Documentation and diagnosis of delirium in Parkinson's disease

Abstract

Objective: To assess the accuracy of documentation of the symptoms and diagnosis of delirium in medical notes of inpatients with Parkinson's Disease (PD). Methods: The DETERMINE-PD pilot study assessed PD inpatients over 4-months. Delirium prevalence was classified prospectively using a standardised assessment at a single visit on the basis of Diagnostic and Statistical Manual of Mental Disorders 5 th Edition (DSM-5) criteria. Incident delirium was diagnosed retrospectively using detailed clinical vignettes and validated consensus method. Inpatient medical notes and discharge summaries of those with delirium were reviewed for documentation of symptoms, diagnosis and follow-up. Results: Forty-four PD patients consented to take part in the study, accounting for 53 admissions. We identified 30 cases (56.6%) of delirium during participants' stay in hospital. Of those with delirium identified by the research team, delirium symptoms were documented in the clinical notes of 72.3%; 37.9% had a delirium diagnosis documented. Older patients were more likely to have delirium (p=0.027) and have this diagnosis documented (p=0.034). Time from documentation of symptoms to diagnosis ranged from <24 hours to seven days (mean 1.6±4.4 days). Hypoactive delirium was significantly less likely to have been identified and formally diagnosed (63% of not documented were hypoactive vs. 37% hyperactive, mixed or unclear, p=0.016). Only 11.5% of discharge summaries included diagnosis of delirium. Conclusion: Delirium in PD is common. Documentation of symptoms of delirium was common; however, fails to lead to a documentation of diagnosis in over half of admissions with delirium and was even less commonly communicated in the Primary Care discharge summaries. This highlights the need for increased education about delirium symptomatology and diagnosis in PD.

Causal relationships between delirium and Parkinson’s Disease: a bidirectional two-sample Mendelian randomization study

“…Hypoactive delirium is characterized by a reduction in psychomotor activity 26 . Cullinan et al 27 . found that delirium in patients with PD is common but often missed, especially in the hypoactive delirium subtype.…”

“…A metaanalysis of 152 observational studies has revealed elevated levels of PD-associated biomarkers, such as IL-6 and C-reactive protein 33 . The presence of shared biomarkers between delirium and PD suggests potential overlapping pathological mechanisms during disease progression 27 . Furthermore, these delirium-related biomarkers may also contribute to the detrimental course of PD, rather than solely being indicative of delirium itself.…”

Delirium is more common and associated with worse outcomes in Parkinson’s disease compared to older adult controls: results of two prospective longitudinal cohort studies

“…First, the methods used for delirium detection were highly heterogeneous, including DSM-IV criteria, a new prescription of antipsychotic medications and the use of delirium screening tools, none of which have been validated in PD [ 5 ]. Second, multiple studies have relied on retrospective medical notes reviews to diagnose delirium, despite delirium in PD often being underreported in patient medical notes [ 7 ]. In older adults without PD, it is well established that delirium is associated with increased mortality [ 32–35 ].…”

“…Parkinson’s disease (PD) may be a risk factor for delirium, but reported inpatient prevalence varies from 11–60% [ 5 ]. This variance is likely due to challenges in recognising delirium in PD due to shared clinical features [ 6 ], the range of criteria and methods used for delirium diagnosis [ 5 ], along with the reliance on retrospective delirium ascertainment in many studies, which has been shown to miss nearly two thirds of cases of delirium in PD [ 7 ].…”

Beyond confusion: Embedding psychiatry in delirium research and clinical practice

“…This makes diagnosing delirium and distinguishing delirium from fluctuations in Lewy body disease difficult (Petersen Hella et al 11 ). Cullinan et al 12 found that even if symptoms of delirium were recognised in patients with Parkinson's disease, a formal delirium diagnosis was only recorded in half of these patients' clinical record. Systemic inflammation is a possible contributor to the pathophysiology of delirium 13 and Klimiec-Moskal et al 14 explored the role of C-reactive in predicting delirium post-stroke.…”