annals of delirium october 2012

7/31/2019 Annals of Delirium October 2012

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European Delirium Association 2012 www.europeandeliriumassociation.com

Annals of Delirium October 2012

Editorial

Last month I was on intensive care and came to an elderly patient who

was recovering from sepsis.. I assessed her mental status by asking

her to tell me the months of the year backwards from December. She

managed to tell me that November came before December but no

more. In the matter of a few minutes, in between telling me how she

was, she was smiling and repeated 5 times that she was there busy

trying to die. The nurse who had recently taken over her care told me

she did not believe this patient was delirious but that it was herpersonality. The patients delirium was quite clear to me. Why is it

that we will always give normal mental status the benefit of doubt?

Delirium is so plausible, a powerful cloak of deception created by a

malfunctioning brain so effective it may stay hidden even when we are

looking di rectly a t it. Even those of us who have a be tter

understanding of delirium will struggle to differentiate it from

depression, agitation or even eccentricity.

In the critical care arena our validated screening tools may be

criticized for not being sensitive enough while at the same time there

are senior intensivists who dismiss the symptoms of delirium as

the inevitable effects of sedation. After all sedation causes inattention

and decreased level of consciousness which is what we base our

diagnosis on. It is almost as if we have a vested interest in believing a

patient is not delirious even when there is evidence to the contrary.

The diagnosis of delirium is fundamental and we still lack an ideal

diagnostic tool but it appears to me that we also need to ask ourselves

is it that clinicians cant see delirium or that they wont see it? And

what can we do about that?! On that theme this edition contains anarticle touching on philosophy and the delirious patient as well as a

contribution regarding the adult learning.

This edition is timed to coincide with the 7th Scientific Congress of the

European Delirium Association being held this year in Bielefeld,

Germany. We hope you all have an enjoyable, stimulating and

productive time. Please share your views and opinions in the next

Annals of Delirium.

Valerie Page

Co-Editor


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Simulation in Delirium Education

Michael Alcorn is a Clinical Teaching Fellow and trainee in Geriatric

Medicine in NHS Lanarkshire, just outside Glasgow, Scotland.

Adult learning theory aims that the learner become autonomous and

self-directed - the ideal role of a teacher then is that of a facilitator of

the students own learning. The process of learning itself requires

participation and emotional engagement. Constructivist and

cognitivist schools of thinking support the view of a teacher as one

who supports, encourages and directs the students autonomous

learningi ii

.Mistakes, when recognised and analysed can be veryinformative tools for learning but as healthcare professionals, how

can we minimise the risk to real people when we are talking about

their wellbeing? Feedback on one individuals performance from more

experienced individuals, who have seen it and done it before, is often

hugely instructive.

Simulation an imitation of some real thing, state of affairs or

process iii is a frequently employed tool across many areas of

medical education. It was imported from high-risk fields such the

aviation industry, fire-fighting and nuclear power. iv In medica l

simulation, the use of role-play and unfolding scenarios, patient actors

and high-fidelity mannequins help recreate the environment of a real

patient encounter and promote the practice of difficult skills in a

controlled environment. Opportunities for enhancing of performance

or mistakes can be explored in a debriefing session with the chance to

repeat the exercise and improve. Evidence is accumulating that the

clinical knowledge, skills and attitudes v vi of students/trainees are

benefited by exposure to simulation-based teaching. While evidence

for improvement in direct measures of patient safety and outcomes is

lacking, Dr David Gaba - one of the pioneers of medical simulation

teaching pointed out 20 years ago, no industry in which human

lives depend on skilled performance has waited for unequivocal proof

of the benefits of simulation before embracing it 2. Basically some

things simply do not need proving.

