Differences in delirium management across categories of psychiatry clinicians in Romania

Introduction

Delirium is an acute neuropsychiatric syndrome characterized by disturbances in cognition and attention, underpinned by neuroinflammatory processes and neurotransmitter imbalance, that lead to disruptions in brain networks. Despite recent advances in its neurobiological understanding, the management remains variable, heterogeneous and in some cases suboptimal with fluctuating evolution of the patients.[1]

Objectives

The aim of this study is to assess whether the current clinicians’ diagnostic and therapeutic approaches to delirium, including screening, diagnostic and treatment, are aligned with current neuropsychopharmacological and neurobiological models and to underline whether there is a difference in practical approach between residents and specialists.

Methods

We conducted a cross sectional survey including a number of 115 residents, specialists and attending physicians, with varying clinical experience, assessing their experiences in clinical practice with delirium. The questionnaire explored choices in frequency of encounter, screening, use of standardized assessment tools, laboratory investigations, pharmacological and non-pharmacological treatment, comorbidities, perceived complications and outcomes across clinical scenarios. Additional variables included prior exposure in different healthcare systems and years of experience.

Results

Delirium was reported as a frequent clinical entity in our country, encountered predominantly in inpatient setting, with many patients initially being managed in psychiatric services before referral to other specialties. Although most responders indicated an etiological or combined approach (82,1%) in the case management, only-symptomatic strategies remained utilized in practice (17,9%).

Screening for delirium was primarily performed only in presence of clinical suspicion (42,6%), with only 19,1% of respondents reporting routine screening in at-risk patients; with limited implementation of systematic screening protocols. Consistently, the use of standardized delirium assessment tools was reported as infrequent (18,3%). Diagnostic evaluation was largely centered on routine laboratory investigations (99,1%), while more targeted and extended assessments – such as toxicological, endocrine or vitamin panels, were less commonly utilized (40-48,7%).

Pharmacological management demonstrated noteworthy variability. Atypical antipsychotics were the most frequently selected medication (64,3%), however, benzodiazepines were also commonly used (60,9%) beyond their established indications, suggesting potential inconsistencies with current neuropsychopharmacological recommendations. In contrast, non-pharmacological interventions, including reorientation, early mobilization, sleep hygiene, cognitive stimulation and family involvement were relatively consistent across respondents and only moderately endorsed (52,2-60%). Difference according to level of training were relatively modest. Residents demonstrated heterogeneous pharmacological approaches and more frequent use of multiple non-pharmacological strategies.

Delirium was widely perceived as underdiagnosed (81,7%), with hyperactive forms more commonly recognized and met than hypoactive presentations. Frequently reported complications included hydroelectrolytic imbalance and prolonged hospitalization (82,6%), followed by infections and cognitive decline (68,7%). Clinical evolution was often characterized by partial rather than complete remission.

Conclusions

The findings of the study suggest a gap between neurobiological knowledge and practice, highlighting the need for improved integration of neuropsychopharmacological principles in delirium management. The predominance of symptom driven approaches, limited use of standardized assessment tools and variability in treatment choices suggest an incomplete translation of the neuropsychopharmacological fundamentals into everyday practice. Strengthening education in our country and implementing mechanism-informed clinical protocols may improve the management of delirium as a model of acute brain dysfunction.

References

1. Mattison, M. L. P. (2020). Delirium. Annals of Internal Medicine, 173(7). https://doi.org/10.7326/aitc202010060