delirium assessment – Go Retire Psychiatrist

Thoughts on Copyright Issues Related to Consultation Psychiatry and Dad Jokes

I want to gas; I mean talk about copyright as it relates to consultation psychiatry or telling dad jokes. By the way, those aren’t the same.

I used to teach medical students and residents how to do certain quick bedside cognitive tests for delirium and dementia. Over the years the instructions about how to administer them (and the restrictions over using them at all) have changed slightly. The major point to make is that they have been copyrighted, which usually means you have to pay to play.

One of them, the Mini Cog, despite being copyrighted, does not require you to pay for the privilege of using it. The video below shows part of it. I didn’t do a comedy bit about the short term recall of 3 objects. The video also flickers when I show the delirium order set; just pause it to stop the flickering.

There used to be a cognitive assessment called the Sweet 16, which started off being non-copyrighted, but then became copyrighted. At first the Sweet 16 mysteriously just disappeared from the internet. You can now download it from the internet, but it’s clearly marked as copyrighted.

The reason the Sweet 16 became unavailable is because a company called Psychological Assessments Resource (PAR) acquired the copyright and then started enforcing it. I found out about this when I could not obtain the PAR version of a cognitive assessment very similar to the Sweet 16 called the Mini Mental State Exam (MMSE) unless I forked over at least $100.

I then started teaching trainees how to use the Montreal Cognitive Assessment (MoCA) because it was free to use without any strings attached. Then it also was copyrighted although you can use it under certain conditions.

Moving right along to telling dad jokes, I found out that dad jokes (and indeed, any joke) can be copyrighted, at least in theory. In fact, it’s hard to enforce the copyright on jokes, even when you can prove originality. Here’s an example of a dad joke I think I made up:

What do you get when you cross marijuana with a Mexican jumping bean? A grasshopper.

Note: this joke may become more important now that the DEA, according to news agencies, plans to reclassify marijuana from Schedule I to III in the near future.

Sena thought it was funny (the joke, not the DEA), which probably means it’s not, technically, a dad joke. That’s according to the authority about dad jokes, Dad-joke University of Humour, (DUH). I’m far from a joke teller at all, as Sena (and anyone else who knows me) would assert. On the other hand, I did graduate from DUH and have a diploma to prove it. You can now give me money.

Furthermore, I also investigated whether something called anti-jokes can be copyrighted. According to the internet, the answer seems to be no. Here’s my attempt of the anti-joke:

Knock, knock.

Who’s there?

The doorbell salesman.

See what I did there? In case you didn’t know, experts say that Knock-Knock jokes are among the hardest to copyright for reasons I suggest you look up later. If you also frame the Knock-Knock joke as an anti-joke (stay with me here), the literalness and mundanity of the so-called punch line makes it virtually impossible to copyright. And, like the dad joke, it’s usually not funny—although there can be exceptions.

Just for the sake of incompleteness, I’ll mention the concept of copyleft, which is not the same as open-source. Although this is usually applicable to computer software, you could broaden it to include dad jokes—I think. Copyleft could mean you can use or modify a dad joke (or anti-joke), spread it freely at parties and whatnot as long as it’s bound by some condition. This includes paying me (no personal checks, please).

What pet do inventors have a love-hate relationship with? A copycat.

You’re welcome.

Time for Another Blast from the Past

I found an interesting blog post from my previous blog, The Practical Psychosomaticist. I wrote it in 2011 and it’s about the patient experience of delirium. I was delirious briefly after a colonoscopy many years ago. I don’t remember much about it. But from what Sena tells me about it, it was similar to other delirium episodes I’ve seen in the hospitalized medically ill. Thankfully, it was not severe.

“Recalling the Experience of Delirium: The Delirium Experience Questionnaire (DEQ)

Have you ever been delirious and recalled the experience? Many patients do and they usually are frightened by the experience which can be marked by delusions and hallucinations that are remembered as fragments of a harrowing nightmare. This has been studied by Breitbart, et al using an instrument they developed called the Delirium Experience Questionnaire (DEQ). In the article there’s a description of the scale:

The DEQ is a face-valid, brief instrument that was developedby the investigators specifically for this survey study andassesses recall of the delirium experience and the degree ofdistress related to the delirium episode in patients, spouses/caregivers,and nurses. The DEQ asks six questions of patients who haverecovered from an episode of delirium including: 1) Do you rememberbeing confused? Yes or No; 2) If no, are you distressed thatyou can’t remember? Yes or No; 3) How distressed? 0–4numerical rating scale (NRS) with 0 = not at all and 4 = extremely;4) If you do remember being confused, was the experience distressing?Yes or No; 5) How distressing? 0–4 NRS; and 6) Can youdescribe the experience? This final question allowed for a qualitativeassessment of the delirium experience through the verbatim transcriptionof patients’ description of the experience (not reported inthis paper). In addition, spouse/caregivers and nurses wereeach asked a single question: 1) Spouse/caregiver: How distressedwere you during the patient’s delirium? 0–4 NRS; 2) Nurse:Your patient was confused, did you find it distressing? 0–4NRS. The DEQ was administered on resolution of delirium[1].