When seen in the light of the coal-face environment, whereoutcomes and patient safety are dependent on practised skills and

intelligent synthesis of diverse information, it is clear why medical

educators the world over have moved to using simulation-based

teaching tools. Most of the evidence and experience over the years has

been gathered in the arenas of medical and nursing practice where

protocols, checklists and algorithms dominate anaesthetics, surgery,

obstetric care and emergency resuscitation and these are all well

represented in the literature. I am interested in asking if a condition

as complex as hyperactive and hypoactive delirium be simulated to

train health care professionals to recognise the condition, the causes

and manage the individual patient or even their relatives? All sorts of

aspects of such interactions can be explored by simulation, whether


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the diagnostic skills of the student, the hands-on medical care offered,

communication with relatives, carers and colleagues or almost any

other facet of our complicated human interactions, otherwise known

as a normal day on the wards! I believe that simulation is a versatile

tool that need not be limited to the application of a didactic set of

instructions in the event of a clinical emergency.

The use of simulation as a teaching tool has obvious benefits offering

the opportunity of practiced experience in a controlled fashion; space

is made to provide immediate, directed feedback to enhance the

learning experience which can then be reflected on. Recent published

material looking at the teaching of Geriatric Medicine in UK medical

schools geriatric medicine topics are often integrated with other areasof medicine vii viii, whereas evidence suggests that a discrete, focussed

place in the curriculum leads to an improvement in attitudes and

knowledge., Actual teaching methods employed across the country

vary along with the curriculum they are designed to teach, but it can

be seen that as curricula adapt to the times (the GMCs template

Tomorrows Doctors was most recently updated in 2011) and the

population becomes older and more complex., there is an imperative

to find reliable, effective methods for teaching undergraduates the

principles of really caring for elderly patients. There is a lack of

published work that specifically looks at using simulation teaching in

Geriatric medicine however, the data published supports the role of

simulation in improving both attitudes and knowledge .

Our group in Lanarkshire are currently in the process of designing and

implementing a novel simulation-based training day for final year

medical undergraduates, aimed at exposing them to challenging

scenarios of caring for elderly, complex patients that they are likely to

encounter on the wards. Scenarios simulating encounters with

delirious patients will be a priority, using high-fidelity mannequins

and unfolding scenarios, pre-recorded video encounters with actors

playing the patient role, video-assisted debriefing and workshops. I

would warmly welcome any enquiries and constructive contributions

from this journals readership as our group seek to refine our

educational intervention, with the aim of improving the care our

junior doctors are equipped to give to some of our most vulnerableinpatients.

References

1 Singh I, Hubbard R; Teaching and Learning Geriatric Medicine.

Reviews in Clinical Gerontology (2011) 21; 18092

2 Fanning RM, Gaba DM; The Role of Debriefing in Simulation-based

Learning. Simulation in Healthcare (2007) 2(2):115-25

3 Rosen K; The History of Medical Simulation. Journal of Critical Care

(2008) 23(2):157-66

4 Gaba DM; Improving Anesthesiologists Performance by Simulating

Reality. Anesthesiology (1992) 76(4):491-94


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5 Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B,

Levine A; The Utility of Simulation in Medical Education: What is the

Evidence? Mt Sinai J Med (2009) 76:330-43

6 Tullo ES, Spencer J, Allan L; Systematic Review: Helping the Young to

Understand the Old. Teaching Interventions in Geriatrics to Improve

the Knowledge, Skills, and Attitudes of Undergraduate Medical

Students . J Am Geriatr Soc(2010) 58:198793

7 Bartram L, Crome P, McGrath A, Corrado OJ, Allen SC, Crome I;

Survey of training in geriatric medicine in UK undergraduate medicsl

schools. Age Ageing (2006) 35 (5): 533-535

8 Gordon AL. Blundell AG, Gladman JR, Masud T; Are we teaching our

students what they need to know about ageing? Results from the UKnational survey of undergraduate teaching in ageing and geriatric

medicine. Age Ageing (2010) 39 (3): 385-388

A philosophical basis for the care of the person with delir ium

Julian C. Hughes MA, MB ChB, PhD, FRCPsych

Consultant in Psychiatry of Old Age and Honorary Professor of

Philosophy of Ageing,

Clinicians are used to the idea that ethics is relevant to the practice of

medicine. Indeed, one might say that all clinical decisions are, at one

and the same time, ethical decisions: every clinical decision has some

sort of ethical relevance. But i t might not be so obvious that

philosophy also plays a part in practice.

