Delirium Common But Often Not Noted on Medical Records

Marisa Wexler, MS avatar

by Marisa Wexler, MS |

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Although common, delirium often goes undocumented in the medical records of many Parkinson’s patients who experience the symptoms, results from a new study show, and those who have been diagnosed with delirium often lack instructions for future care.

The study, “Documentation and Diagnosis of Delirium in Parkinson’s Disease,” was published in Acta Psychiatrica Scandinavica.

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Delirium — a rapidly developing disturbance of attention, awareness, and/or cognition related to a medical condition — is common, estimated to affect more than one out of every four people on general and old age medical wards. Although the condition can substantially affect a person’s health and quality of life, delirium is generally underdiagnosed.

Identifying delirium in people with Parkinson’s disease can be especially challenging, since some disease symptoms such as psychosis may overlap with manifestations of delirium.

In the study, a team of scientists in the U.K. conducted an analysis of data for 53 hospital admissions from 44 people with Parkinson’s, with the aim of assessing how delirium is documented among Parkinson’s patients during acute hospital admissions.

“Identification of delirium is essential to allow targeted investigation for underlying causes, treatment of these and management of the delirium itself, with delays in treatment of delirium associated with increased mortality rates,” the researchers wrote. “It is also important to remember that delirium is not only treatable but preventable, so early identification of risk factors and early symptoms could have significant impact on reducing morbidity and mortality.”

Based on detailed review of the patients’ medical records, as well as standardized assessments filled out by caregivers, 30 hospital admissions from 26 patients showed signs of possible or probable delirium. Patients with delirium tended to be older and had longer hospital stays.

The most common delirium-associated symptom was confusion, recorded in all 30 cases. Hallucinations and delusions also were common. These symptoms were more likely to be reported by family members than found in medical records, suggesting under-documentation, the researchers noted.

Although 30 cases had documented delirium-like symptoms, only 11 had a documented diagnosis of delirium.

Among these patients, it took on average more than a day-and-a-half from the first documentation of delirium-like symptoms in the medical record, to the documentation of the diagnosis. The researchers noted that the delay tended to be longer if the initial symptom was recorded by a nurse or allied health professional, compared to when the first symptom was recorded by a doctor.

“This is suggestive that the problem does not wholly lie with the ability of staff to detect the common symptoms of delirium but also with communication of these symptoms between professionals and making a connection between these and the relevant diagnosis,” the researchers wrote.

The team also highlighted that delirium was only noted in the discharge instructions for three patients, even though 11 had a documented diagnosis.

“Discharge letter documentation was the most notable in its lack of delirium documentation, with only a tenth of letters providing evidence of the delirium present during the hospital stay,” the team wrote.

The researchers stressed discharge documentation for patients with delirium should note this diagnosis and also provide information about management strategies, including what was or was not helpful while the patient was in the hospital. This is especially important since people who experience one episode of delirium are at heightened risk of experiencing future episodes of delirium and developing dementia.

“Improved communication and transfer of this information better allows primary care doctors and community teams to identify those patients at risk of developing dementia, but also those at risk of further delirium,” the scientists wrote. “Early interventions and the use of management strategies known to be helpful, and avoidance of those known to not have previously helped … could significantly improve [patients’] risks of morbidity and mortality.”

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Among the 30 patients with possible or probable delirium, most (57%) had the hypoactive subtype, which is characterized by reduced movement. The other patients either had hyperactive delirium, characterized by increased movements, or showed a mix of the two types.

Compared to the other subtypes, significantly more participants with hypoactive delirium were undiagnosed in medical records (63% vs. 37%).

“Hypoactive delirium was, as expected, the more frequently missed delirium subtype. This is of concern as hypoactive delirium is associated with greater morbidity and mortality,” the researchers wrote. “Along with the poor rate of diagnosis documentation, this highlights the need for improved education and awareness of delirium, subtypes, symptom profiles in [Parkinson’s] and the importance of recognizing this and documenting it.”