- Department of Psychiatry, Clinical Psychologist, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
- Professor Emeritus, University of Illinois at Chicago, Director of the Neuropsychiatric Division, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
Rebecca A. Stout
Professor Emeritus, University of Illinois at Chicago, Director of the Neuropsychiatric Division, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
DOI:10.4103/2152-7806.76976© 2011 Stout RA This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Stout RA, Gaviria MF. On delirium. Surg Neurol Int 21-Feb-2011;2:20
How to cite this URL: Stout RA, Gaviria MF. On delirium. Surg Neurol Int 21-Feb-2011;2:20. Available from: http://sni.wpengine.com/surgicalint_articles/on-delirium/
Delirium represents a common neuropsychiatric syndrome that impacts an estimated 20% of postoperative neurosurgical patients.[
One of the frustrations that impede proper identification of delirium concerns disrupted communication. While delirium is a defined disorder with a definite name, there continues to permeate an unclear and inconsistent language in describing the illness among professionals. It is common, in our experience to have delirium communicated using a host of names, such as ICU psychosis, sun-downers, change in mental status, new-onset dementia, acute psychosis, acute brain syndrome, and so on. As long as this inconsistency in language persists, the problem of undetected delirium will continue.
The confusion of terms also leads to another interesting dilemma of responsibility for treatment of the illness. When terms, such as “psychosis” or “dementia,” are used to describe the delirium, the focus on determining the underlying medical cause can be lost in favor of attempting to find a psychiatric basis for the presentation. Delirium is a psychiatric illness that occurs in the context of underlying toxic, metabolic, structural, infectious, and other medical problems. In other words, before delirium can be adequately managed, it must be viewed as a joint effort between psychiatry and the other medical teams involved in the care of the patient, including neurosurgery.
Another barrier in successful identification is the wide variety of the presentation of delirium in individual patients. The diagnosis of delirium includes common symptoms across persons, including disturbances in arousal, attention, cognition, and perception. However, the phenomenology of these deficits ranges wildly. These differences in presentation at least partially account for the errors in description of the illness described above. Patients with hyperactive delirium who are actively hallucinating, combative, and disrupting their own care are much more likely to elicit the attentions of medical personnel and generally be identified as delirious, but also more likely to be described as having a psychiatric illness. In contrast, patients with hypoactive delirium face greater risk to go undetected given the absence of more disruptive behaviors and the appearance of greater medical plan compliance despite their significant impairments. Both types of patients are equally likely to suffer the negative medical outcomes associated with prolonged delirium if untreated, highlighting the need for improved assessment of the disorder.
Appropriate assessment of delirium should be routinely performed throughout a patient’s hospitalization, especially for those groups at increased risk, including postsurgical, geriatric, and, chronically ill patients among others. Use of validated assessment tools for delirium appears to be woefully lacking in routine care. Estimates suggest that only 16% of medical units use a specific instrument to assess delirium.[
Pharmacologic and nonpharmacologic methods are available to assist in the management of delirium. The antipsychotic haloperidol has long been used as a first-line treatment, and more recently, the usefulness of atypical antipsychotics, such as quetiapine and olanzapine,[
Consistent and repeated education among all medical staff is crucial to increase understanding and successful identification of delirium. Top-down and peer-to-peer pressure to utilize the correct terminology when describing delirium will be the essential first step in improving accurate identification of delirium. Given the prevalence and potential negative consequences of delirium, we remain optimistic that appropriate assessment and treatment of this condition will flow from increased education by members of psychiatry departments.
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