Delirium frequently goes undiagnosed

Researchers in the United States and the United Kingdom have found that whilst delirium is widespread amongst older people, it frequently goes undiagnosed. The condition can severely impact the cognition and independence of sufferers, yet a study led by Dr Babar Khan from the Indiana University’s Regenstrief Institute, found that it is often viewed as inevitable by medical professionals.

The team looked at a total of 585 studies representing 45 years of delirium-related research, and found that a third of cases were preventable. The authors of the paper, which was published online in the Journal of Hospital Medicine, are calling for prompter diagnosis of delirium to improve long-term prognosis.

I spoke to Dr Chris Fox, co-author of the paper and Clinical Senior Lecturer at the University of East Anglia (UEA), to find out how healthcare systems can more effectively tackle this frequently unrecognised condition. He began by outlining some of the major differences between delirium and dementia.

"Delirium is sometimes referred to as acute confusion," explained Dr Fox. "It is a condition that is associated with the disturbance of consciousness and the loss of orientation, and its severity can fluctuate. Dementia, on the other hand, is a disease in which two or more deficits affect brain function or cognition. Its effects are progressive and irreversible. The classic example of dementia is Alzheimer’s disease. One complicating factor is that patients with dementia are at greater risk of suffering from delirium. There is also a difference between the causes of the two conditions. Urinary tract infections (UTIs) and certain medications might lead to delirium, whereas they would not result in dementia. The chronicity and progression of delirium and dementia also differ."

Dr Fox and his colleagues discovered that in general patient groups, 60 per cent of delirium cases go unrecognised or untreated. Moreover, the team found that significant numbers of elderly patients are discharged from hospital with undiagnosed delirium. According to Dr Fox, this situation is placing a major burden on healthcare services.

"Our results show that delirium is very common across the age range within hospitals," he said. "With younger patients, the condition tends to be more prevalent within intensive care units. In terms of the elderly, however, the range of patients exhibiting symptoms is wider. Recognition of delirium is very poor in healthcare systems around the world as training in this area is not brilliant. Even when the condition is diagnosed, sedation and other inappropriate treatments are often used. With delirium, it is important to identify the fundamental cause. On the whole, the condition is treatable, but only when it is noticed at an early stage. If it is not picked up quickly, delirium can have chronic consequences and can increase a patient’s risk of mortality."

Far from being inevitable, a third of the delirium cases that the researchers investigated were found to be preventable. Even so, the condition is going largely untreated. It seems, therefore, that education will have to play an integral role if this problem is to be addressed.

"It is quite possible for healthcare workers to be educated and assisted to spot delirium early on," said Dr Fox. "This can be achieved through the use of appropriate tools that flag up some of the symptoms. If a patient scores x on tool y, for example, the assessor can take appropriate action. This is what seems to be lacking at present. Whilst there are tools out there to identify delirium, they are fairly time consuming and they require specialist training. Healthcare workers just don’t have the time. Last year, the government put out a funding call to researchers for the development of an easy-to-use tool to deliver a very quick, five-minute screening for delirium. The United Kingdom’s Department of Health recognises that there exists a problem that needs to be addressed.

"In addition to viewing the condition as an inevitable consequence of old age, healthcare workers sometimes mistake delirium for dementia. Older patients with delirium on hospital wards often get mislabelled as having dementia. Whilst there is very little that can be done to treat dementia as it progresses, measures can be taken to treat delirium. It is therefore important to have appropriate tools to tell the two apart."

Whilst the level of diagnosis needs to be improved, it is also important to have effective measures in place to treat delirium once it has been recognised. I asked Dr Fox about the ways in which medical professionals can help patients suffering from delirium.

"It really does depend on what has caused the condition," he replied. "There are several techniques that can be used such as keeping sensory stimulation as constant as possible and ensuring that the patient is not taking too many sedatives. The patient’s surroundings shouldn’t be too bright, nor should they be too noisy, and sedatives can actually make the delirium worse. Another technique is to administer antibiotics if you suspect a UTI.

"In the United States, patients with delirium are sometimes restrained with leather straps. Our research shows that this is not appropriate as it can actually serve to worsen the condition. There are relevant guidelines available. The National Institute for Clinical Excellence (NICE) produced a step-by-step delirium guide in 2010, but there is still a problem."

In an attempt to address this problem, Dr Fox and his colleagues are working to develop user-friendly tools for the speedy diagnosis of dementia.

"It is vital that we develop effective assessment tools and appropriate vehicles to deliver relevant information to medical staff," he reiterated. "To this end, my colleagues and I are working to develop a tool that can be used across various settings. We are also involved in a project concerning dementia in hospitals. We hope to develop advanced care pathways to help patients suffering from both dementia and delirium. Obviously, this is a situation that can make life very difficult for healthcare workers."