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More attention, less confusion: Time to lessen the burden of delirium

Delirium represents a major healthcare challenge for our increasingly aged society. No other neuropsychiatric disorder has equivalent penetration of health services, reaching from settings as diverse as intensive care units to community-based nursing homes. Like a cognitive ‘superbug’, it is preventable but once established can impact gravely upon outcomes. The quality of delirium care is a key marker of (dys)functionality in our health systems, highlighting the need for greater cohesion in dayto-day clinical management, more emphasis in educational programming, and the need for administrative structures to ensure that this extremely common and prognostically significant condition is addressed right across healthcare services. In the first paper of this special issue, John Holmes sounds a clarion call for delirium, exhorting greater awareness in frontline staff served with the responsibility of recognizing and responding to delirium at the individual patient level, right up to policy makers at national and international level who can mandate that delirium be a major focus within our healthcare services. In between, clinical thought leaders, those who design educational curricula, and research bodies can all make vital contributions. Delirium will continue to fall between the cracks unless ownership occurs at a higher level than the subspecialty boundaries that demarcate our acute and continuing care services. Holmes highlights the gap in identification for research purposes versus that evidenced in health service activity data – a key block to progressing care in real-world settings that is all the more bemusing given the considerable economic potential of providing better care for delirium. Delirium is sometimes viewed as a nebulous condition, important by virtue of its nuisance value rather than as a discrete entity that warrants therapeutic effort in its own right. In simple terms, proactive management of delirium must become more attractive. Problems with delirium detection remain the single biggest issue that hinders clinical and research effort. Over the past fifteen years, the Confusion Assessment Method (CAM) has emerged as the gold standard for delirium screening in research studies but it lacks sensitivity when applied in real-world clinical settings by non-expert healthcare workers. Improving detection further requires innovative approaches that can be readily applied across a range of often busy and chaotic environments and that can be interpreted by staff with varying levels of medical knowledge. Novel technologies offer the prospect of accurate assessment of the cognitive domains that are disturbed in delirium, with emphasis on those elements that are disproportionately and most consistently disrupted. Exton and Leonard in their paper discuss the potential of eye tracking technology (ETT) to provide discrete and involuntary assessment of attention across a range of populations (including those at age extremes) and in patients who have limited verbal and gestural abilities. Improving delirium-related knowledge and skills is predicated upon gaining access to a wide range of healthcare professionals and settings. Irving and colleagues describe the rationale behind an e-learning package that uses virtual technology to produce interactive problem-based educational interventions. The significant advantages in relation to convenience of access, cost, flexibility and ease of dissemination make this an attractive option that has immense potential to improve awareness of delirium, while allowing the development of the specific skills that are crucial to better detection and optimal management. To date, genetic research into delirium has been dominated by studies of the role of genetic polymorphisms in predicting risk for alcohol-withdrawal delirium. Recent studies in delirium due to general medical factors have attempted to identify how genetic factors might predict treatment response or shape other aspects of clinical profile such as phenomenological presentation and reversibility. Clearly, this is a field that holds much potential as described by Adamis and colleagues in their comprehensive review. Delirium is traditionally distinguished from dementia by its potential for reversal, but