World Delirium Awareness Day 2019: an opportunity not a problem
Dr Shibley Rahman is an academic physician with interests in dementia, frailty and delirium. He tweets @dr_shibley
Delirium is serious and treatable, and yet some healthcare professionals appear to rather indifferent towards it. Although exact estimates vary, delirium is one of the most prevalent acute disorders in general hospitals.
Delirium independently predicts several adverse outcomes for a hospital admission, including higher mortality, increased length of stay, long-term cognitive and functional decline, and increased risk of institutionalisation.
Underdiagnosis of delirium therefore has very serious consequences. Furthermore, an episode of delirium is emotionally highly distressing and stressful for patients and carers. Recognition can improve outcomes as well as the experience of patients and carers. Prevention is also possible.
Given all this, it is utterly ludicrous that not only is delirium missed altogether – for example it might even be omitted from discharge summaries - but also is not especially high up on people’s agendas. The case for ‘delirium awareness’, quite frankly, is a “no-brainer”.
A research paper in Age & Ageing (2009) by Daniel Davis and Alasdair MacLullich concluded that:
"UK training doctors' lack of basic knowledge of the diagnosis and management of delirium, rather than a lack of awareness of its high prevalence and clinical significance, appears to be important in determining its under-recognition."
Through contacts within the British Geriatrics Society, they recruited a National Delirium Survey Group, which comprised 37 doctors working in 34 acute hospitals in the UK.
The results from this study were striking.
For example, a poor knowledge of the diagnostic criteria for delirium was easily identified. Inattention is a core diagnostic feature of delirium, and yet 32% recognised this. But the vast majority (97%) of participants agreed or strongly agreed that doctors working in acute medical settings should have a good working knowledge of delirium.
Arguably, delirium care is as valuable as the management of anticoagulation in someone with a metallic heart valve, or knowing which coronary arteries to stent after a particular acute coronary syndrome.
But somehow, delirium care definitely hasn’t the same kudos.
Unbelievably doctors might put ‘CNS – NAD’ for someone with florid delirium.
Today March 13th 2019 is "World Delirium Awareness Day".
Barriers to recognition of delirium exist at an individual and organisational level. Some reasons include:
- A lack of education and general ignorance of delirium, in particular about the benefits of early recognition and treating delirium, can be a strong barrier to diagnosis.
- Delirium might not be perceived as belonging to a specific specialty, a reflection on its multi-organ contributions and its complexity.
- Views about delirium may further be compounded by cultural ageist attitudes which are prevalent in modern societies, for example a general expectation of ‘disorientation’ amongst older patients may contribute to missed diagnoses.
- There is undoubtedly a poor awareness of 'delirium' as an entity, as opposed to, for example dementia or cancer.
The most obvious solution to this indifference to delirium is that delirium education at all stages of training for all healthcare professionals should expand in scope, such that it occupies a position proportionate to its clinical impact.
Finally, whilst "World Delirium Awareness Day" is literally only for one day every year, it may be worthwhile to consider that we actually require something much more ambitious. We, as a society, might need to have a fundamental re-think of our beliefs, ideas, and attitudes towards delirium; otherwise called “collective consciousness”.