| Abstract|| |
Objective: To evaluate the predictors of delay in psychiatry referral for patients with delirium.
Materials and Methods: The consultation liaison psychiatry registry and case notes of 461 patients referred to psychiatry consultation liaison services and diagnosed as having delirium were reviewed. Data pertaining to sociodemographic variables, clinical variables, Delirium Rating Scale-Revised 98 version, etiologies associated with delirium were extracted.
Results: Older age, presence of and higher severity of sleep disturbance, presence of and higher severity of motor retardation, presence of visuospatial disturbances, presence of fluctuation of symptoms, being admitted to medical ward/medical intensive care units, and absence of comorbid axis-1 psychiatry diagnoses were associated with longer duration of psychiatric referral after the onset of delirium. Of these only four variables (presence of sleep disturbance, presence of motor retardation, being admitted to medical ward intensive care units and absence of comorbid axis-1 psychiatry diagnoses) were associated with longer duration of psychiatric referral in the regression analysis.
Conclusion: The variables associated with delay in psychiatry referral for delirium suggest that there is a need to improve the understanding of the physicians and surgeons about the signs and symptoms, risk factors, and prognostic factors of delirium.
Keywords: Delay in referral, delirium, predictors
|How to cite this article:|
Grover S, Kate N, Mattoo SK, Chakrabarti S, Malhotra S, Avasthi A, Kulhara P, Basu D. Delirium: Predictors of delay in referral to consultation liaison psychiatry services. Indian J Psychiatry 2014;56:171-5
|How to cite this URL:|
Grover S, Kate N, Mattoo SK, Chakrabarti S, Malhotra S, Avasthi A, Kulhara P, Basu D. Delirium: Predictors of delay in referral to consultation liaison psychiatry services. Indian J Psychiatry [serial online] 2014 [cited 2020 Jul 8];56:171-5. Available from: http://www.indianjpsychiatry.org/text.asp?2014/56/2/171/130501
| Introduction|| |
Delirium is the most common psychiatric diagnoses seen in patients referred to psychiatry consultation liaison (CL) services.  Although highly prevalent, data suggest that 32-67% of patients with delirium in medical units go unrecognized. ,, Delirium has also been shown to be independently associated with significant increases in the length of hospital stay, inpatient mortality, long-term mortality, cognitive decline, requirement for institutional care, functional decline, healthcare costs, distress to the patient and family. ,,,,,,, Taking all these facts into consideration, it is very important to identify and manage delirium as early as possible to improve the morbidity, mortality, and reduce the associated distress in patients and caregivers.
In many cases, the physicians and surgeons fail to identify the patients with delirium in the early phase and this leads to delay in psychiatric referral. Studies suggest that mean duration of delirium at the time of psychiatry referrals is about 3-5.3 days with range varying from 1 to 40 days. ,,,,, Any effort to reduce the impact of delirium should involve reduction in the lag period of psychiatric referrals.
However, only occasional studies have evaluated the predictors of delay in psychiatry referral for delirium. An earlier study from our center, which included 80 consecutive patients with delirium, showed that presence of delirium at the time of hospitalization, presence of sleep-wake disturbance, and surgical specialty of referral were significant predictors of delayed diagnosis.  Considering the fact that the previous study included a smaller sample size, the present study aimed at evaluating the predictors of delay in psychiatry referral for patients with delirium in a large sample size.
| Materials and Methods|| |
The study was carried out at the Postgraduate Institute of Medical Education and Research, Chandigarh, a multispecialty teaching hospital in North India. The Department of Psychiatry provides CL psychiatric services for the entire hospital. A patient referred to CL psychiatry services is first seen by a junior resident (trainee psychiatrist) under the supervision of a senior resident (a qualified psychiatrist). Final diagnoses are made according to the International Statistical Classification of Diseases and Related Health Problems-10  after the case is reviewed by a consultant psychiatrist. The CL psychiatry team regularly reviews the patient till discharge from the hospital. While evaluating and managing the patient, besides documenting the main psychiatric clinical details in the medico-surgical case file, the CL team maintains a separate psychiatric referral file for each patient. The CL team also maintains a registry in the department of psychiatry for patients seen in CL psychiatry services; the variables included in the registry are demography (age, gender) and clinical data (source of referral, physical diagnosis, reason(s) for psychiatric referral, psychiatric diagnosis, management done and outcome). The commonest diagnostic category among all referrals received by the CL team is delirium.  The patients diagnosed with delirium are rated on Delirium Rating Scale Revised-98 version (DRS-R98)  by the trainee resident under the supervision of a qualified psychiatrist(s). The etiologies associated with delirium are also recorded in the psychiatric referral files. Additionally, data with respect to the outcome of psychiatric symptoms is coded on the basis of level of improvement of psychiatric symptoms. In case of mortality, it is recorded as an outcome.
For this study, the psychiatric referral registry was reviewed and case records of all patients seen by the CL team during the period of January 2010 to December 2010 were reviewed. Data for all the patients diagnosed with delirium were extracted from the files for the patient's age, gender, clinical profile, ratings on DRS-R98 version,  and outcome at last contact during the inpatient stay. The study was approved by the Ethics Review Board of the Institute.
