From the total sample (N = 345), 65 patients (19%) developed ACS; 20 (31%) were female patients and 45 (69%) male patients. Forty-nine percent (49%) of the patients diagnosed as delirious by the Psychiatry staff had been misdiagnosed by the non-psychiatric consultees, whereas in fifty-one percent (51%) of the cases the diagnosis was correctly made by medical and surgical staff. It remains interesting to highlight though, that throughout the year 2010 the rate of under-diagnosis was higher than in the period January – June 2011. Psychiatry’s resident staff had been working throughout the year making use of each request to give medical house staff the indications for recognizing, managing, and treating ACS. After those interventions, the percentage of misdiagnosis diminished to 37% while correct diagnoses reached 63% [see Fig. 32.1a, b].

Patient study sample demographics included a mean age of 56.5 (range: 18–95), revealing a significant divergence between the periods January–December 2010 and January–June 2011. During the first period, the group which was mainly affected involved patients between 60–69 years old, with a lower peak that extended to the 50–59-year-old group. During the second period, the age range varied between 20 and 29, in direct relation with the increase of traumatic brain injury and substance abuse.

Among the “correct” referrals, 46% were diagnosed as psychomotor agitation, 18% as acute mental state, and 15% as sensoperceptive alterations. With regard to the “incorrect” requests, 19% were requests for assessment, approximately 40% were grouped as mood symptoms, and 13% demonstrated lack of adherence to medical treatment.

Taking into account that this disorder obeys organic etiology which, at the same time, determines the evolution and prognosis of the patient, it is of interest to recall that the most prevalent related diseases during 2010 were infectious processes (34%), malignant formations (15%), and kidney impairment and polytrauma (12%).

In 2011, the percentage of infectious processes remained in the first place, though to a decreased extent (26%), and polytrauma and substance abuse became the highlights (14%) (See Fig. 32.1a, b).

This study identified over an 18-month period, out of 345 patients, that 65 suffered from delirium. This was consistent with the bibliography [25], and what is expected for an institution with the characteristics of a polyvalent hospital whose population is around 55 years old. The patients come from a low cultural and income level, and carry multiple comorbidities which make them liable to polypharmacy.

The house staff that referred the patients to the Psychiatry Department included medical specialties that related to inpatient wards, for example, surgical specialties (General Surgery, Orthopedics and Traumatology, and Urology), the Intensive Care Unit, the Coronary Unit and the Emergency Department. Most request forms came from the medical staff, followed by the surgical staff, Orthopedics being the service to solicit the fewest request forms.

Taking the 18 months as a whole, the percentage of under-diagnosis reached 49%, in accordance with current bibliography [22]. Nevertheless, when split into two periods (January–December 2012/January–June 2011), a difference could be observed (Fig. 32.1a, b) between the two with regard to recognition of ACS.

This change may result from two elements. On one hand, the educational activity that the Psychiatry Department undertook towards the training of non-psychiatric house staff concerning screening and recognition of ACS, and on the other hand, to the fact that by January 2011 the resident doctors were going through the last third of their academic year, which means that they had probably gained many new skills and could provide a better semiological performance concerning this condition.

According to the correct referrals, confusional state (17%), sensory-perceptive alterations (15%), and psychomotor agitation (48%) had the highest incidence. On the other hand, among incorrect referrals, the highest were lack of adherence to treatment (15%), distress or anguish (19%), and request for assessment (23%). Circa 45% of referrals identified depressive symptoms when, in fact, it was a question of hypoactive delirium.

In many countries, the symptoms of delirium are attributed to dementia or depression, and a delay in correct diagnosis entails a longer stay and risks major complications [26].

A propos the psychomotor subtype, various similarities were found between the Provincial Centenary Hospital and other polyvalent hospitals with regard to the major incidence of mixed delirium [27]. This explains why this condition turns out so difficult to recognize, leading to mismanagement, a late referral to the specialized service, under-diagnosis, and under-estimation of a medical condition with high morbidity/mortality.