Current Medical Issues

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 19  |  Issue : 2  |  Page : 78--82

Clinical profile of patients with delirium who presented to the department of psychiatry of a tertiary care teaching hospital


Mathews Joseph Panicker, Anil Kakunje 
 Department of Psychiatry, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India

Correspondence Address:
Dr. Mathews Joseph Panicker
Department of Psychiatry, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka
India

Abstract

Background: Delirium is characterized by decline in cognitive performance and is associated with various medical and psychiatric comorbidities. Each of these may be further associated with deranged clinical investigations. Objectives: To determine the clinical profile of delirium in patients referred to the department of psychiatry in a tertiary care hospital from October 2019 to October 2020. Methodology: This was a cross-sectional study which was conducted in a tertiary care teaching hospital among 48 in-patients who satisfied the criteria for delirium as per ICD-10, over a period of 1 year after obtaining clearance from the institutional ethics committee. A specialized pro forma was used to record demographic, medical, psychiatric, and other relevant clinical data. Results: The mean age of all participants was found to be 56.73 years ± 17.2 years. Among 48 patients with delirium, 45 had hepatic risk factors and 34 patients had multiple risk factors. Results of electrolytes between patients with and without encephalopathy were found to be statistically significant for sodium and chloride. Conclusions: Delirium continues to be a clinical diagnosis without any specific laboratory parameters and hence it becomes quite difficult to predict its onset and poses a threat for its management. Therefore, the awareness of such risk factors that increase the risk for developing delirium will lead to a better understanding of this complex syndrome which is crucial for its prevention and management.



How to cite this article:
Panicker MJ, Kakunje A. Clinical profile of patients with delirium who presented to the department of psychiatry of a tertiary care teaching hospital.Curr Med Issues 2021;19:78-82


How to cite this URL:
Panicker MJ, Kakunje A. Clinical profile of patients with delirium who presented to the department of psychiatry of a tertiary care teaching hospital. Curr Med Issues [serial online] 2021 [cited 2021 May 13 ];19:78-82
Available from: https://www.cmijournal.org/text.asp?2021/19/2/78/313814


Full Text



 Introduction



Delirium is a complex neuropsychiatric disorder characterized by global yet transient impairment of consciousness (clouding of consciousness), resulting in disturbance in orientation, reduced level of alertness, attention, memory, and perception of the environment, and thence cognitive performance.[1],[2],[3]

It is believed to be due to physiological abnormalities and/or structural changes affecting the brain which potentially may be reversible. Delirium is a word derived from the Latin words de (away, from) and lira (furrow, track). Delirium is considered a medical crisis and must be dealt with and managed along the same lines. It is found to be associated with consequential increases in the length of hospital stay, need for institutional care, decline in overall functioning, rate of death and health-care costs all of which are important in a resource-scarce country like India.[2] It was initially believed that delirium did not have any long-term consequences but research now shows that it is associated with a decline in cognitive functioning and even development of a possible dementia. Mortality rate in patients with delirium ranges from 6% to 18% and is an important risk marker for dementia as well as death.[2],[3]

Epidemiology of delirium has been assessed across various treatment domains globally and the incidence and prevalence is influenced by the treatment setting (intensive care units [ICU], medical/surgical ward, postoperative patients, consultation-liaison psychiatry services), population assessed (elderly, pediatrics, adult, mixed age group), and the method used for estimation (screening instrument, diagnostic instrument) of delirium.[1] Delirium is associated with certain risk factors which can be categorized as predisposing factors or precipitating factors. Some of the factors predisposing to delirium are older age, male sex, dementia, immobility, individual physical and mental health, and comorbid substance use whereas some of the precipitating factors include severe acute illness, urinary tract infections (UTIs), hyponatremia, hypoxemia, hypoglycemia, shock, ICU admission, various surgical procedures and even the use of certain drugs like benzodiazepines.[4],[5]

In general, data suggest an incidence rate and prevalence rate of 3%–42% and 5%–44% in hospitalized patients, respectively.

