Delirium

Background: This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction: Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method: An initial audit measured delirium prevalence using 4AT in patients aged >65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. Staff answered questionnaires relating to delirium awareness and screening. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented, and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results: 36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion: Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.

This Quality Improvement Project (QIP) addressed the pressing need for increased awareness of delirium among patients' relatives. With a 26% rise in the elderly population in Cambridgeshire, surpassing the 18.6% national average, the project provides crucial information to enhance patients’ relative's access to information about delirium, a condition affecting up to 50% of older hospitalised patients. This prospective QIP was conducted across seven Cambridge University Hospital (CUH) geriatric wards. Qualitative surveys determined delirium awareness, understanding, interest and perception of information availability among patients’ relatives with delirium. Measurements included data on the views of online Trust delirium information. Interventions included designing a new eye-catching delirium information poster with a QR code linked to the Trust delirium information leaflet, strategically placing QR code-enabled posters in the wards, awareness campaigns targeting healthcare professionals, liaison with the inpatient Dementia team, and targeted communication at Dementia and Delirium Champion training sessions for nursing and healthcare staff. Pre and post-intervention questionnaires, involving 13 relatives visiting these wards, showed a 16%, 10%, and  20% respective increase in respondents' awareness, understanding, and interest in delirium. There was a 29% increase in awareness of location of delirium information on post-intervention. After the interventions, views of the Trust delirium website increased by 132%. Cycles of the QIP highlighted the importance of laminated posters to comply with infection control measures and the need of liaison with ward teams about strategic poster placement. In conclusion, this QIP successfully demonstrated the effectiveness of QR code enabled access to patient/relative information and that a multi-faceted approach is required to facilitate effective information provision. We also demonstrated these measures increased delirium awareness in the relatives. Future recommendations include continuous monitoring of the availability of posters within clinical areas, content evaluation, and work with the Dementia team to roll this out to all wards with older people within Trust.

Background Delirium is an acute impairment of attention and cognition, precipitated by physiological stressors (Wilson et al., Nature Reviews, Disease Primers, 2020, 6(1)), associated with adverse outcomes (Huraizi et al., Journal of Clinical Medicine, 2023, 12(16), p. 5346) and often under-diagnosed in hospital (Lochlainn, Frewen and Bryant, Age And Ageing, 2018, 47(suppl_5), pp. v1–v12). Integrating early assessment into clinical practice is vital (Hopper et al., Geriatric Medicine GIRFT, 2021). This project assessed compliance with delirium guidelines from the National Institute for Health and Care Excellence (NICE) and Geriatric Medicine Getting It Right First Time (GIRFT), and introduced a cost-effective, easily embedded ward-based intervention to improve adherence. Methods This single-centre, retrospective observational audit was conducted on a 28-bedded Acute Senior Health Unit (ASHU) at our hospital. A previous cohort of trainees demonstrated statistically significant improvement in formal delirium assessment using education-based interventions (Cycle 1; C1). We re-audited the sustainability of this change and consequently introduced a digital admission proforma (Cycle 2; C2) to expand on this work. This incorporated the 4-AT assessment and prompting completion of an electronic assessment. This proforma’s impact was evaluated. All data was anonymised. Results 71 patients were included in C2. Re-audit of C1 showed a decline in patients receiving a formal delirium assessment with 4-AT (56.6% to 8.3%), while delirium diagnoses increased (27.6% to 66.7%). Following proforma introduction, delirium assessment increased (8.3% to 34.0%, p<.05) however this was associated with a concurrent decline in formal delirium diagnoses (66.7% to 44.7%). conclusions an easy-to-access, low-cost digital intervention may be useful tool improve assessment. however, project demonstrates the challenges of sustaining change across multiple cycles and trainee rotations. single is unlikely ‘silver bullet’ aligning practice national guidelines. continual re-audit necessary ensure sustainability.