Data were analyzed using the Statistical Package for Social Scientists (SPSS-14). Frequency, percentage, mean, and standard deviation were calculated for the descriptive data.
Various groups were compared using Chi-square test and t-test. Correlations between different variables were studied using the Pearson product moment correlation and Spearman's rank correlation analysis. Multiple regression analysis was carried out to study the predictors of delay in referral of patients with delirium to the CL psychiatry services.
| Results|| |
During the 12-month study period (January to December 2010), referrals received by the psychiatry CL services from various medicosurgical wards numbered 1137, of which 487 (42.83%) were diagnosed as having delirium. Data for these patients were extracted from the files. Of the 487 patients, complete data were available for 461 cases, which formed the study sample for the present study.
Delay in psychiatry referral
The ''mean number of days of delay in psychiatric referral'' was calculated differently for the cases with hospital emergent delirium and those who had delirium at the time of admission. For the patients with hospital emergent delirium, it was calculated as the difference between the ''day of onset of delirium'' and ''the day of referral.'' For the patients with delirium at the time of admission to the hospital, the mean number of days of delay in psychiatric referral was calculated as the difference in the ''day of admission'' and ''day of referral.'' The mean duration of delay in psychiatry referral for all 461 cases considered together was 2.36 days [standard deviation (SD): 2.14; range 0-14 days). The mean duration of delay in psychiatry referral for hospital emergent delirium cases (n=322) was 2.37 days (SD: 2.37; range 0-14 days). The mean duration of delay in psychiatry referral for those with delirium at the time of admission (n=139) was 2.33 days (SD: 2.40; range 0-12 days).
Demographic and clinical profile
The study included 461 patients with delirium. The mean age of the study sample was 48.06 years (SD: 19.03; range 2-95 years), with nearly one-fourth (n=109; 23.64%) of the sample aged ≥65 years. Slightly more than two-third (n=321; 69.6%) of the sample comprised of male patients. The mean duration of delirium at the time of first psychiatric assessment was 4.02 days (SD: 6.10; range 0.17-60). Majority of the patients (69.8%) had hospital emergent delirium (i.e., delirium starting after being admitted to the hospital) and only 30.2% had delirium at the time of admission to the hospital. Only about one-fifth (21.3%) of the patients had comorbid psychiatric diagnosis and comorbid dementia was present in very few patients (n=6; 1.3%). The mean numbers of etiologies associated with delirium were 4.12 (SD: 2.3; range 1-27) per patient.
Nearly, half of the patients (n=338; 49.6%) were treated with haloperidol and another one-fifth of the patients (n=149; 21.8%) received olanzapine. Other medications which were used for treatment of delirium included lorazepam (n=41; 6%), risperidone (n=38; 5.6%), chlordiazepoxide (n=5; 0.7%), and quetiapine (n=4; 0.6%). By the time of discharge from the hospital, about two-third (n=435; 63.8%) were rated as recovered (i.e., all the symptoms of delirium had resolved) or improved (there was some improvement in the symptoms of delirium). About one-fifth of the sample (n=148; 21.7%) had no change in the symptoms of delirium and very few patients (n=4; 0.6%) had further worsening of delirium. About one-sixth (n=90; 13.2%) of the patients died during the inpatient stay.
Symptom profile of delirium
The mean DRS-R98 severity score was 17.87 (SD: 4.93; range 8-30) and mean DRS-R98 total score was 23.76 (SD: 5.26; range 12-37). On DRS-R98 diagnostic items, all patients fulfilled the criteria of ''presence of an underlying physical disorder.'' Symptoms seen in >90% of the patients included disturbances in sleep-wake cycle, motor agitation, disturbance in attention, and disorientation. The least common symptoms were motor retardation and delusions [Table 1]. The DRS-R98 severity score was more than two for the items of acute onset of symptoms, disturbances in sleep-wake cycle, impairment in the domain of orientation, and impaired attention [Table 1].
Factors associated with delay in psychiatric referral
We evaluated the effect of sociodemographic factors, clinical factors, and symptoms of delirium as assessed on DRS-R98 (both in terms of frequency and severity) on delay in psychiatry referral. As shown in [Table 2], age in years, being elderly, being admitted in a medical ward, absence of psychiatric diagnosis, DRS-R98 severity score on sleep disturbance and motor retardation, presence of motor retardation, visuospatial disturbance, and fluctuation of symptoms as per the DRS-R98 were associated with delay in psychiatric referrals [Table 2].
