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 her personality. 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 directly at it. Even those of us who have a better 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 an article 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 very informative 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 processiii 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 medical 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 attitudesv 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 it2. Basically some things simply do not need proving. When seen in the light of the coal-face environment, where outcomes 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 areas of medicinevii 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 vulnerable inpatients. 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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Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B,

sort of ethical relevance. But it 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 is the 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

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 UK national 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 delirium 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

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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 might seem 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: julian.hughes@ncl.ac.uk

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 is entirely 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 printed copy 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 on September 20th to 21st. Watch the website for more information http://www.europeandeliriumassociation.com/ New training resource An excellent videocast is now available on the EDA website, Dr Andrew Teodorczuk giving an introductory lecture on delirium for healthcare professionals. Access via the homepage news banner or log on to http://www.europeandeliriumassociation.com/news/delirium- essential-facts-a-short-lecture-by-dr-andrew-teodorczuk/ Use of restraints in ICU The BBC Radio 4 Inside the Ethics committee series covered the use of physical restraints in a man who needed ventilation for pneumonia who was autistic and developed delirium. Listen again at http://www.bbc.co.uk/programmes/b01ksc3b

2013 American Delirium Society 3rd Annual Meeting American Delirium Society, Omni Hotel and Conference Center Indianapolis, Indiana, June 2-4, 2013. The American Delirium Society (ADS) invites you to attend its 3rd Annual Meeting. This is a great opportunity to network, meet like-minded clinicians and scientists from many different disciplines, specialties and to develop research partnerships. A preconference course will be offered for clinicians of all 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 Keynote Address >6/3/13, 08:00-18:00 Scientific Program includes Oral Presentations and Symposia >6/3/13, 18:00-21:00: Poster Session & Cocktails >6/4/13, 08:00-18:00 Scientific Program includes Oral Presentations and Symposia > 6/4/13, 18:00 Meeting Adjourns Important dates: Deadline for proposal/paper abstracts December 16, 2012 Online registration begins November 15, 2012 Deadline for poster abstracts March 3, 2013 Early registration ends April 28, 2013 American Delirium Society www.americandeliriumsociety.org

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