Introduction: Delirium is a common and reversible neurobehavioral condition with significant morbidity and mortality ramifications. Consequentially, clear guidelines exist pertaining to its swift identification and management. However, studies suggest adherence to these guidelines is poor. This audit evaluates compliance to the National Institute for Health and Care Excellence’s (NICE) delirium guidelines in an Acute Senior Health Unit (ASHU) and presents a single centre experience of low-cost ward-based interventions for improving guideline adherence.

Methods: A retrospective observational audit was conducted on patients admitted to ASHU between 01/07/2023 and 30/07/2023. Data on delirium assessments, diagnoses and causes of delirium were obtained through retrospective database searches. Posters and education based multidisciplinary team (MDT) interventions were designed and initiated following grounded thematic literature analysis and ward discussion. A methodically equivalent audit was then conducted between 01/09/2023 and 30/09/23. Data was anonymised and blinded and analysis was performed on SPSS V12.0.

Results: A total of 128 patients were included in the study. Initial audit revealed suboptimal compliance with NICE recommendations. Chi-square test of independence found that patients were statistically more likely to receive a full delirium assessment (1.9% vs. 56.6%, p=0.001) and formal diagnosis (5.8% vs. 27.6%, p=0.002) after the ward-based intervention.

Conclusion: This study provides limited evidence in favour of low-cost MDT based interventions for improving adherence to NICE delirium guidelines and provides a 5-step framework for future studies. This study also explores the potential patient implications of these interventions. A repeat audit should be conducted to ensure lasting and sustainable change is achieved. Trial registration/clinical trial number: AUDI003614

Introduction: Delirium is a common and serious complication in frail older patients undergoing emergency hip fracture surgery, often resulting in prolonged hospital stays, increased morbidity, and a greater risk of long-term cognitive decline. Recognizing and managing delirium effectively is critical in improving patient outcomes. However, initial assessments indicated variability in the confidence and capability of surgical postgraduate doctors to assess and manage delirium appropriately. A baseline survey revealed that 50% of staff were not familiar with hospital delirium guidelines, and 62% rated their confidence in managing delirium as 3 out of 5. Additionally, over one-third of staff inappropriately used the AMT10 as a delirium screening tool, and many lacked confidence in interpreting the 4AT score.

Method: To address these gaps, we implemented a multipronged educational program to improve staff knowledge and confidence in delirium assessment and management. This approach included formal teaching sessions, the display of delirium infographics in ward areas, and the dissemination of key information via email and WhatsApp. The program emphasized the appropriate use of the 4AT for screening and highlighted common delirium triggers and their management.

Results: Post-intervention analysis showed an improvement in both the confidence and accuracy of delirium assessment among staff. All staff were able to use the 4AT correctly, and everyone reported increased confidence in assessing delirium. Management practices revealed that pain, infection, constipation, and electrolyte abnormalities were generally well-addressed in patients. However, there remained a lower frequency of medication reviews, along with insufficient attention to nutrition and hypoxia as potential contributors to delirium.

Conclusion: Our educational intervention significantly enhanced staff confidence and competence in detecting and managing delirium in the trauma and orthopaedic ward setting. Following these improvements, the next phase of our project is to introduce a standardized delirium care bundle in the surgical setting. This care bundle aims to establish a structured approach to delirium management, thereby minimizing delirium-related complications and improving overall patient care.

Introduction:

Delirium, characterized by disturbances in attention and consciousness, is common in individuals with pre-existing medical conditions, particularly the elderly, but can affect people of any age. It can lead to significant morbidity, mortality, prolonged hospital stays, increased healthcare costs, and long-term cognitive decline. Despite its impact, delirium is often underdiagnosed and undertreated, underscoring the need for better diagnostic strategies. The 4AT tool, recognized by NICE, is valued for its rapid delirium assessment, unlike the AMT-10, which is more suited for chronic cognitive disorders.

Objective:

This study was conducted to assess the usage of the 4-AT tool in the assessment of delirium to aid in the early detection of delirium in the elderly population.

