A Call to Action for More Dedicated Research into Delirium of the Incarcerated

Abstract

Delirium is a common mental health condition encountered in hospitals that increases mortality, hospital length of stay, and healthcare costs. Incarcerated individuals have higher rates of known risk factors for delirium, including mental and physical illness, psychological distress, and stigmatization and may be at increased risk of developing the condition. Despite this, there is a paucity of research in this specific area of psychiatry. We identified ethical concerns, feasibility with the electronic medical record, and stigmatization as reasons why adequate research into this population is limited. Nevertheless, we call on more dedicated research into delirium within the incarcerated population to enhance better care practices and advocate for these patients.

1. Background on Delirium

Delirium is a clinical syndrome that usually presents as an acute change in attention and awareness that develops over a relatively short time interval and associated with additional cognitive deficits such as memory deficit, disorientation, or perceptual disturbances [1]. It is a manifestation of acute encephalopathy and has been referred to as altered mental status, acute brain dysfunction, and other names throughout time [2]. Delirium most often is associated with an underlying condition that precipitates the presentation such as acute medical illness, adverse drug reactions, or infection [3]. Delirium most often occurs in older patients, with a recent meta-analysis finding its prevalence to be around thirty-six percent in older hospital patients, but previous research has shown prevalence of up to eighty percent [4,5]. In patients who have suffered traumatic brain injury, the prevalence is around sixty percent [6]. Although a transient condition, those with delirium maintain a higher risk of long-term cognitive decline, likelihood of mortality within 30 days of hospital discharge, and risk of subsequent emergency department visits and hospital readmissions [7,8].

Worldwide, the incarcerated population is a historically marginalized and large population encompassing close to eleven million people [9]. In the United States, one of the largest contributors to this population, the number is approximate two million people in prison or jail [10]. A majority of these incarcerated individuals do not receive adequate healthcare, including many, who maintained a previous mental health diagnosis, report losing access to their psychiatric medication at the time of their arrest [11]. Additionally, it has been found that every year of incarceration is correlated with a two-year loss of life expectancy [12]. These social factors within the prison system have led to health quality inequity when incarcerated persons seek healthcare, and these discrepancies are exacerbated by gender and socioeconomic status [13,14]. In the intensive care setting, incarcerated individuals face additional barriers due to the acuity of their presentations, decreased capacity for medical decision-making, and lack of healthcare privacy [15].

It is not surprising to learn that the incarcerated population exhibits many risk factors for delirium, and with the previously noted disparities in the delivery of their healthcare, may be at increased risk of developing it. Despite this, little research on the topic has been conducted. Only one study, to our knowledge, has attempted to investigate the incidence of delirium in the incarcerated population within the United States. In this study, the researchers found no difference in delirium incidence between the incarcerated population and general population [16]. They do note that these results are limited by a small sample size and the heterogenous use of ICD codes amongst providers. They also believe that the true incidence is probably higher and that many cognitive disorders are likely underreported in this group [16]. Nevertheless, we feel compelled to ask the following: Why has only one study been published regarding a population that appears to be at significant risk of delirium? This write-up intends to discuss this disparity. This paper is a perspective piece that will discuss the need for increased awareness and dedicated research into delirium within the incarcerated population. This paper does not aim to propose direct solutions or interventions for delirium in incarcerated individuals. Instead, we hope to highlight critical gaps in our understanding of delirium in this population and explore the structural and systemic barriers that have prevented meaningful research from being conducted. Rather than conducting a systematic literature review, this perspective will discuss existing literature and will advocate for research initiatives and potential personal, institutional, and policy solutions, while describing barriers that teams may face when attempting to conduct research on this population. This paper aims to encourage future psychiatric research teams to develop studies and systemic changes to improve understanding of delirium for the incarcerated, a population that is particularly vulnerable to mistreatment and exploitation.

To advance research in this topic, this paper will outline key research questions the authors have identified that remain unanswered and should be prioritized in future studies. We will then examine the existing literature on delirium and discuss how the existing literature suggests an underappreciated risk of delirium in the incarcerated population. We will end with an exploration of barriers that make researching these questions challenging and propose potential solutions to facilitate future research. Some of the key research gaps include:

• What is the true prevalence of delirium for incarcerated persons before or after admission to hospitals or psychiatric facilities?
• Are individuals who have been in prison for longer lengths of time at increased risk of delirium compared to those who were recently incarcerated?
• What conduct that occurs in correctional facilities may increase the risk of delirium within this population, including handcuffing, solitary confinement, or other restrictive practices?
• What screening tools, such as the Confusion Assessment Method (CAM), are the most effective and feasible within correctional facilities to monitor for delirium onset?
• What is the role of stigmatization within the criminal justice system and its impact on delirium risk and associated costs?
• What interventions have been used to reduce delirium incidence in high-risk populations, and can these interventions be applicable to the incarcerated population?
• What are the long-term cognitive, psychiatric, and functional outcomes for incarcerated persons who experienced delirium during hospitalization?
• How do gaps in the electronic medical record impact the ability for healthcare professionals to provide equitable and cost-effective care to incarcerated individuals who experience delirium?

