Delirium

Introduction: Over one-third of older people with unplanned admissions to hospital are frail, but data on the burden of delirium, dementia and other cognitive frailty are lacking. Reliable hospital-wide and specialty-specific prevalence estimates are needed for service-planning including understanding the role of non-geriatricians in caring for this population.

Methods: ORCHARD includes pseudo-anonymised EPR data for consecutive admissions with a length of stay of >1 day (2017-2019) to four hospitals in Oxfordshire (population=800,000). Data are collected using a standard cognitive screen comprising dementia history, delirium diagnosis (Confusion Assessment Method-CAM), and 10-point Abbreviated Mental Test-AMTS that is mandated on admission for all patients >70 years. Cognitive frailty was defined as delirium, diagnosed dementia, delirium+dementia or AMTS<8 without delirium/dementia. We analysed the ORCHARD data to determine the prevalence of delirium/cognitive frailty trust-wide and by specialty (n=29 with >50 admissions).

Results: Among 51,202 admissions with mean/sd age=82/7 years and Hospital Frailty Risk Score=8/6, any cognitive frailty was present in 34.5% (95%CI 34.0-34.9%; n=17,466) of which delirium accounted for 14.6% (n=7,411), delirium+dementia=9.4% (n=4,757), dementia=7.5%, (n=3,784), AMTS<8=3% (n=1,514). The prevalence of cognitive frailty in general medicine, general surgery and trauma/orthopaedics, which accounted for 80% of admissions (n=41,016), was 41% (n=13,879), 21% (n=801) and 35% (n=1,304) in each, respectively. The prevalence was 44% in geriatric medicine admissions (n=133/301), 36% in palliative (n=128/356), 29% in stroke (n=135/468), 27% in infectious disease (n=41/152), 22% in neurosurgery (n=154/702) and 10-20% in all other specialties except two. Delirium was the most prevalent form of cognitive frailty in 24/29 specialties.

Discussion: Cognitive frailty is common in older unplanned hospital admissions across a broad range of specialties, with delirium accounting for most cases. Our findings support the need for hospital-wide and specialty-specific training and service development to reflect the needs of these older complex patients and increased emphasis on delirium in policy.

Background

Delirium is associated with psychological and cognitive complications that have impacts beyond the patients. Although family members and carers can play a significant role in the management and recognition of delirium, there is limited research on the experience of family caregivers in the context of delirium. This study aims to explore the needs and experiences of family caregivers for a person with delirium and offer suggestions to support them.

Method

A qualitative interview study with family caregivers of persons with delirium. Data were analysed using an abductive analysis approach.

Results

Fourteen family caregivers were interviewed. Carers explained their feeling of responsibility to support their loved ones with delirium, however, they perceived their caregiving role negatively because of increasing demands and the lack of sufficient support. Carers attributed their emotional exhaustion and distress to the onset of delirium, change in the personality of the person with delirium, confusion and progression of delirium. Additionally, carers indicated the negative impact of caregiving on the quality of the relationship between them and person with delirium. This highlights the need to enhance the support provided to carers to mitigate the emotional and relationship impact of caregiving on the carer. We identified needs of carers for people with delirium including: education on delirium, reassurance, information on care pathways and support from formal carers to take breaks.

Conclusions

Viable solutions to assist family caregivers include more support for the carer in formulating care plans for people with delirium, development of support groups for family caregivers of people with delirium, and a case worker. These solutions may help to decrease re-hospitalisation and admission to care homes. Future research should focus on approaches to better support carers of people with delirium, and to shift the care plan from person-centred into person and family-centred approach.

Introduction

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

Methods

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

Results

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. 151 met inclusion criteria and were included in the final review. Much of the literature focusing on hospitalised participants (n=140) explored MLTC as a risk factor for delirium (n=125). Fewer studies explored the impact of MLTC on delirium presentation (n=5), duration (n=3) or outcomes (n=6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n=107/151) and Confusion Assessment Method (n=88/151), respectively.

Conclusion

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Introduction: Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimize assessments and investigations by implementing the Delirium Bundle.

Methodology: A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilized. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions.

Results: In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a hematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a hematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done.

Conclusion: The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

Introduction 

The National Hip Fracture Database (NHFD) is the mandatory national clinical audit for patients presenting with hip fracture. Since 2007, the NHFD has made admission cognitive assessment using the Abbreviated Mental Test Score (AMTS) routine for people presenting with this injury. In 2024, the NHFD plans to replace the AMTS with the 4A test (4AT), so all patients are additionally assessed for delirium on presentation. This study aims to compare the AMTS and 4AT for this patient group, so the NHFD and our local team can anticipate the consequences of this change in patient assessment.