For a start, ethics is a branch of philosophy. The great moral

philosophers have established the theories which are brought to bear

on clinical practice. Thus, virtue ethics (which stresses our

dispositions) stems from Aristotle; utilitarianism (maximizing

pleasure or happiness) comes from Jeremy Bentham and John Stuart

Mill; and deontology (where morally right actions are a matter of

duty) is associated with the name of Immanuel Kant.

But, secondly, philosophy is often regarded as providing conceptual

clarification. This could bring us closer to the topic of delirium. Where,

for instance, is the clear dividing line between dementia and delirium?Of course, we can identify clear-cut cases of either dementia or of

delirium. But at the borderline are matters so distinct? Clouding of

consciousness, for example, once seemed to delineate delirium.

Dementia was global cognitive impairment without clouding of

consciousness. But now we have the fluctuations of dementia with

Lewy bodies which can look like delirium. Sure, this conceptual

problem does not tend to present many real life clinical problems. But

the bigger issue is that the reality we are faced by isthe ageing brain ,

which shows itself in a variety of ways. Not only does research need to

take note of this reality, because answers may come from shedding

light on broader manifestations of ageing rather than finely focusing

on the particular, but also thinking of the ageing brain helps to explain


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the close link on the ward or in the clinic between dementia and

delirium.

Thirdly, at a deeper level perhaps, philosophy is about foundational

concepts. And here, briefly, I wish to consider the notion of

personhood . To be a person is to have legal and ethical standing. In the

clinic and the ward we deal with persons. But what is it to be a

person? How do we conceive persons? There is a pervasive tendency

to think in dualistic terms (a tendency derived from another famous

philosopher, Ren Descartes), either of bodies or of minds. The

medical profession, perhaps unfairly, is often criticized for focusing

too much on the body; this is what biomedicine is seemingly about.

There is, however, a broader view of personhood: the SEA view!Hence, the person can be characterized as a Situated Embodied Agent

(for fuller descriptions of this view see Hughes 2001 or Hughes 2011).

The key notion is that of being situated; for we are all as persons

situated in a variety of fields: biological, psychological, social, spiritual,

geographical, historical, legal, moral, cultural and so on. We are agents,

too, with an interest in exercising our autonomy to control our lives as

freely as possible. But our agency is situated agency. I cannot do just

anything, because what I do will have effects on others. In delirium,

my agency is compromised. But being situated means that those

around me, professionals and family, can try to ensure that what is

done to me still recognizes my essential standing as an individual with

rights and interests.

Similarly, as a person I am a body. But not just a body. A famous

contemporary philosopher, Charles Taylor has written:

Our body is not just the executant of the goals we frame ... Our

understanding is itself embodied. That is, our bodily know-how, and

the way we act and move, can encode components of our

understanding of self and world. ... My sense of myself, of the footing I

am on with others, is in large part also embodied. [Taylor 1995, pp.

170-171]

This implies at least two things. First, there is no gap between the

mind and the body (dualism is dead): you understand what is going on

inside me by what is going on outside; as a consequence, what you

do to my body, you do to me as a person. Secondly, even in what mightseem like a random gesture, there might be embodied meanings. My

random movements and bizarre behaviours should still be regarded

as potentially meaningful. So, the person with delirium still needs to

be treated with respect, afforded dignity and attended to seriously. Of

course, good clinicians will do all of this instinctively, but in so doing

their actions are in keeping with and underpinned by the situated

embodied agent view of the person.

Delirium is, after all, a condition which affects the whole person. We

deal with it best when we take the broad view (the SEA view). We

have to deal with the persons situated body: we listen carefully to the

persons history, we perform appropriate examinations and tests, we

treat the underlying conditions. But the person is also a situated agent


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in a specific environment, which we might need to modify, whose

wishes and beliefs we should attempt to accommodate by listening to

them and by involving those who know and love them.