Critically ill patients definitely require an ICU admission of which delirium is a common complication.[6] Data hints that the prevalence of delirium is significantly higher among such patients and is reported to be as high as 82%.[3] Due to this, such patients invariably have longer hospital stays which in turn increases their short-term and long-term mortality by 2.5 times and 3.2 times, respectively.[6] Among the elderly, the prevalence of delirium is about 1%–2% whereas that among the patients presenting to the emergency department is 8%–17%.[1]

Studies that looked at patients in the emergency setting, suggest that around 40% of patients have delirium.[3] Similar studies conducted in India, which have evaluated the incidence of delirium in multiple ICUs, have reported prevalence rates to vary from 26.2% to 68.2% and incidence rates to vary from 9.27% to 59.6%.[3] Studies assessing the course of delirium in ICU settings, suggest that the delirium usually has its onset after 2 days of admission to the ICU and lasts for approximately 4 days.[3]

Alcohol being a common drug of abuse has an enormous social and economic impact globally.[7] Patients with alcohol dependence develop many complications of which alcohol withdrawal delirium is one of the most concerning. It occurs when there is a decline in blood or tissue level of alcohol due to reduction in intake, dose or a significant period of cessation of alcohol.[8]

Postoperative delirium (POD) is another unexpected and bewildering complication encountered following most surgeries. It can become chronic following surgery in the elderly due to its enduring sequelae in the form of deficits in cognition although it is reversible. According to a study done by Reddy et al., the overall incidence of delirium rises to around 14%–24% postoperatively.[9] In addition, these values were found to be further increased in those admitted in the postanesthesia care unit, ICU, and palliative care settings.[9]

Unfortunately, delirium is not identified in many instances or there is a delay in its detection.[3] Keeping all this in mind, it is essential that physicians and psychiatrists alike, are to be aware of this entity and have a fundamental idea on how to manage it.[2]

This study will help us to look at clinical profile of patients with delirium referred to the department of psychiatry in a tertiary care hospital. It is important to understand the various etiological factors for delirium, because these may vary from one setting to another and awareness about common etiologies can help identify persons at high risk.

Aim

This study aims to determine the clinical profile of patients in delirium who presented to the Department of Psychiatry of a Tertiary Care Teaching Hospital.

 Methodology



This was a cross-sectional study carried out at a tertiary care teaching hospital over a period of 1 year from October 2019 to October 2020. The study included all adult patients aged 18 years and above who satisfied the criteria for delirium as per ICD-10 and presented either to the outpatient department or who were referred to the department of psychiatry. The sample size obtained at 5% level of significance, the standard table value = 1.96(Z) and power = 80%, using the formula n = Z2 pq/d2, was a total 48 and they were included in our study. Institutional ethical committee approval was sought before commencing the study and the study bears the protocol no YEC2/152. Written informed consent was obtained from the legally authorized representative after which all other required information was collected from the patients' file. The participant had to fulfill criteria for delirium as per ICD-10.

Statistical analysis

Data were entered into Microsoft excel and analyzed in terms of frequencies and percentages using the Statistical Package for Social Sciences (SPSS) Statistics for Windows (Version 23.0. Armonk, NY, USA: IBM CORP).

 Results



There were a total of 48 patients included in the study of which 32 (66.7%) were male whereas 16 (33.3%) were female [Table 1].{Table 1}

[Figure 1] shows the distribution of patients with delirium as per risk factors. A total of 45 patients had hepatic cause as risk factors whereas 1 patient had no identifiable risk factor. Totally 34 patients had multiple risk factors which contributed to delirium.{Figure 1}

[Figure 2] shows psychiatric comorbidities among patients with delirium. Among all patients, 52.1% had no psychiatric comorbidities whereas 37.5% of the patients had comorbid alcohol dependence syndrome.{Figure 2}