A multiple regression analysis with stepwise method was done in which ''delay in referral in days'' was used as the dependent variable and all the other variables (age in years, age groups, medical surgical setting, severity of sleep disturbances and motor retardation, presence of sleep disturbances, motor retardation, visuospatial disturbances, and fluctuation of symptoms) which had significant association with the delay were used as independent variables. In the regression analysis among all the independent variables, severity of sleep disturbance, presence of motor retardation, being admitted in a medical ward or intensive care unit associated with a medical specialty and absence of comorbid axis-I psychiatric diagnosis emerged as the significant predictors [Table 3]. However, taken together these variables explained only a minor proportion of variance in ''delay in referral'' (adjusted R 2 value=0.049) and most of the variance remained unexplained [Table 3].
| Discussion|| |
To reduce the impact of delirium on patients, caregivers, and hospital services, it is important to identify the patients with delirium as early as possible. As many cases of delirium are managed by CL psychiatry services, it is important to identify the risk factors associated with delay in psychiatric referrals for patients with delirium. There are very few studies which have evaluated the predictors of delay in psychiatry referral of patients with delirium. The present study attempted to fill this void. The major strength of the present study was a larger sample of consecutive patients with delirium referred to psychiatry consultation liaison team.
Findings of the present study suggest older age, presence of and higher severity of sleep disturbance, presence of and higher severity of motor retardation, presence of visuospatial disturbances, presence of fluctuation of symptoms, being admitted to medical ward/medical intensive care units and absence of comorbid axis-1 psychiatric diagnoses were associated with longer duration of psychiatric referral after the onset of delirium. Of these, only four variables were significant predictors of delay in referral in the regression analysis. The variables like difference in delay in referral between different age groups, of visuospatial disturbances, presence of fluctuation of symptoms, possibly reflects a small difference between the groups and hence, this did not emerge as a significant predictor. In general, it can be concluded that all these associations possibly reflect poor knowledge or awareness among physicians and surgeons about the signs and symptoms, and predictors of outcome of delirium. Studies have shown that older age and hypoactivity are associated with lower rates of detection of delirium , and hypoactivity is associated with higher rates of mortality in patients of delirium. , Data also suggest that longer duration of delirium is associated with higher rates of mortality during the hospitalization  and the subsequent 1 year.  Taken together all these findings suggest that physicians and surgeons miss delirium in the early stages, especially when the patient is elderly and has more hypoactivity, and this leads to delay in referral. Considering the fact that the same variables are associated with mortality, this relationship becomes very important. Hence, there is an urgent need to make the physicians and surgeons aware about the manifestations of and the various risk factors associated with delirium, so that delirium can be identified as early as possible.
Disturbance in sleep-wake cycle is one of the early indicators of delirium and has also been reported in the prodromal phase of delirium.  A previous study from our center also indicated that disturbances in sleep-wake cycle were one of the important predictors of delay in psychiatry referral of patients with delirium. This again reflects the attitude of physicians and surgeons, who may consider some level of disturbance in sleep-wake cycle as a normal phenomenon during hospitalization and would not give due importance to the same as one of the early indicators of delirium.
In the previous study from our center,  delirium at the time of admission (prevalent delirium) and admission to a surgical ward were found to be significant predictors of delay in psychiatric referral for delirium. However, in the present study, we did not find any association between prevalent delirium and delay in referral. In contrast to that study,  the present study showed longer delay in referral from medical wards compared with the surgical wards. These differences could be due to a larger sample size in the present study and possibly as to how the delay was defined.
Relationship of absence of comorbid axis-1 psychiatric diagnosis with delay in psychiatric referral possibly reflects that the physicians' and surgeons' attitude toward psychiatric services and patients with psychiatric disorders. It can be postulated that in general physicians and surgeons tend to refer only those patients who are known to have a psychiatric disorder. Possibly in these patients, the manifestations of delirium are taken as signs and symptoms of relapse of primary psychiatric diagnosis and; hence, early psychiatric consultation is sought and when the patient does not have any known psychiatric disorder, either the symptoms are ignored or the physicians/surgeons try to manage these symptoms themselves, seeking psychiatry consultation only when the symptoms become prolonged or troublesome.
Previous studies from our center too suggest that hypoactive delirium is associated with less distress in caregivers  and it is quite possible that the caregivers do not perceive difficulty in managing these patients and hence, donot report the same to the primary physician/surgeons. This possibly contributes to delay in referral. The relationship between delay and medical speciality could be due to both due to good or poor knowledge.
The present study has certain limitations which must be kept in mind while interpreting the results of the same. These include retrospective study design and we did not evaluate the patients who were not referred to CL psychiatry services. We also did not assess the attitude and knowledge of the physicians and surgeons toward delirium. Further, the variables associated with delay in psychiatry referral explained only a small amount of total variance; hence, there may be many other variables, which were not assessed as part of this study, which may be associated with delay in psychiatry referral.
To conclude, the present study suggest that sleep disturbances, motor retardation, being admitted to medical ward/medical intensive care units, and absence of comorbid axis-1 psychiatry diagnoses are associated with longer delay in psychiatric referral after the onset of delirium. In general, it can be concluded that all these associations possibly reflect poor knowledge about signs and symptoms of delirium among the physicians and surgeons. Hence, efforts should be made to inform the primary team members about the signs and symptoms and risk factors of delirium to reduce the referral delay and improve the outcome of delirium.
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Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]