earlier study in Marmara University Hospital, we demonstrated that the mean drug number per case of delirium patients was as high as 6.69 12_{. We}

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delirium in medical school and further training during residency and in-house service could support good clinical practice in delirium.

The study was conducted in adult inpatient wards. Yet, delirium in specific need groups is one of the main focuses of recent delirium research due to the high prevalence and mortality rates. For that reason, delirium in chemotherapy, elderly and critical care patients remains an important issue and should be addressed in future research 14-16. Similarly, delirium in other specific need groups such as children has not been researched in detail and remains an important clinical agenda 17. One of the important aspects of the current study is to promote application of the study findings to clinical settings. Delirium still remains an important clinical emergency in clinical practice. We hope this study will promote further insight for daily clinical routines in Marmara University Hospital. We believe such effort will provide ground to develop new consensus guidelines for management of delirium, which will improve the outcome and treatment process of this clinical condition.

REFERENCES

1. Diagnostic and Statistical Manual of Mental Disorders- Fourth edition. Washington, DC: American Psychiatric Association,1994:123-133.

2. Wise MG, Trzepacz P. Delirium (Confusional States). In: Rundel RJ, Wise MG, eds. Textbook of Consultation Liaison Psychiatry. Washington, DC: The American Psychiatric Publishing,1996:259-274.

3. Smith L, Dimsdale J. Postcardiotomy delirium: conclusion after 25 years. Am J Psychiatry 1989;146: 452-458.

4. Gustafson Y, Berggren D, Brannstrom B. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc 1988;36:525-530. 5. Johnson J. Identifying and recognizing delirium. Demen

Geriatr Cogn Disord 1999;10: 353-358.

6. Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: A case study. Heart & Lung 1996;25:388-400.

7. Weddington WW. The mortality of delirium: an underappreciated problem. Psychosomatics 1982;23:1232-235.

8. Young LJ, George J. Do guidelines improve the process and outcomes of care in delirium ? Age Ageing. 2003;32:525-528.

9. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106:565-573.

10. Bornsteşin BH, Emler AC, Chapman GB. Rationality in medical treatment decisions: is there sunk-costeffect? Soc Sci Med 1999;49: 215-222.

11. Lacko L, Bryan Y, Dellasega C, Salerno F. Changing clinical practice through research: the case of delirium. Clin Nurs Res 1999;8:235-250.

12. Kuşcu MK, Topçuoğlu V, Altunel Ö, Bez Y. Deliryum tanısıyla takip edilen hastaların izlem sonuçları. Anadolu Psikiyatri Dergisi 2004;5:16-21.

13. Norman GR, Shannon SI . Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal. CMAJ 1998;158:177-181.

14. Ljubisavljevic V, Kelly B. Risk factors for development of delirium among oncology patients. Gen Hosp Psychiatry. 2003;25:345-352.

15. McCarthy MC. Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments. Res Nurs Health 2003;26:203-212. 16. Litton KA. Delirium in the critical care patients: what

the professional staff needs to know. Crit Care Nurse 2003;26:208-213.

17. Manworren RC, Paulos CL, Pop R. Treating children for acute agitation in the PACU: differentiating pain and emergence delirium. J Perianesth Nurs 2004; 19:183-193.