[Table 2] depicts the results of laboratory investigations performed on these patients with delirium. In this study, we considered investigations such as complete blood count, blood glucose profile, renal function tests, urine routine, serum electrolytes, thyroid function tests, and liver function tests. Most patients were found to have hyponatremia (39, 81.3%) followed by anemia (31, 64.6%).{Table 2}

The results of laboratory investigations were compared between two groups, i.e., patients with risk factors and patients without risk factors. The difference in hemoglobin and total leukocyte count were computed between the patients with and without infections using Student's t-test. The difference in total leukocyte count was found to be statistically significant with a P = 0.037. Similarly, results of electrolytes between patients with and without encephalopathy was computed and was found to be statistically significant for sodium and chloride (P = 0.002 and 0.003, respectively).

 Discussion



Although delirium is a time-limited disorder, it is associated with significant mortality and morbidity with up to a two-fold increase in risk of death and the need for in-patient care and management.[10],[11]

The mean age in our study was found to be 56.73 ± 17.22 years with a male preponderance. This contrasted with findings from a study done by Kim H and et al. where the mean age was found to be higher (68.9 ± 13 years).[5] Studies have shown age and gender to be potential demographic risk factors for the development of delirium.[5]

Half of the patients did not receive higher formal education and most were from a rural background. More than three-fourth of the patients were examined as a part of consultation liaison. A study by Bellelli et al. showed that patients with delirium belonged to higher age group and also had lesser years of education.[12]

In our study, the most common etiologies were hepatic risk factors (45/48, 93.8%) followed by substance related (32/48, 66.7%) and encephalopathy (24/48, 50%) whereas 34 (70.8%) had multiple risk factors which contributed to delirium. This was contrary to the study findings done by Grover et al. where the most common etiology was found to be metabolic disturbances (n = 192/321; 60%), followed by organ dysfunction (n = 155; 48%), and medication related (n = 128; 40%).[2] These findings imply that it is essential to treat even the minutest metabolic derangements in severely ill patients to reduce the risk to develop delirium. Similarly efforts must be taken to treat organ insufficiency and reduce medication loads. In addition, it is important that family members be involved in the treatment of these patients so as to make easy early diagnosis and nonpharmacological preventive measures.

In a study done among patients in the surgical ICU the predisposing factors for delirium were categorized as diseases or symptoms and laboratory variables.[13] Within the disease or symptoms category, highest number of patients had fever followed by anemia. Hyponatremia was the highest contributing factor among laboratory variables followed by elevated level of serum urea nitrogen.[13]

In our study too, among the laboratory variables most patients were found to have hyponatremia (39, 81.3%) followed by anemia (31, 64.6%). These findings were also in line with the findings of another study done by Grover et al. who identified hyponatremia as one of the most common metabolic factor.[14] This finding also varied among other studies which have found other abnormal laboratory investigations. This variation may be related to the severity of the patient's condition enrolled in the studies.

UTIs were seen among 25.9% to 32% of patients with delirium whereas delirium among patients with UTI accounted for 30% to 35% in a study by Balogun S A et al. This study also found that patients with UTI and delirium had other co-existing medical conditions such as Alzheimer's, multi-infarct dementia, heart failure, or depression that could have influenced the occurrence of delirium.[15],[16]

A review study by Oh-Park et al. was done among patients in rehabilitation facilities which probed into exploring the predisposing and precipitating factors of delirium.[17] Among various clinical settings, the highest prevalence of delirium was found in patients in ICU followed by postsurgical settings.[17] Delirium among stroke patients accounted for 33%.[18] Delirium was prevalent in 89% of the posttraumatic patients coma or stupor.[19]

We set out to overcome few limitations mention in previous studies by taking into consideration multiple possible risk factors of delirium. In addition, our study is one among the few done in an Indian context which was conducted in a general hospital setting. The use of both clinical as well as laboratory parameters is another strength of our study.

