Delirium

Background:  

Delirium is common and experienced by 20% of all admissions to hospital1. Studies have shown a link between delirium and development of dementia2 but there are not many services to follow such patients up post-discharge. A new service has been developed at New Cross Hospital run by Care of the Elderly Consultants with an interest in Cognition.

Methods:

A delirium follow up clinic was designed to assess these patients after 6 to 8 weeks from discharge following hospital admission or reviews in Frailty. We set up a referral criteria for prolonged or recurrent delirium follow up. The clinic is run by a consultant and a registrar. A thorough history is taken and memory is assessed using the Addenbrooke's Cognitive Examination III or RUDAS. Data was collected and analysed from the clinic and the outcome was fed into an Excel sheet.

Results:

31 patients reviewed post admission with delirium, with 8 of those having a suspected cognitive impairment. 12 patients were diagnosed with dementia and 6 with Mild Cognitive impairment (MCI). The subtypes were as follows: Alzheimer's (2), Mixed Dementia (2), Vascular Dementia (6), Lewy Body Dementia (1), Fronto-temporal dementia (1) Only one patient had fully resolved delirium with no cognitive impairment. The rest of the patients had a diagnosis of BPSD (Korsakoff's) (1), ongoing reviews (4), cognitive impairment not quantified (6) and pseudodementia/depression (1).

Conclusion:

This service has ensured follow up for patients with delirium and has shown a significant relationship between complex delirium and MCI or dementia. It has provided a medium to diagnose, treat and signpost patients and carers for support with community services. Very few regions have such pathways in place and the services to follow up patients with delirium discharged from health care settings. This service offers quick and comprehensive follow-up for patients with concerns regarding cognition. 

Delirium is common especially in the older adult (≥65 years) and is characterised by disturbed consciousness, cognitive function or perception. It develops acutely, often has a fluctuant course and is associated with several adverse outcomes including increased length of hospital stay, increased mortality and increased incidence of developing dementia. Delirium is under-recognised, however assessment tools such as 4AT and abbreviated mental test score (AMTS) have been developed to help clinicians assess for the presence of delirium. The “TIME” bundle developed by Healthcare Improvement Scotland helps clinicians to think about underlying triggers for delirium. Baseline data collected from a care of the elderly ward showed that 26% (5/19) of patients aged ≥65 years had a delirium assessment tool used on admission. 42% (8/19) of patients were given a diagnosis of delirium on admission. Out of the 8 patients diagnosed with delirium, only 13% (1/8) of patients was assessed for urinary retention, 50% (4/8) for pain and constipation and 25% (2/8) had blood glucose measured. Several PDSA cycles were implemented including an educational session to promote early detection and management of delirium, poster detailing 4AT assessment and “TIME” bundle and use of a 4AT sticker in the medical admission booklet. The sticker was the most successful intervention as results showed 50% (13/26) of patients aged ≥65 years had a delirium assessment tool filled in on admission. For those diagnosed with delirium, assessment for urinary retention and blood glucose measurement improved to 78% (7/9), pain assessment improved to 67% (6/9) and 100% (9/9) of patients were assessed for constipation. In conclusion, this project has improved use of delirium assessment tools at the front door and when delirium is recognised, there is greater awareness of common underlying causes. Planned future cycles include a ward “delirium champion” to help with recognition and management of delirium.

Background

NICE and SIGN guidelines recommend screening of inpatients at risk of delirium using the 4AT (www.the4at.com) and communication of delirium to patients’ General Practitioners (GP). The aim of this audit was to establish whether delirium is currently being screened and documented, as recommended, in our Orthopaedic Trauma unit.

Methods

Data was collected by two junior doctors across four days (14/11/2022, 29/11/2022, 08/12/2022, 05/02/2023). Trauma and orthopaedic inpatients over the age of 65, who were more than four days post-surgery were included. Each patients’ medical notes, nursing notes, and drug Kardex was reviewed. Subsequently, all discharge letters available up until 8/2/23 were reviewed and documentation of delirium recorded.

Results

Forty patients were included in the study, of which, 29 (72.5%) were screened using the 4AT on both day-one and day-four post-operation. Of these 29 patients, 13 had delirium documented. Nine had a positive 4AT score and four had a negative 4AT score. One patient had documented delirium without a 4AT assessment. Of the 14 patients who had delirium documented, eight had delirium recorded on their discharge letter and four were yet to be discharged at the time of final data collection. Potential reasons for not using the 4AT included expressive dysphasia, review completed by a senior doctor using continuation rather than the proforma pages used by junior doctors, and documented confusion (unclear whether acute or chronic).

Conclusion

As per NICE and SIGN guidelines all patients with indicators for delirium (i.e. older trauma patients) should be screened for delirium using the 4AT. This audit identified a delirium screening rate of 72.5% in our unit. The majority of patients with delirium (8/10) had it documented on their discharge letter and thus was communicated to their GP. Further work to raise delirium awareness and confidence in delirium management in our unit is planned.