These questions represent just a few of the many knowledge gaps that exist regarding delirium in incarcerated individuals. We hope these questions will help to guide and encourage future research inquiries and provide a useful foundation for teams that wish to conduct research on this population. Next, we will discuss recent existing research on delirium and how the associated risk factors suggest the underlying underappreciation of delirium risk in the incarcerated population.

2. Risk Factors for Delirium in Incarcerated Population

There are many risk factors for developing delirium. Every year, more research emerges identifying new risk factors that help to clarify what clinicians should assess in their patients. For example, older age, the use of sedatives, hypertension, a history of delirium, emotional disturbance, malnutrition, vision or auditory impairment, infection, sleep rhythm disorders, and pain were all found to be associated with the development of delirium [17]. A study conducted in 2023 identified older age, longer time spent in the hospital before admission to the intensive care unit, mechanical ventilation, sepsis, higher Mortality Probability Model II score, and central nervous system disease involvement as risk factors for delirium [18]. The researchers also observed that delirium was associated with higher intensive care unit mortality [19]. More recent studies have highlighted high pain scores, hypernatremia, higher Acute Physiology and Chronic Health Evaluation—IV (APACHE IV) scores, and higher Richmond Agitation–Sedation Scale (RASS) scores also increase the risk of delirium [20,21]. Regarding mental illness, a prior history of any kind of psychiatric illness puts one at higher risk of delirium, specifically a prior history of depression and anxiety [22,23]. Male sex, smoking or alcohol abuse, the use of restraints, and antipsychotic use were all found to be associated with delirium, as well [22].

Many of the above risk factors are more prevalent in the incarcerated population. The relevant literature will be discussed in the following paragraphs, and for the sake of organization, this paper will limit its literature review to major risk categories of delirium. These are age, physical illness, mental illness, and the use of restrains. Age is the first risk factor to be discussed. The prevalence of delirium is only one to two percent in younger adults but increases to as much as thirty percent in elderly patients [1]. While the median age of the general incarcerated population is slightly lower than the median age in the United States, it has increased dramatically in the last thirty years, rising from thirty to thirty-six years from 1993 to 2013 [24]. Additionally, there are four times as many incarcerated individuals aged 55 and older in 2013 as there were in 1993. This trend is thought to be caused by the increasing average age of the United States population, resulting in older individuals becoming incarcerated and younger prisoners who were arrested during the imprisonment “boom” in the 1970s growing older [25]. This rapidly aging population increases the cost of healthcare as older patients require closer health monitoring and more frequent hospitalizations [26]. These individuals are also predisposed to age-related health conditions including dementia, functional impairment, mental illness, incontinence, and delirium [27].

Next, as incarcerated persons have higher rates of physical and mental illness compared to non-incarcerated peers, additional scrutiny in identifying delirium and its risk factors is needed in this population. First, a look at the prevalence of physical illness in persons who have been incarcerated: A large meta-analysis found that incarcerated persons have an increased incidence of infectious illness like hepatitis C, hepatitis B, HIV, tuberculosis, and chlamydia [28]. A large survey conducted in the US found that prisoners had higher rates of many chronic medical conditions including diabetes mellitus, hypertension, prior myocardial infarction, asthma, and cirrhosis [11]. In New York state, those with more contact with the criminal justice system have higher chronic mental and physical health conditions, triple the number of hospitalizations, four times as many visits to the emergency room, and double the risk of overall mortality compared to those with less criminal justice system exposure. Notably, those with more exposure to the criminal justice system cost 12,000 USD more annually for inpatient hospitalizations, and total Medicaid expenditures are more than 33,000 USD or twice as much than for an individual without criminal justice exposure [29].