Methodology:

The retrospective review of medical records over six months was conducted and divided into two cycles to evaluate delirium assessment using the 4AT. Initially, data from 59 patients 49 at FPH and 10 at WPH established a baseline of 4-AT usage across the trust. Post-intervention, 60 patient records were reviewed to reassess 4AT usage. Interventions included: 1. In-person Training sessions in completing 4AT 2. Informative posters placed in ED and Medical wards (AMU and Elderly-care) 3. Continuous reminders to enhance early detection.

Results:

Before the intervention, only 6.8% of patients were assessed using the 4AT tool, 55.9% with the AMT, and 37.2% without assessment. Post-intervention, the overall assessment rate rose to 62.7%, significantly increasing 4AT usage. Among 28 delirium-diagnosed patients, only 14.3% were screened with the 4AT, indicating room for further improvement. Discussion and

Conclusion:

The increased use of the 4AT tool post-intervention highlights the effectiveness of educational initiatives in improving delirium screening. Early detection through the 4AT facilitates timely interventions and better patient outcomes. However, the small sample size and underutilization among diagnosed patients suggest the need for ongoing efforts to improve its usage.

Introduction: Wearable technology that continuously monitors physiological metrics has become increasingly popular and allows remote patient monitoring in virtual ward settings. Wearable technology has been shown to be effective in disease monitoring among younger adults. However, its use among older adults, including those with cognitive impairment, is yet to be explored. Aim: We aim to explore the acceptability of remote monitoring using wearable technology among older adults with delirium. Methods: Participants were recruited from an in-patient rehabilitation unit. Inclusion criteria included documented delirium and age over 65 years. Participants were enrolled until delirium resolved or until discharge. Wearable technology was worn continuously, except when being charged or the patient was washing. Device data was recorded every minute. Premorbid Barthel index and Hierarchical Assessment of Balance and Mobility (HABAM) was collected for each participant. Participants were assessed daily for delirium and mobility using the Memorial Delirium Assessment Scale and HABAM respectively. At point of discharge from the study, participants completed a questionnaire to gather feedback on their experience. Results: 20 participants were included, with a mean age of 83.0 years and an average premorbid Barthel’s index of 72. 6. Mean data capture from the wearable technology was 44.1% (12.8-65.8). None of the participants could independently manage the device. Three participants stated that the device interfered with their normal activities with five reporting the device uncomfortable to wear. However, nine participants stated they would wear the device again if asked to by a healthcare professional. Conclusions: Our findings demonstrate that wearable devices are tolerated by delirious older adults with delirium. We found that this group cannot manage these devices independently and need support from either a carer or healthcare professional. These results provides useful information to help pilot these devices among older adults with delirium in virtual ward settings.

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.

Introduction: Delirium is common in hospital inpatients, under-recognised, and associated with increased morbidity and mortality. NICE quality standards are that all at-risk adults newly admitted to hospital receive tailored interventions to prevent delirium.

Aims: 1. To reduce time to diagnosis of delirium. 2. For 100% of patients with delirium to have tailored interventions, including behaviour/ bowel/ food charts, medication reviews, and family involvement. 3. To increase junior doctors’ confidence in recognising and managing delirium.

Methods: Two changes were implemented and three cycles of data from inpatients on the geriatric wards were collected over an 8 week period. Qualitative data was also collected from doctors. The first change was teaching delivered to clinicians working in geriatrics. The second was implementing a new Delirium Bedside Bundle which was advertised in posters on the geriatrics wards.

Results: Data was collected from 60 inpatients, of whom 20 were diagnosed with delirium. The time to diagnosis was reduced from 3.5 days in cycle 1 to 1.6 days in cycle 3. There was an increase in documented medication reviews / cessation of sedating drugs from 0% in cycle 1 to 62.5% in cycle 3. There was an increase in family involvement from 60% in cycle 1 to 75% in cycle 3. Data collected from 19 junior doctors showed that confidence in caring for people with delirium increased from 57% to 92%.

Conclusion: Simple interventions such as teaching and implantation of an easy to use Bedside Bundle can positively impact recognition and management of delirium.

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.