Clinical practice guidelines for management of delirium in elderly

INTRODUCTION Delirium is an acute, transient, usually reversible neuropsychiatric syndrome, seen in medical-surgical set-ups. It is considered to be a serious problem in acute care settings. Although delirium is encountered in all age groups, elderly are considered to be a high-risk group for development of delirium. It basically reflects decompensation of cerebral functions, as a result of one or more pathophysiological processes. Unfortunately, on many instances delirium is not detected or the detection is delayed. Delirium is known to be associated with varied negative outcomes like prolonged hospital stay, need for institutional care, poor functionality and high treatment costs. It has also been shown to be associated with high short-term and long-term mortality. Besides these, delirium has been shown to be associated with significant distress to the patient and the family. Due to all these negative consequences, it is very important to prevent the development of delirium in medically ill patients. It is also important to detect this entity at the earliest and manage the same to reduce the associated morbidity, mortality and distress among patients and their caregivers. Earlier it was thought that delirium is not associated with any long-term consequences, but now it is increasingly being recognised that in the long run, delirium is associated with cognitive decline and development of dementia. Indian Psychiatric Society had published clinical practice guidelines (CPGs) for management of various psychiatric disorders amongst elderly for the first time in the year 2007. In the earlier version, management of delirium was included under the CPGs for management of Psychosis amongst elderly. This time it is felt that management of delirium involves a broader range of evaluations and interventions and hence, an effort is made to have separate CPGs for management of delirium. The new guidelines are an attempt to provide updated information on the subject and use the newer information in formulating the guidelines. Although these guidelines are published as part of CPGs for Geriatric Psychiatry, these guidelines can also be applied to patients of other age groups with delirium. For these guidelines, Internet searches were carried out by using search engines of PUBMED, Embase and Google Scholar to find out the available evidence based literature both for non-pharmacological and pharmacological management. Available treatment guidelines on the topic by different organizations were also reviewed for formulation of the guidelines. Epidemiology of delirium Epidemiology of delirium has been evaluated across different treatment settings across the world and the incidence and prevalence is influenced by the treatment setting (Intensive care units, medical/surgical ward, post-operative patients, consultation-liaison psychiatry services), population assessed (elderly, pediatrics, adult, mixed age group) and method used for estimation (screening instrument, diagnostic instrument) of delirium. In general, data suggest an incidence rate of 3 to 42% in hospitalized patients and prevalence to vary from 5 to 44% amongst the hospitalized patients. Data also suggests that the incidence and prevalence of delirium is much higher among patients admitted to various intensive care units (ICUs) with prevalence reported to be as high as 82% with higher rates amongst those requiring mechanical ventilation. Studies evaluating patients in the emergency department, suggest that about 40% of patients have delirium. Studies from India, which have evaluated the incidence of delirium in various intensive care units, have reported prevalence rates to vary from 26.2% to 68.2% and the incidence rates to vary from 9.27 % to 59.6%. Studies, which have evaluated the course of delirium in ICU settings, suggest that the delirium usually starts after 2 (SD-1.7) days of admission to the ICU and lasts for 4.2 (SD-1.7) days. Nosology With each revision of the Diagnostic and Statistical Manual (DSM), American Psychiatric Association has made certain modifications in the diagnostic criteria of delirium. The DSM-III version gave importance to ‘clouding of consciousness with a reduced capacity to shift, focus and sustain attention’ as the core feature. Subsequent revision, i.e., DSM-III-R, shifted the emphasis from ‘clouding of consciousness’ to ‘reduced attentiveness’ and ‘disorganized thinking’. Each of these was defined as a major criterion and the term ‘clouding of consciousness’ was dropped. The DSM-IV took a reverse turn and again laid emphasis on ‘disturbance in consciousness and inattention’ as one of the major criteria. The most recent version, i.e., DSM-5 again lays importance on disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment) and do not consider clouding of consciousness in its clinical criteria of delirium (Table-1). Some of the researchers have questioned this change in emphasis and have shown that the interpretation of the criteria can influence the epidemiology of delirium.Table 1: DSM-5 criteria for DeliriumThe World Health Organization's International Classification of Diseases (10th revision) defines delirium by disturbance in cognition manifested by both ‘impairment of immediate recall and recent memory’ and ‘disorientation to time, place and person.’ Additionally, criteria in ICD-10 include ‘disturbance in sleep wake cycle’, ‘psychomotor disturbances’, and ‘emotional disturbances’. ICD-10 also specifies the upper limit of 6 months for delirium. Some of the studies which have evaluated the concordance between DSM-IV and ICD-10 criteria suggest that DSM-IV is more sensitive than ICD-10 for the diagnosis of delirium. Clinical features of delirium The clinical features of delirium include a constellation of symptoms encompassing physical, biological and psychological disturbances. It is characterised by an acute onset of symptoms, with a fluctuating course. The symptoms of delirium are broadly divided into cognitive, non-cognitive and motoric symptoms. The cognitive symptoms include disturbances in attention, memory, orientation, comprehension, vigilance, visuo-spatial abilities and executive functioning. Of the various cognitive functions, inattention is considered to be the most consistent feature and accordingly is included as a diagnostic criterion. Disturbance in attention involves all aspects, i.e., ability to mobilize, shift and sustain attention. Impairments in memory can involve both short- and long-term memory with significant impairment in recent memory. Disorientation to time, place and person is also very common. Visuo-spatial disturbances and executive dysfunction when present impair the functionality of the patients. The non-cognitive symptoms of delirium include disturbances in the sleep wake cycle, speech and language disturbances, affective lability, perceptual abnormalities (hallucinations, illusions etc.) and delusions. Sleep-wake cycle disruptions can range from napping and nocturnal disruptions to asevere disintegration of the normal circadian rhythm. The motoric symptoms of delirium include an increase or decrease in the psychomotor activity. Based on the psychomotor activity, delirium is subtyped as hyperactive, hypoactive and mixed. The most common subtype of delirium varies from one treatment setting to the other. Studies based on referrals to the consultation-liaison psychiatry (CLP) teams suggest that hyperactive delirium is the most common subtype of delirium. On the other hand, studies involving ICU patients or studies that have reported data of inpatients screened for delirium suggest that hypoactive delirium is the most common subtype of delirium. Recognising the subtypes of delirium can have an important prognostic implication, as studies have shown that hypoactive subtype is associated with higher mortality rates. Risk factors/etiology for delirium Delirium is often multi-factorial in origin. Data on risk factors is mainly available from the hospital-based studies. Certain risk factors have been found to be consistent across various treatment settings, whereas other risk factors are specific to a particular treatment setting. The commonly identified risk factors are shown in Table-2. Among these factors, certain factors are considered to predispose or increase vulnerability to develop delirium while certain factors have been shown to be associated with development of delirium. Keeping this in mind, some authors categorise the factors associated with delirium as risk factors/predisposing factors and etiological/precipitating factors. Accordingly, predisposing factors are defined, as factors, which depict the vulnerability of an individual to develop delirium and these, are usually present prior to admission to the hospital and are considered to have a larger contribution than the precipitating factors for the onset of delirium. In contrast to these, precipitating factors are noxious insults or hospital-related factors, which contribute to the development of delirium and are often detected at the time of detection of delirium. However, this categorisation is arbitrary, as there is some overlap in these factors.Table 2: Risk factors for deliriumOf all the risk factors, higher age, presence of cognitive impairment, severe concomitant medical illnesses, and receiving medications are considered as ‘robust risk factors’. The commonly associated risk factors for delirium among elderly in acute hospital medical units include presence of dementia, older age (> 70 years), higher severity of medical illness, infection, use of ‘high-risk’ medications, reduction in activities of daily living, being immobile, sensory deprivation/impairment, presence of insitu urinary catheter, raised urea levels, electrolyte imbalance, malnutrition and longer duration of hospital stay. Differential Diagnosis The differential diagnosis of delirium includes dementia, depression and psychosis/schizophrenia. Dementia is a risk factor for delirium and is also a differential diagnosis for delirium. Careful history taking can help in distinguishing the two disorders. Delirium is characterised by an acute onset of illness; in contrast, dementia usually has an insidious onset. The cognitive symptoms in dementia manifest in the absence of an altered level of consciousness, whereas delirium is often characterized by an altered level of consciousness. Further, dementia usually follows a downhill course, whereas delirium is often reversible. However, it is important to remember that many patients may present with delirium superimposed on dementia and the symptom profile of patients with delirium with or without dementia do not differ much. Depression is also considered as a risk factor for delirium. History taking should focus on eliciting the history of persistent sadness of mood and morning worsening of symptoms. In contrast to this, delirium is often characterized by lability of mood and evening worsening of symptoms, which is also known as sun-downing effect. Primary psychiatric disorders are often characterized by presence of auditory hallucinations, whereas delirium is predominantly characterized by presence of visual and tactile hallucinations. Cognitive disturbances are present in patients with primary psychotic disorders though these are not as prominent as seen in patients with delirium. Assessment Scales for Delirium As delirium is commonly seen in medical-surgical settings, detection of the same requires a high index of suspicion on the part of the have been to and rate the severity of delirium. and diagnostic have been to delirium in different treatment medical-surgical and Additionally, have also been for different age groups as as to rate the motoric symptoms in Scales for Assessment of are for the various and diagnostic Assessment is commonly used for both and delirium by It can be in a of time 5 and has been shown to have Assessment for has been to delirium in the ICU setting. 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