In regard to mental illness in incarcerated persons, it is well established that this population suffers from much higher rates of psychiatric conditions compared to the general population. One study found a mental disorder prevalence of 92.9% in their incarcerated population [30]. This was demonstrated in Spanish speaking countries as well [31]. Within this large prevalence, they found subcategories of conditions including alcohol abuse (40%), paraphilias (43%), and personality disorders (53.6%). Substance use appears to be the most common co-morbid psychiatric condition within the incarcerated population, with one study finding that half of all prison patients with either a psychotic or depressive disorder had a substance use disorder [32]. Another group found that incarcerated persons had a mental illness prevalence of 90.7% [33]. Within this number they found co-morbidities including substance abuse (87%), PTSD (23.9%), panic disorder (5.6%), generalized anxiety disorder (8.7%), bipolar disorder (11.1%), and more. Unfortunately, despite the overwhelming prevalence of mental illness in this population, many still face barriers when trying to access mental health services. Some of these issues include distrust in the system, lack of referrals, and perceived lack of access to mental healthcare [34].

Lastly, restraints and shackles are a source of frustration and controversy amongst providers, especially when caring for individuals who are imprisoned. Almost all incarcerated patients who are brought to the hospital are in some form of restrictive equipment. Many times, these are not removed for the entire hospital admission [35]. Using restraints in the hospital is a well-known risk factor for developing delirium, with the most relevant study finding a pooled significant increased risk of delirium by various studies over the last decade [36]. Delirium was also the most frequently encountered co-morbidity associated with the use of restraints, being more frequent than post-traumatic stress disorder, physical complications like abrasions, and neurofunctional decline [36]. The duration and number of restraints were both associated with an increased risk of becoming delirious [36]. Because patients who become delirious are also more likely to receive restraints, this can create a vicious cycle where the restraints are used to treat the physical risk of harm from the patient but also prolong the patient’s delirium [37]. Patients who are incarcerated almost always enter the hospital in restraints, have them on throughout the hospital stay, and leave in them. Although there are almost no data to support this, it can be speculated that these constant restraints, even when sedated and in end-of-life care, may increase the incarcerated individual’s risk of developing delirium, though there is promising research that techniques and policy like clinician–patient concordance may decrease the likelihood of delirium after the use of restraints [38].

With evidence that the incarcerated prison population is becoming older, exhibits a high prevalence of physical and mental illness, and is frequently restrained, all of which are risk factors for delirium, why is there a dearth of research on the topic? This is what the next section of this perspective seeks to discuss.

3. Call to Action: Barriers and Solutions to Researching Delirium in Incarcerated Population

Providers face many difficulties when attempting research on the incarcerated population. Some of these issues include ethical concerns, inadequacy of the electronic medical record (EMR) to deliver the needed information, and perceived stigmatization by providers and patients, alike. We will tackle these issues one at a time. The first regards the ethical problems when conducting research on incarcerated individuals. The ethics of research involving persons who are imprisoned is a long-standing academic dilemma because incarcerated persons are at an increased risk of exploitation and abuse due to their lack of freedom [39,40,41,42]. Therefore, their ability to meaningfully consent to research practices can be less than informed, and confounding issues including learning disabilities, language differences, and literacy barriers add additional challenges to ensuring that incarcerated persons understand what the research entails [39]. With the Belmont report in 1979, protections for research participants in an ethical sense were advanced, including providing protections for vulnerable populations like the incarcerated [43]. However, this does not mean that research on imprisoned persons is perfect, and imprisoned people still face ethical challenges today. The most notable way this happens, paradoxically, is that because of the perceived barriers and over-regulation of conducting research on prisoners, many researchers opt to conduct research on non-prisoners instead [44]. This leads to a lack of research conducted on prisoners, which may negatively impact their health. This may be happening with delirium in the incarcerated population. For example, validated screening tools such as the 4 ‘A’s Test (4AT), CAM, and the Nursing Delirium Screening Scale (Nu-DESC) have been widely used for high-risk populations [45]. However, these tools have not been specifically validated for use in incarcerated individuals, leaving uncertainty for their applicability within this population. While these screening tools may still be effective in screening for delirium, no study has been conducted to fully assess the generalizability to incarcerated persons. This represents a critical research gap that may in part be due to researchers opting to conduct research on non-incarcerated persons due to the ethical constraints that emerge when starting research on incarcerated populations. A possible solution may be to ensure the proper documentation of benefits, risks, consent, and total participants whenever one wishes to conduct research on an incarcerated individual. The facility where the research is conducted should attempt to include translators and a translated paper that assists in the understanding of the study trial. It may also be useful to have protocols that allow for incarcerated persons to be reminded of the voluntarism of the research and ensure that they do not feel compelled, and easy-to-understand language of the research materials to ensure informed consent and understanding. Institutional review boards (IRBs) play a critical role in ensuring that the ethical standards of research be upheld, and the committees at institutions should be aware and well-informed of the ethical quandaries when conducting research on incarcerated persons [46]. However, the IRB should also be informed of the need for more research on this population, and another solution may be for institutions to expedite research proposals when the subjects are incarcerated persons. This way, the researchers would know if ethical guidelines were violated in a timely manner, and, if not, then research on incarcerated persons would be able to move more swiftly through the IRB process. Research proposals should be well-written and well-informed as this has been shown to benefit the rate of approval for IRBs. Trust from incarcerated persons and healthcare professionals is what will allow for more accessible and effective research. Ultimately, it is important to continue to include the incarcerated population in research because, in most cases, they are the ones in need of the benefits from successful clinical trials and future research.