This study had certain limitations to be noted. First, this study was a cross-sectional study and secondly our study was conducted in a hospital setting rather than in a community. Both these factors limit definite conclusions. Hence, it is suggested that further studies be conducted which include longitudinal investigations of various etiologies and these should be carried out in the community which will help us to identify its diverse prevalence and improve generalization of the findings. A small sample size is another limitation of our study. Finally, although patients were assessed during follow-ups, all investigations and evaluation were done by the primary treating doctor and that limited the primary investigators from better identification and management of the severity of delirium.

 Conclusions



Delirium although common is a life-threatening problem experienced in hospitalized patients which may lead to significant morbidity or death especially when under managed. One must also keep in mind that delirium continues to be a disorder with no specific laboratory parameters and hence it becomes quite difficult to predict its onset and poses a threat for its management. It is emphasized that when these factors that increase the risk for delirium are brought to light it will lead to a better understanding which is vital for its prevention and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and Ethics statement

All authors of this manuscript declare that this study is in compliance with the standard reporting guidelines set forth by the EQUATOR Network. The authors also attest that this scientific clinical investigation was determined to require Institutional Ethics Committee review, and the corresponding protocol / approval number is YEC2/152. We also certify that we have done a Plagiarism Check and have not plagiarized the contents in this submission.

References

1Harrison P, Philip C, Burns T, Fazel M. Shorter Oxford Textook of Psychiatry. 7th ed. New York, NY: Oxford University Press; 2018. p. 1-1681.
2Mattoo SK, Grover S, Gupta N. Delirium in general practice. Indian J Med Res 2010;131:387-98.
3Grover S, Avasthi A. Clinical practice guidelines for management of delirium in elderly. Indian J Psychiatry 2018;60:S329-S340.
4Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004;75:362-7.
5Kim H, Chung S, Joo YH, Lee JS. The major risk factors for delirium in a clinical setting. Neuropsychiatr Dis Treat 2016;12:1787-93.
6Kanova M, Sklienka P, Roman K, Burda M, Janoutova J. Incidence and risk factors for delirium development in ICU patients-a prospective observational study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017;161:187-96.
7Thavorncharoensap M, Teerawattananon Y, Yothasamut J, Lertpitakpong C, Chaikledkaew U. The economic impact of alcohol consumption: A systematic review. Vol. 4, Substance Abuse: Treatment, Prevention, and Policy; 2009. p. 20.
8Mainerova B, Prasko J, Latalova K, Axmann K, Cerna M, Horacek R, et al. Alcohol withdrawal delirium-diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015;159:44-52.
9Reddy SV, Irkal JN, Srinivasamurthy A. Postoperative delirium in elderly citizens and current practice. J Anaesthesiol Clin Pharmacol 2017;33:291-9.
10Thom RP, Levy-Carrick NC, Bui M, Silbersweig D. Delirium. Am J Psychiatry 2019;176:785-93.
11Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA 2010;304:443-51.
12Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, et al. “Delirium Day”: A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016;14:1-12.
13Aldemir M, Ozen S, Kara IH, Sir A, Baç B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5:265-70.
14Grover S, Agarwal M, Sharma A, Mattoo SK, Avasthi A, Chakrabarti S, et al. Symptoms and aetiology of delirium: A comparison of elderly and adult patients. East Asian Arch Psychiatry 2013;23:56-64.
15Balogun SA, Philbrick JT. Delirium, a symptom of UTI in the elderly: fact or fable? A systematic review. Can Geriatr J 2014;17:22-6.
16Kuswardhani RAT, Sugi YS. Factors Related to the Severity of Delirium in the Elderly Patients With Infection. Gerontol Geriatr Med. 2017;3:1-5.
17Oh-Park M, Chen P, Romel-Nichols V, Hreha K, Boukrina O, Barrett AM. Delirium screening and management in inpatient rehabilitation facilities HHS Public Access. Am J Phys Med Rehabil 2018;97:754-62.
18Turco R, Bellelli G, Morandi A, Gentile S, Trabucchi M. The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation. J Geriatr Psychiatry Neurol 2013;26:63-8.
19Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc 2000;48:618-24.