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Annals of Delirium March 2012

Annals of Delirium March 2012

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Published by tony_jameson-allen
The newsletter of the European Delirium Association. http://www.europeandeliriumassociation.com
The newsletter of the European Delirium Association. http://www.europeandeliriumassociation.com

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Published by: tony_jameson-allen on Mar 14, 2012
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03/14/2012

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Editorial
Spring 2012 and momentum is building up as delirium features moreoften and more prominently in published medical literature. Last month the British Medical Journal published the largest intensive careunit (ICU) delirium study to date. In the accompanying editorial Itried to make the point that the science is clear: failing to detect andmanage delirium adequately is failing the patients. ProfessorMacLullich went further in a personal communicati
on “
excellence indelirium care should be the expectation in all ICUs; anything less,given the resources and expertise in ICU, is frankly unacceptable.
 Delirium in UK critical care patients has been particularly topical inthe lay press with a videocast and an article from Times columnist David Aaronovitch describing his own experience then the Scottishnewspaper, Sunday Post, publishing an interview with Peter Gibb of ICUsteps. Consequently the website www.icudelirium.co.uk  has had an increase in patients sharing their own experiences relieved toknow
they are not “going mad”. Will this
lead to patients and relativeswanting to know more about delirium and what we, the health careprofessionals are going to do about it?How can we influence this? Let us gather our previously low rankingcards into a winning hand. I believe we need to keep doing what weare all doing already, making a difference one patient at a time. Inaddition if we each aim to inform two clinicians a month one or twofacts about delirium, and they inform two other clinicians a month, bythe end of 10 months each of us could be responsible for an additional500 clinicians knowing more about delirium!This bumper edition includes a collaborative article highlighting theimportance of subsyndromal delirium, Dr Davis tells us all we need toknow (and we do need to know) about epidemiology and Dr Wilsonhas provided an inspiring descriptive piece about altering the wardenvironment for at risk patients with dementia. The news section willbring you up to date with events and initiatives including the first European Delirium Survey and an announcement for the next annualmeeting.Finally, I am pleased to announce that Dr Andrew Teodorczuk will bea co-editor of the Annals of Delirium from the next edition.Contributions all welcome for the summer edition
prose or poetry!Valerie Page
 
Capturing psychiatric phenomena: what deliriumresearchers can learn from dementia epidemiologists
Daniel Davis and Carol BrayneInstitute of Public Health, University of Cambridge
At delirium conferences, we often hear the call for ‘more research onthe epidemiology of delirium’. There have been very few studies on
delirium prevalence in the general population. Perhaps this is becausesuch studies are difficult to undertake and is compounded byproblems of how to define psychiatric syndromes in epidemiology.Research in dementia has faced similar obstacles
what lessons havebeen learned?
What do we mean by ‘population’?
 
Epidemiology is concerned with the inter-relationship betweenpopulations, exposures and outcomes. Intrinsic to this is the problemof definitions and how they are conceived, framed and articulated. Inconsidering the importance of defining a population, we are asking: Isthe chosen population one that is relevant to the full spectrum of persons with delirium? How does the approach to sampling enable avalid capture of the chosen population? These are critical questions asthe provenance of the sample population has the potential tosystematically bias findings both in magnitude and direction.The majority of studies in delirium have been undertaken in hospitalsettings, and these have been comprehensively reviewed.
1
Thesestudies indicate that delirium is a common problem in inpatients withserious adverse outcomes. However, there are two limitations to theinferences that can be drawn about delirium as a whole. Firstly, onecannot assume that all persons with delirium will actually present tohospital. Secondly, once in hospital, there is only retrospective (and
therefore limited) information of a person’s cognitive and
performance function
before
the onset of delirium. Ideally, one wouldstart with a broad, unselected denominator (i.e. a true population-based study) followed-up with serial cognitive assessments. Thiswould represent a comprehensive range of symptoms (and severities),but also identify what happens, to whom, and when. This is essential if we are to understand the determinants and effects of delirium most completely. A working definition for population-based study might be:
‘a study where all subgroups of the population are sampled, regardlessof disease or residential status’.
2
Of course, ensuring that a studypopulation is comprehensive in this way requires substantial effort,but there are gains of equal degree in terms of achieving results withexternal generalisability.
 
Psychiatric epidemiology: a problem of standardisation
In order to reliably track states of health in populations, looking foremerging patterns and trends, one must be able to define exposuresand outcomes of interest in a standardised way. All diseases can be
nosologically classified, each with their ‘reference
-
standard’
definitions. However, where these conditions are psychiatricsyndromes, the reference-standard is necessarily a set of clinicallyagreed descriptions of psychopathology rather than any objectivequantities.
 
There are two different approaches for neuropsychiatric definitions,the International Classification of Diseases (World HealthOrganization) and the Diagnostic and Statistical Manual of MentalDisorders (American Psychiatric Association). There are somedifferences between these two systems (see references for adiscussion on how these might affect case-ascertainment in dementia
3
 and delirium
4
). However, both are subject to common problems.Firstly, these definitions are not stable over time (ICD-9 vs 10, DSM-III-R vs DSM-IV, with further iterations in evolution). Nor are thesedefinitions easily transferrable across cultural contexts. Yet moreproblematic is that these clinical criteria have the potential to vary,and so can be interpreted differently by different clinicians. Anexample is how the definition might be applied to persons of different ages depending on the expectations of normality for that age group. Inother words, the threshold for abnormal cognitive or functionalimpairment may decrease with age, in line with a belief that someimpairment is to a degree expected (and therefore not abnormal) inolder age.
5
Finally, in the research setting, a core problem is how tooperationalise these criteria so that case-ascertainment can beachieved in a consistent manner.Underlying these difficulties is the problem of how to agree theboundaries for a spectrum of psychiatric symptoms. While there isrelatively little disagreement about moderate and severe dementia,studies that include milder cognitive deficits lead to much lessconsistent estimates of prevalence (see references for review
6
). Mildcognitive impairment (MCI) has been regarded to be of possiblerelevance to dementia, but applying the MCI construct to population-based cohorts has not been straightforward.
7, 8
The equivalent entityin delirium
i.e. subsyndromal delirium
also needs to be consideredin light of these issues.
Dementia epidemiology: some approaches
Dementia is clinically defined by identifying progressive deficits intwo or more cognitive domains sufficient to impair function inactivities of daily living. Three population-based studies can be usedas examples to illustrate the different ways in which this definition hasbeen operationalised in the context of research (Table 1). Vantaa 85+

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