Another potential barrier may be the nature of the electronic medical record (EMR). Most EMRs have protections on incarcerated persons medical record to protect their privacy. Unfortunately, this may increase the difficulty of documenting acute diagnoses, like delirium, across multiple specialties. This decreases the accessibility of the patient’s chart when conducting research at a future point in time. International Classification of Diseases (ICD)-10 codes are commonly used in the administrative tracking and financial reimbursement of diseases that providers encounter in the hospital [47,48]. For all their benefit, however, the use of these codes may impede the proper documentation of the diagnosis. These codes may prove unreliable because, many times, the selection and imputation of codes is up to provider preference. This causes diagnoses like delirium to fall under many kinds of names within the EMR. Acute delirium could be placed as delirium, but it could also be placed under psychosis, violent behavior, unspecified behavioral disorder, and more, which causes a non-standardized approach to documenting this behavior. When researchers go back into the EMR to attempt to conduct a retrospective study, it can be challenging to figure out which condition the provider used to explain what happened to their patient. A solution to this may be institutional protocols, which standardize ICD-10 code usage across providers, or researchers only evaluating psychiatrist diagnostic documentation for more accurate coding. Research has shown that non-correctional healthcare workers know very little about healthcare within the correctional system [49]. So, a possible policy correction could be additional training for healthcare workers in hospitals with large amounts of incarcerated persons so that the hospital healthcare workers are aware of the types of documentation and coding that occur in the correctional facility, thereby decreasing the potential heterogeneity of ICD-10 codes when the patient arrives at the hospital. This will decrease complications when attempting to conduct retrospective analysis of patients who present from this correctional facility. One other possible solution is conducting research in a prospective, longitudinal manner, thereby decreasing the likelihood of bias when professionals input ICD-10 codes and increasing the likelihood of working in tandem when producing research.