Introduction

Frailty is defined as “a condition characterised by loss of biological reserves, failure of physiological mechanisms and consequent increased risk of experiencing a range of adverse outcomes, including hospitalisation, longer length of inpatient stay, and delirium” [1-4]. We aim to investigate the association between baseline frailty and functional recovery amongst hospitalized older adults and its association with inpatient delirium.

Method

Retrospective analysis of patients admitted to a Geriatrics ward from August to November 2022. Interactions between clinical outcomes with age, length of stay (LOS), discharge destination, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated plus incidence of inpatient delirium.

Results

In total, 58 patients reviewed, mean age 78.8 (±15.1) years, 43 (74%) woman. 79% were admitted from their own home with 56% same discharge destination and 9% inpatient mortality. Median LOS in hospital was 13 days with 8 days on the Geriatrics ward. Mean CFS on admission compared to discharge was (4.9 vs 5.7 (p<0.001)), with no significant difference in CCI. There was a significant association between CFS and LOS, both overall and on the Geriatrics ward (P<0.001). 17 patients (29%) developed delirium, with increased LOS (45 days vs 9 (P<0.001)), increased CFS both on admission (5.9 vs 4.4 (p=0.002)) and discharge (7.4 vs 5.0 (p<0.001)) and were less likely to be discharged to their own home (33.3% vs 84.8% (p<0.001)).

Conclusion

Frailty is a powerful predictor for possible risk of deconditioning and is associated with longer acute hospital stay in our more vulnerable patients. The coexistence of frailty and delirium significantly increased the risk of a prolonged hospital stay. This indicates that a multidisciplinary approach to provide a comprehensive geriatric assessment, is necessary to decrease LOSand the incidence of adverse outcomes as during this time period we had limited specialist therapy staff on the ward

Introduction

Delirium is a common condition in older hospitalised patients causing high morbidity and mortality. The neurobiological basis for delirium is uncertain and, for numerous reasons, research in this area has been limited. Several recent studies have demonstrated that functional neuroimaging in delirium is achievable and has suggested that a brain region termed the default mode network (DMN), may play a cardinal role in delirium pathogenesis. We set out to develop a pilot study to demonstrate that it is feasible to undertake functional magnetic resonance imaging (fMRI) scans in older patients with acute delirium.

Methods

Observational pilot study obtaining a fMRI scan of inpatients in an Australian, tertiary hospital, geriatric ward. Eligible patients diagnosed as delirious by a geriatrician were compared against non-delirious controls. Informed consent was obtained. A novel scanning paradigm was developed. Sequences assed brain structure and functional networks in resting state and during a simple task of sustained attention and response inhibition.

Results

11 participants have been scanned. 6 participants were delirious: mean age 81 years (range 77 – 85 years), 3 female. 5 participants were non-delirious: mean age 83.4years (range 79 -90 years), 2 female. 10 of the 11 participants completed the full imaging protocol, including task engagement. Head movement during scanning, was generally within acceptable limits. Data demonstrates considerable cortical atrophy and ventricular enlargement consistent with age. Preliminary fMRI analyses show a variable pattern of cortical recruitment during task engagement in delirious patients.

Conclusions

These findings show it is ethically and logistically feasible to engage elderly patients with acute delirium into a high end structural and functional imaging study.

Introduction

“Pathway three delirium” is a short-term placement in a care home specific to North Yorkshire, for patients diagnosed with delirium during hospital admission, who are medically fit but have not recovered cognitively enough for discharge home. The goal is to allow extra time to recover from delirium, to allow return to patients’ own homes. At this placement, patients are followed up by the acute hospital liaison team.

Aims

To assess final discharge destinations after pathway three delirium placement.

To analyse characteristics between discharge groups.

Methods

We analysed electronic records of patients on this pathway between August 2020 and November 2021. Data was gathered on age, gender, prior cognitive impairment, visual impairment, hearing impairment, living alone, requiring package of care, and alcohol misuse.

Results

64 patients were included, 39 females (61%), 25 males (39%), average age of 83.7 years.

20 (31%) were discharged home, 26 (41%) remained in residential or nursing homes, 10 (16%) were readmitted to hospital, 8 (12%) discharge location was unknown or “other”.

Average age of those discharged home was 82.65yo, those discharged to residential/nursing homes: 83.88yo, and those readmitted: 85.8yo.

80% of those discharged home were women, compared to 61% of the total group and 50% of those who remained in nursing/residential care.

The discharged home group contained 80% patients who lived alone, versus 58% in the residential/nursing home group, and 30% in readmitted. 25% of the home group had a care package pre-admission: versus 46% in the residential/nursing home group, and 38% across all groups.

Cognitive impairment, sensory impairment and alcohol intake showed no apparent difference across destination.

Conclusions

These findings show that this short-term delirium placement enables some patients to return to their own home. Analysis suggests that younger patients, women and those with apparently less social support were more likely to go home.

Background: Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Our aims: improve delirium detection using the 4AT screening tool as a validated approach, Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Methodology: Plan Do Study Act (PDSA) methodology was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results: Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion: Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway.Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.