Methods

The clerking house officer completed both AMTS and 4AT for patients admitted consecutively under the ‘femur fracture pathway’ to University Hospital Wales between August-October 2023. We classified an AMTS < 8 and 4AT = 1-3 as suggestive of cognitive impairment. A 4AT ≥ 4 also indicated possible delirium.

Results

A total of 100 patients were included, 65 female and 35 male. 4AT was normal (0) in 67/75 patients with normal AMTS (8+). 4AT was abnormal (1+) in 24/25 patients with abnormal AMTS (<8). Screening with 4AT highlighted possible delirium in 15 patients (15%) which may not have been identified by AMTS. Four questions from AMTS form the ‘AMT-4’ sub-domain of 4AT. AMT-4 was normal (0) in 73/75 patients with a normal AMTS, and abnormal (1+) in 22/25 patients with an abnormal AMTS (sensitivity 0.88, specificity 0.97).

Conclusion

The 4AT provides invaluable training in delirium recognition for junior doctors, and highlights aspects of cognition (such as delirium) missed by the AMTS whilst being a quick, user-friendly tool. The AMT-4 subdomain of 4AT proved remarkably consistent with full AMTS results. Our findings are being integrated into local clerking protocols and used by the NHFD in its redesign of cognitive screening nationally.

Introduction: Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness. This has serious consequences including the increased risk of dementia, death, length of hospital stay and increased chance of new admission to long term care. Therefore, prompt identification and management is essential. NICE recommends the use of the 4AT score in identification of delirium to improve subsequent management.

Methodology: A retrospective descriptive study was done identifying all patients admitted to Wigan infirmary who received a 4AT during the 1/4/22- 30/9/22. Patients were excluded if aged 64 4AT score of 1-3 (a score over 4 is positive for delirium) and had multiple admissions. This reduced the sample size to 275 from 8648 patients, of these data was collected from the individual electronic records from the first 110 patients.

Results: The average age of patients within the sample is 81, average 4 AT score of 6 and the average CSF was 5. There was a diagnosis of delirium in 32 (29%), and 'confusion' in 10 (15%), a past medical history of dementia in 49 (45%) and cognitive impairment/ suspected dementia in a further 10 (9%), PD was found in 9 (8%) of patients. A basic blood test screen to identify a cause for delirium was done in 50 (45%) of patients. DNA CPR was present in 59 (54%) of patients, and a DOLS in 43 (39%) during the admission reviewed. Patients were on a significant number of medication (mean of 10 on discharge) and had an average of 3 ward moves. Length of stay was 20.3 days and 51 (46%) were deceased within a year of admission.

Conclusion: Embedding 4AT in electronic records improves recognition of delirium. Further work will be undertaken to improve management of this condition once it is recognised.

Introduction

Improving delirium screening in hospital patients is a recognised important goal to improve patient outcomes, with consequences of delirium including increased mortality, falls, length of stay and dependence on discharge. We undertook a rolling audit over 8-years to examine the use of screening tools to identify delirium and how many cases of delirium were potentially missed in acute medical inpatients in a District General Hospital.

Methods

4 cycles of audit were completed over an 8-year period (2015–2023) through a snap-shot prospective review of all acute medical inpatients aged over 65 years during a 24-hour period.  The medical records were examined for admission delirium screen and the delirium documentation within the first 48 hours. Where a diagnosis of delirium had not been made, the notes were reviewed to see if an inference of delirium during this period could be made.

Results

A total of 873 patient notes were reviewed between 2015–2023. The completion rate of screening for delirium increased to 87% in 2023 (2015/2017/2019=3%/13%/69%). Overall, the diagnosis of delirium that was explicitly stated in the notes (made via CAM/4AT or clinical assessment) similarly increased to 32% in 2023 (2015/2017/2019=10%/22%/12%). However, in the recent results a delirium diagnosis was potentially still missed in 10% of cases, though this similarly had improved from prior years (2015/2017/2019=18%/13%/26%). Overall, in hospital the number of patients >65 admitted under the care of medicine with delirium in the initial 48 hours has remained constant since 2015 between 30%-42%.

Conclusions

A significant improvement in the screening for delirium has occurred between 2015 to 2023 due to multiple changes: electronic notes, pop-up notifications, obligatory completion and change from CAM to 4AT.  Reassuringly, the potential missed cases of delirium have reduced also.

Background: Delirium is a fluctuant clinical syndrome caused by an underlying condition not better explained by a pre-existing neurocognitive disorder. Clinical presentation is characterised by alterations in attention, cognition and consciousness. It is categorised into hyperactivity and hypoactivity based on behaviours displayed. 25% of elderly patients are diagnosed with a delirium on admission to hospital. Delirium is associated with a 70% mortality rate 6 months post discharge. R.A.D.A.R is a 3 part questionnaire recommended by NICE to use as a daily screening tool to aid early diagnosis of delirium.