Finally, stigmatization and bias impact the ability for incarcerated persons to receive equitable care and is an issue that healthcare systems still wrestle with. There are many definitions of stigma, and ongoing research seeks to determine how stigma is conceptualized and measured as a psychological phenomenon [50]. One such definition from the World Health Organization is “a sign of shame, disgrace or disapproval that results in an individual being rejected, discriminated against and excluded from participation in a number of different areas of society.” [51]. Martin et al., 2020 introduced the first review of stigma and its impact on the health of those in the criminal justice system [52]. They focused on literature surrounding stigma and healthcare in the criminal justice system with an emphasis on the United States. The researchers found that stigma directly and indirectly influenced the quality of care those in the criminal justice system received, which negatively impacted young African American men the most [53]. Perceived stigma decreases the likelihood of healthcare utilization, increases the risk of substance use relapse, and causes psychological and physiological distress, among other negative outcomes [53]. Another contributing factor to stigmatization is chronic illness. The diagnosis of a chronic illnesses increases the risk of becoming stigmatized, and with a prevalence as high as 80–90% of the prison population being diagnosed with a chronic illness, their likelihood of incurring stigmatization and mistreatment increases dramatically [11]. Once incarcerated persons leave the criminal justice system, self-stigmatization from incarcerated persons themselves may make it difficult to re-enter society and makes seeking healthcare services less desirable, further impacting quality of care even when released from prison [42]. This is just a small sample of the available literature on the negative effects of stigmatization, and it is important for clinicians to be aware of their own stigmatization and bias, lest it impacts their ability to deliver quality care. Providers rarely ask about incarceration history, but incarcerated persons coming from prison to the hospital do not have this anonymity, causing a higher likelihood of stigmatization from providers [11]. Many times, prisoners do not feel respected or heard by their caring providers, and this manifests, especially in male incarcerated persons, as suicide and violence [54]. This is a population that, in most cases, feels that they cannot advocate for themselves. Clinicians should feel empowered to advocate for their patients, especially in instances like acute delirium where the patient is unable to attend to his or her own needs and wants. Ahad et al., 2023, identified four ways to decrease stigma within a psychiatric context, and we feel that these solutions are relevant here, as well [51]. The first is improving the awareness of stigma and dispelling myths surrounding those who are stigmatized, like incarcerated persons. This may include social media campaigns, the use of clinicians using their voices to speak out about incarcerated healthcare, and teaching classes to students and young learners. Next is cultural competency training, and this could include providing new healthcare professionals with modules and other methods of learning about incarcerated persons, their physical and mental healthcare, and equipping them with knowledge and skills to combat misinformation. Thirdly, the researchers identified peer support groups as a way to decrease stigmatization. In the correctional community, this could be providing more opportunities for incarcerated persons to interact in supervised but open communication and reduce perceived “otherness” amongst themselves and for the correctional workers. Finally, they identified community-based services, such as service providers that may come to correctional facilities, as ways to decrease perceived stigma and have incarcerated people feel more in-touch with the community. For those who are incarcerated, this is a very serious issue, and despite the lack of research on this topic, clinicians should proudly speak up about the risks incarcerated persons face. This increasing awareness of the importance of promptly diagnosing delirium in all patients, but especially vulnerable populations like the incarcerated, could save lives and resources in the long run. Delirium increases healthcare costs dramatically, with an almost 20,000 USD increased 30-day cumulative cost to the hospital when it occurs [55]. Another study found that delirium costs the hospital almost 6000 USD per patient due to the additional length of stay [56]. Stigmatization only increases these costs through decreased participation in treatment plans and re-presentation to the hospital [57]. In summary, stigmatization for the incarcerated negatively impacts healthcare outcomes, and it is important for providers to be aware of bias to afford these individuals the care they need and deserve, especially in cases of delirium where patients are unable to advocate for themselves.

4. Conclusions

Delirium poses a significant yet poorly understood risk to the incarcerated population, a group known for disparate physical and mental health outcomes. To the author’s knowledge, only one study has explicitly sought to understand the prevalence of delirium in this population. This perspective sought to understand why only one study has been conducted on this clinically relevant topic. We first identified eight research questions that represent current knowledge gaps in our understanding of delirium within the incarcerated population. These questions are meant to be foundational research questions for clinical groups seeking to begin research on delirium within the incarcerated population.

Then, we examined the existing literature on delirium in general. Delirium is associated with many risk factors including age, chronic medical conditions, previous psychiatric diagnoses, sudden severe illness, mechanical ventilation, the use of restraints, and more. These risk factors for delirium are found to occur at much higher rates within the incarcerated population, suggesting that the incarcerated population suffers from delirium at a high rate that is yet poorly understood and underreported. It also presents a higher risk of mortality and morbidity, and significantly increased healthcare costs. Thus, determining the incidence of delirium within the incarcerated population would benefit clinical teams and legislative leaders immensely, yet little to no research has been conducted on this issue.

Therefore, we identified that the lack of research in this population may stem from issues including ethical concerns, challenges with electronic medical records, and stigmatization. Ethical concerns include the increased risk of exploitation and vulnerability within the incarcerated population due to a loss of autonomy and anonymity, and concerns for lack of informed consent. To address this, we discussed using translators and easy-to-understand language, expediting IRB review, and building trust between healthcare professionals and incarcerated persons. Challenges in the electronic medical record stems from the non-uniform use of ICD-10 codes, which makes conducting retrospective research challenging on incarcerated persons as they may visit many different facilities for healthcare. To address this issue, we explored institutional policy to make ICD-10 implementation uniform across facilities, hospital training to increase awareness of how healthcare is conducted within the correctional system, and the use of prospective research. Finally, stigma is a relatively well-known issue within the healthcare field, especially for vulnerable populations like incarcerated persons. We identified solutions including advocating for anti-discrimination legislation, increased social contact of incarcerated, and improving awareness of mental health issues within the incarcerated community.

Despite these concerns, understanding and addressing delirium in this marginalized group is crucial for improving patient outcomes and reducing healthcare costs. This call to action emphasizes the importance of dedicated research to fill these knowledge gaps. Prioritizing this research will lead to better care practices and enhanced advocacy in this vulnerable population, ensuring that incarcerated individuals receive the comprehensive care they deserve.