Cognitive Superbug! Why is delirium an important public health issue?

March the 15th is World Delirium Day, and like all health awareness days it should be critically assessed for its relevance in our lives. Why should delirium stand out? It matters because delirium should inspire one to take the opportunity to reflect on this major public health crisis and imagine a better future. A new way of thinking about health care and mental health in Ireland needs to arise.

Delirium (also known as “acute confusional state”) is a form of brain failure, and like dementia is one of the many forms the brain/psyche takes when it is dying. As a form of brain failure, delirium is intimately associated with poor healthcare outcomes and according to many researchers delirium should be considered a cognitive superbug. As a neuropsychiatric syndrome, it is characterised by a complex variety of features and experiences which include, disturbances in memory, language, thought processing, attention, orientation, motor functioning, and even our sleep wake cycles. Together these features manifest the florid nightmares that patients have when they exist in a state between being asleep and awake. Indeed in J. Allan Hobsons classic text, Dreaming as Delirium (1999), dreaming and delirium share many features both at a psychological and neurophysiological level, and understanding one can help in understanding the other.

According to Inouye et al., (2014) the aetiology of delirium is complex and reflective of multiple contributing factors, which include critical illness, polypharmacy, and pre-existing cognitive impairment.  It is estimated to have a prevalence of 20% in general hospital inpatients, over 50% of the over 65s inpatient population, and then it can escalate to a prevalence of over 80% of inpatients in the intensive care unit and palliative care setting Research has confirmed its high prevalence in the acute Irish hospital setting, for example, Ryan et al., (2013). The high prevalence of delirium is such that there are hundreds of terms to describe delirium in the medical literature, for example it is reported in Zbigniew Lipowski’s book, Delirium: acute confusional states (1990), Hippocrates used 16 terms to describe what we now call delirium.

Despite its prevalence, it is overlooked in two-thirds of cases. Worse still, long after they have been discharged from hospital, the individual can suffer an abrupt and noticeable decline towards worsening frailty, increased risk of dementia and even death. And for those that may endure this process, there is the spectre of post-traumatic stress disorder and a lingering feeling of alienation.

In 2014, as part of the New Programme for Government 2011-2016, The National Dementia Strategy was launched which mapped out the different aspects of dementia/ delirium care in Ireland. It highlighted the economic (estimated cost €21 million) and health care burden of dementia (estimated prevalence of 29%) in the acute hospital setting. The National Strategy for Dementia identified the interface between dementia and delirium in the Irish acute hospital setting and the vulnerability of these patients to developing both. A key component to this strategy was the establishment of cognitive friendly hospitals. However, a national audit of dementia care in Irish acute hospitals (conducted by Timmons et al., 2015) highlighted the absence of delirium screening in over 70% of patient records. However, the authors highlight that this disparity between policy and practice is unfortunately a common trend internationally.

Although many of the features of a cognitive friendly hospital have been established in Ireland, there is significant room for improvement in terms of staff training and routine screening. Delirium is not an issue that can be approached without any critique of the ideas and notions surrounding it. From a wider perspective, delirium is also part of the great untold narrative of mental health problems across Ireland.

The past few decades have seen tremendous blustering and bumbling from different HSE managerial phenotypes, from the ill-informed to the melancholic, and all within the spectrum of the ineffective. An accumulative spectacle of nothingness punctuated by nastiness cannot continue in line with the fatalistic discourse that now dominates health care policy in Ireland, particularly mental health policy. The Republic of Ireland is in an excellent position to develop and implement a national screening programme for delirium as a focal point of cognitive friendly hospitals. Research from Ireland has contributed significantly to the discourse on delirium and its economy of size, offers an exciting prospect of utilising an effective strategy to enable the Irish healthcare system to tackle this major public health problem.

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