The review article, case presentations, and commentary on delirium in this issue of Psychiatric Issues in Emergency Care Settings provide a comprehensive overview of a challenging medical disorder. This issue is particularly useful for physicians and mental health care providers who work in emergency departments (EDs), on psychosomatic services, and on inpatient units with a significant geriatric population.
Delirium, while an omnipresent disorder, remains a perpetual clinical enigma. The waxing and waning symptoms of delirium can perplex even the most highly experienced and seasoned clinician. In addition, the cause of many or most cases of delirium is difficult to determine. The absence of definitive diagnostic tests for this serious and potentially life-threatening medical condition can add to delays in diagnosis and treatment. These delays not only heighten the risks of morbidity and mortality in delirious patients but also contribute to the distress of both patients and their families. Furthermore, these delays strain underresourced medical care facilities that are responsible for the treatment of these patients. For all these reasons, a review of the etiological factors, assessment, and treatment of delirium is warranted and most welcome.
Drs Heinrich and Sponagle, from the Medical College of Wisconsin, authored "Delirium: Emergency Evaluation and Management," an overview article that covers many facets of the condition. They discuss current progress in delirium detection and management and infuse renewed interest into a prevalent disorder. The text is exceptionally well written. Tables in this article highlight DSM-IV-TR diagnostic criteria, etiologic mnemonics, assessment instruments, and laboratory tests for the delirium workup and make for convenient reminders for the busy clinician.
In addition, Drs Heinrich and Sponagle review the medical treatment of patients with delirium, including pharmacological management of the acute condition. The authors note that although all medications used to manage delirium are done so on an off-label basis, antipsychotic medication and benzodiazepines have been used successfully for decades. A balanced view of the advantages and disadvantages of typical antipsychotics, atypical antipsychotics, and benzodiazepines in delirium management is provided.
Three case presentations are included, and each case illustrates a different clinical aspect or challenge and offers excellent coverage of relevant issues. Drs Sponagle and Heinrich review the differential diagnosis, etiology, and treatment. They also discuss the standard of care for each presentation and address the more controversial therapies often observed clinically. The patient evaluations and respective treatments provide valuable and practical advice on patient management. Experienced clinicians may find this to be a good review of current standards of care, and junior clinicians may benefit from the clear delineation of issues and thought behind available interventions.
Insightful commentary on the feature article and case presentations is provided by Drs Triplett and Rabins from John Hopkins University School of Medicine. These authors address the alarming dual trends of the graying of America and the increasingly overburdened and underresourced EDs; these clinical areas are often in the vanguard for diagnosing and treating delirium. Drs Triplett and Rabins note that the US population older than 65 years will double by 2030 and will account for 20% of the total population--an important consideration given that delirium is a common disorder of the elderly. The authors also mention that EDs are under intense pressure to triage patients quickly, which creates a paradox for the care of patients with delirium, a condition that often takes time to properly assess and treat.
These articles, cases, and commentary add significantly to the scientific literature. They reflect current conceptual models, assessment methods, and treatments. Clinicians working with the elderly or consultation services or in emergency care settings will benefit from a detailed reading of this issue.
Douglas H. Hughes, MD
Associate Professor of Psychiatry
Boston University School of Medicine