Aims: Initiating mandatory use of R.A.D.A.R  questionnaire during nursing drug rounds to increase early detection of delirium during inpatient COTE admissions.

Methods: R.A.D.A.R questionnaires were completed by nursing staff during daily drug rounds for four weeks.Patients scoring 1 or above were screened using 4AT and referred to dementia and delirium outreach team (DDOT) as appropriate.Data collected was analysed to assess sensitivity of R.A.D.A.R in detection of acute delirium.

Results:R.A.D.A.R proved sensitive detecting delirium and/or known cognitive impairment recognising 35 patients known to DDOT. It highlighted 7 patients at end of life or with advanced dementia. R.A.D.A.R identified 8 new diagnoses of acute hypoactive delirium over a 4 week period.

Conclusion: Initial detection of delirium, completion of 4AT and referral to DDOT is done well. Reassessing patients throughout their admission could be improved. We recommend using R.A.D.A.R as a mandatory part of nursing evaluation as it has proved sensitive and efficient in detection of new delirium.

Introduction:

Delirium is a common presentation in older people and associated with falls risk, longer inpatient stay, post-discharge institutionalisation, accelerated cognitive decline and higher mortality. While median duration of delirium is reported as 1 week but for one third patients, symptoms may persist 3 months or more, even a proportion of patients will never fully recover to their pre-delirium cognitive baseline.  It is essential we are sharing the diagnosis with people and their relatives in order to provide information, facilitate discussions around the risks of hospital versus home, reduce distress and highlight the role that carers play in delirium management. Physicians should be aware that delirium sufferers often have an awareness of their experience and for affected person and their family, delirium can be a cause of significant distress. Identification of risk factors, education, and a systematic approach to management can improve the outcome and experience of the syndrome [1].

Aim: To provide delirium education and Improve documentation up to 95 % in GAU.

Methodology:

• Prospective data collection.
• Jan 2023 to March 2023.
• Monthly data analysis of 20 patients in GAU with the confirmed diagnosis of delirium.

• PDSA 1 Departmental teaching and SIGN delirium leaflet awareness and availability .
• PDSA 2 Poster as Visual prompt.

Results:

 After 2 PDSA cycles, we noticed significant improvement in delirium education and documentation up to 95%.  A further Qi project is ongoing to embed the TIME bundle within our daily practices which will hopefully ensure that this improvement is sustained by giving another prompt to discuss and document diagnosis. 

Conclusion:

 Along with prompt diagnosis and management, good educational approach and clear documentation will lead to improve understanding about delirium, reduce distress and facilitate safe early discharge.

Reference

Healthcare Improvement Scotland SIGN

Risk reduction and management of delirium

March 2019

Introduction

• Delirium is common in hospitalized older patients. It is associated with increased mortality, poorer functional outcomes and increased length of stay.
• It has also been shown to be positively associated with level of co-morbidity in older postoperative patients.
• The aims of the study is to assess the correlation between delirium and co-morbidity in older medical inpatients. It also aim to determine the effect of gender on this association.

Method:

• This was a prospective, cross-sectional analysis carried out as part of a Quality Improvement Project on screening for delirium in older patients admitted acutely on medical wards from 6th to 12th October 2022.
• Patients were included if they were 65 years and over.
• Exclusion criteria were patients younger than 65 years. Patients with incomplete data were also excluded from analysis.
• Patients were screened for delirium using the 4-AT screening tool which is well validated.
• In addition the patients’ co-morbidities were assessed using the age-adjusted Charlson’s Comorbidity Index(CCI).
• The SPSS 29 IBM software was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics. Pearson’s correlation co-efficient and linear regression analysis were used to calculate correlation.

Results:

• 233 patients in total were assessed - 119 males and 114 females.
• Median age was 79.4 years in males (Interquartile range – IQR – 11) and 83.5 years in females (interquartile range – IQR – 12).
• Overall mean age was 81.6 years (SD 8.1).
• The prevalence of likely delirium was 32.2 %.
• There was a statistically significant positive correlation between 4-AT and CCI  (r=0.236; p<0.001).
• This effect was stronger in male than female patients (r=0.275, p=0.002 vs r=0.197;p=0.035 ; respectively).

Conclusion:

• There was a statistically significant positive correlation between elevated 4AT score and CCI in acutely hospitalized older medical patients. This correlation was stronger in males.

  • The association needs more studies to validate these findings.