54% of patients recalled their delirium experience. Perceptual disturbances were among the best predictors of recall. Delusions were the most significant predictor of distress. Patients with hypoactive delirium were just as distressed as those with hyperactive delirium. Mean distress levels for patients were rated at around 3 by patients and their nurses and close to 4 by family members.

In another more recent and similar study using the DEQ, the numbers were even more sobering. 74% of patients recalled being delirious and 81% reported the experience as distressing with a median distress level of 3[2].

In my work as a consultant, I’ve interviewed many patients who are delirious and their relatives and friends, who suffer as well from the experience of watching someone they love suffer from delirium. It’s very difficult to watch this kind of mental torture caused by medical disorders and medications.

The 6^th question of the DEQ often produced accounts that sound terrifying. The point of the article was that the subjective report of delirium sufferers confirms that the distress levels are very high indeed and remind us of the major reason for developing systematic methods of preventing it or detecting it early and managing the syndrome—reducing suffering.”

1. Breitbart, W., C. Gibson, and A. Tremblay, The Delirium Experience: Delirium Recall and Delirium-Related Distress in Hospitalized Patients With Cancer, Their Spouses/Caregivers, and Their Nurses. Psychosomatics, 2002. 43(3): p. 183-194.

2. Bruera, E., et al., Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer, 2009. 115(9): p. 2004-12.

Informal Bedside Tests for Delirium

Most of this post is an updated redux from years ago about an informal bedside test for delirium called the oral trails test. I learned about it from my senior resident when I was a junior psychiatry resident in training at the VA Medical Center.

There was an elderly patient admitted to the psychiatry unit who was thought to be psychiatrically ill but who actually seemed confused to me and the senior resident. We consulted medicine in order to get him transferred to the general medicine unit but it was tough going. I think the medicine resident disagreed with our clinical impression that he was confused and didn’t think medical transfer was necessary.

Anyway, my senior resident showed me her version of the oral version of the mixed Trails A and B Test for executive function. There is a written form which is part of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). First, she asked him to count from 1 to 7; then she asked him to recite the letters of the alphabet from A to J. She then asked him to try reciting those letters in alternating sequence. Of course, he failed miserably and was eventually transferred to internal medicine. The Trails actually is a paper and pencil test and it looks like a dot to dot game, like the example below:

My senior resident told me she learned the oral Trails test from her senior resident and couldn’t remember anything else about it. I used the test for years but a neuropsychologist criticized the practice, questioning the test’s validity, and rightly so.

Of course, I’d been doing it wrong. You’re supposed to have the patient count to 25, then recite the letters of the alphabet, then recite the numbers and letters in alternating sequence from 1 to 13 and A to M. More than two errors in pairings indicate cognitive impairment.

There are limitations to the verbal Trails and caution is advised in more recent literature, indicating that there are moderate education effects in older patients and that it may be wiser to use both paper and pencil and oral versions together.

Still the search goes on for quick and dirty ways to screen for cognitive impairment in the elderly because this and advanced age are two main risk factors for delirium.

Nowadays, I do the Mini-Cog (shown in the video below) or the Single Question in Delirium (SQiD) test, which just involves asking a family member if the patient seems confused lately.

References:

Mrazik, M., Millis, S., & Drane, D. L. (2010). The oral trail making test: effects of age and concurrent validity. Archives of clinical neuropsychology: the official journal of the National Academy of Neuropsychologists, 25(3), 236–243. doi:10.1093/arclin/acq006

Ricker, J. H., & Axelrod, B. N. (1994). Analysis of an Oral Paradigm for the Trail Making Test. Assessment, 1(1), 47–51. https://doi.org/10.1177/1073191194001001007

Sands, M., Dantoc, B., Hartshorn, A., Ryan, C., & Lujic, S. (2010). Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 24(6), 561–565. https://doi.org/10.1177/0269216310371556