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LETTER TO EDITOR  
Year : 2014  |  Volume : 56  |  Issue : 3  |  Page : 309-310
How can we avoid delay in referrals of patients with delirium?


1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, KEM Hospital, Mumbai, Maharashtra, India

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Date of Web Publication12-Sep-2014
 

How to cite this article:
Grover S, Kate N. How can we avoid delay in referrals of patients with delirium?. Indian J Psychiatry 2014;56:309-10

How to cite this URL:
Grover S, Kate N. How can we avoid delay in referrals of patients with delirium?. Indian J Psychiatry [serial online] 2014 [cited 2019 Dec 13];56:309-10. Available from: http://www.indianjpsychiatry.org/text.asp?2014/56/3/309/140670


Sir,

We are thankful to Shaji and Jyothi [1] for their comments on our published article. [2] We agree with the observation of the Shaji and Jyothi [1] that major cause of delay in referral of patients with delirium is possibly due to lack of proper knowledge about the disorder in physicians and surgeons. Accordingly, there is a need to improve awareness about all psychiatric disorders and delirium per se in our colleagues from different specialties. Shaji and Jyothi [1] suggest that the awareness should begin in the undergraduate level and should continue during the internship with minimum detail evaluation of one patient with delirium by an intern.

Other important issues which were raised by Shaji and Jyothi [1] are that of nonreferral of patients with delirium, especially those with hypoactive delirium and misdiagnosis of delirium as psychosis. These issues can also be addressed by increasing the awareness about this disorder.

With regards to training of physicians and surgeons about mental health issues, we would go further to suggest that it is important to recognize that learning is an ongoing process and accordingly all the physicians and surgeons should be time and again made aware about recognizing and treating delirium at the earliest. For this, mental health professional have to take their role seriously and whenever they are called to evaluate patient, certain minimum basic points must be kept in mind. First, after evaluation of the patient, it is very important for the psychiatrists to talk to the primary treating team (physician/surgeon), and should provide details about the disorder, causation, role of medical factors in causation of mental symptoms and how these can be managed. While doing so, role of both pharmacological and nonpharmacological intervention of delirium should be discussed. Second, in our interaction with the colleagues from other specialties, it is important for us to emphasize that lack of recognition delirium contribute to the poor outcome of their patients despite their own best efforts. According to our experience, this kind of emphasis at times catches the attention of our colleagues from other specialties than anything else. Third, we need to make our colleagues aware that if appropriate measures are taken into account, delirium can be prevented. This involves making them aware about the common risk factors associated with development of delirium. For this it is important to inform the colleagues about certain modifiable factors like total number of medications, certain type of medications, malnutrition, patients with history of alcohol dependence and recent use of alcohol and metabolic disturbances etc., make the person prone to develop delirium. Fourth, emphasis must be put on increasing the surveillance for delirium in patients with unmodifiable risk factors like older age, sensory deprivation, presence of cognitive deficits etc., Fifth, as delirium is most often seen in medical surgical wards, mental health professionals working in general hospital psychiatry units should organize joint academic rounds to discuss cases with delirium to increase the awareness about the same in colleagues from other specialties. At Post Graduate Institute of Medical Education and Research, Chandigarh these academic rounds are called "Psychosomatic Rounds," in which combined rounds are held with Internal Medicine, Neurology, General Surgery and Pediatrics. These rounds are held once a month, separately with each of the four departments listed, which are attended by the trainee residents and faculty members of both the departments in which patients with various psychiatric problems are discussed to increase awareness about identifying and managing mental and behavioral issues of patients with various physical disorders.

In addition, in a country like ours were health care resources are scarce, optimal use must be made of other health professionals like nurses in identifying patients with delirium. Many researchers from the West have developed scales for screening patients admitted to various medical and surgical wards and in the intensive care units for delirium. [3] These instruments require minimal training and when introduced as part of routine clinical assessment of patients by nursing staff can provide important information about patients with delirium. Routine screening by the nursing staff can help in identifying the patients at the earliest and result in reduction in the delay in referral to the mental health professionals. Similarly, screening instruments are also available, which can be used by physicians/nurses to screen patients with delirium in ICUs for different age groups. [3] The commonly used instrument for the same is confusion assessment method for intensive care unit, which take 1-2 min for completion. It has high sensitivity and specificity to detect delirium. [4],[5]

 
   References Top

1.Shaji KS, Jyothi KS. Clinical recognition of delirium. Indian J Psychiatry 2014;56:306.  Back to cited text no. 1
  Medknow Journal  
2.Grover S, Kate N, Mattoo SK, Chakrabarti S, Malhotra S, Avasthi A, et al. Delirium: Predictors of delay in referral to consultation liaison psychiatry services. Indian J Psychiatry 2014;56:171-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Grover S, Kate N. Assessment scales for delirium: A review. World J Psychiatry 2012;2:58-70.  Back to cited text no. 3
    
4.Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703-10.  Back to cited text no. 4
    
5.Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29:1370-9.  Back to cited text no. 5
    

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Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.140670

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