Philosophical thought, therefore, supports a holistic approach. But this

is not some nebulous notion or wishy-washy ideal. True holism takes

serum calcium as seriously as good lighting and a quiet environment.

References

Hughes, J.C. (2001). Views of the person with dementia. Journal of

Medical Ethics , 27 , 86-91.

Hughes, J.C. (2011). Thinking Through Dementia . Oxford: Oxford

University Press.Taylor, C. (1995). Philosophical Arguments . Canbridge, Mass.: Harvard

University Press.

Julian C. Hughes MA, MB ChB, PhD, FRCPsych

Consultant in Psychiatry of Old Age and Honorary Professor of

Philosophy of Ageing,

Northumbria Healthcare NHS Foundation Trust, North Tyneside

General Hospital, Rake Lane, North Shields, Tyne and Wear, NE29

8NH, UK; and Institute for Ageing and Health, Newcastle University,

email: [email protected]

Editors Choice of recent reviews

While this editor (VP) personally has reservations regarding the UK

National Institute for Health and Clinical Excellence 103 there was an

useful updated review of selected new evidence published in April

download from www.evidence.nhs.uk/evidence-update-14

Best Practice and Research Clinical Anaesthesiology Volume 26,

Issue 3, September issue isentirely devoted to delirium in hospitals

with review articles provided by the great and good covering just

about every single clinical aspect.

If you do have access to a comprehensive electronic library then log on

and take your pick. If not then take a look at the content and maybe if

you have access to a librarian they should be able to get you a printedcopy of the articles you want to read.

In no particular order this Editors 3 picks would be the article on

pharmacologic prevention and treatment (pages 289-309), delirium

detection and monitoring from outside the ICU (367-383) and finally

Is sleep important? (355-366) as I am always being asked about sleep

in critically ill patients.

Valerie Page


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News

2013 EDA congress

The EDA Congress for next year is being held in Leuven, Belgium onSeptember 20 th to 21st . Watch the website for more information

http://www.europeandeliriumassociation.com/New training resourceAn excellent videocast is now available on the EDA website, DrAndrew Teodorczuk giving an introductory lecture on delirium forhealthcare professionals. Access via the homepage news banner or logon tohttp://www.europeandeliriumassociation.com/news/delirium-essential-facts-a-short-lecture-by-dr-andrew-teodorczuk/

Use of restraints in ICUThe BBC Radio 4 Inside the Ethics committee series covered the use ofphysical restraints in a man who needed ventilation for pneumoniawho was autistic and developed delirium. Listen again athttp://www.bbc.co.uk/programmes/b01ksc3b

2013 American Delirium Society 3rd Annual Meeting

American Delirium Society, Omni Hotel and Conference CenterIndianapolis, Indiana, June 2-4, 2013. The American Delirium Society

(ADS) invites you to attend its 3rd Annual Meeting. This is a greatopportunity to network, meet like-minded clinicians and scientistsfrom many different disciplines, specialties and to develop researchpartnerships. A preconference course will be offered for clinicians ofall backgrounds:>6/2/13 13:00 17:00 Approach to the Delirious Patient

This course includes a hands-on, practical approach to the recognition,treatment and prevention of delirium in the hospitalized patient.

The conference schedule includes:>6/2/13, 18:30-22:00 Welcome Reception and Presidential KeynoteAddress>6/3/13, 08:00-18:00 Scientific Program includes Oral Presentationsand Symposia>6/3/13, 18:00-21:00: Poster Session & Cocktails

>6/4/13, 08:00-18:00 Scientific Program includes Oral Presentationsand Symposia> 6/4/13, 18:00 Meeting Adjourns

Important dates:Deadline for proposal/paper abstracts December 16, 2012Online registration begins November 15, 2012

Deadline for poster abstracts March 3, 2013Early registration ends April 28, 2013

American Delirium Societywww.americandeliriumsociety.org

annals of delirium october 2012

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