Delirium

1. Delirium Associate Professor Dianne Wynaden RN, PhD 9th September 2008

2. Other team members Mr Malcolm Hare – Fremantle Hospital Ms Sunita McGowan – Fremantle Hospital Ms Gaye Speed – Fremantle Hospital Mr Ian Landsborough – Curtin Ms Shirley McGough – Curtin Ms Lynn Moore – Curtin/Fremantle

3. Background • Increasing number of “confused” elderly patients in acute care setting led to many questions being asked around how to provide quality care • High acuity, high cost, stress on health professionals, the patient and relatives

4. Background • Implementation of dedicated rooms with permanent specialling facilities including the use of: • Music • Fiddle blankets • Clock • Non-slip mats etc • 1950s furniture

5. So What? • 10% of all hospitalised patients will suffer from a delirium • Up to 89% in high risk groups (dementia) • 50% or more of delirium goes unrecognised Financial Cost The economic impact of delirium is substantial, rivalling the health care costs of falls and diabetes mellitus

6. Cost of specialling/medical care Cost of complications Increased length of stay Higher level of care on discharge

7. Emotional cost • Patient / family/ carer stress • Impact on nursing staff • Decreased quality of life Health Cost • Increased mortality • Increased morbidity • Loss of function

8. Why study delirium? International research: • Medical and nursing staff not good at recognising delirium • No definitive treatment • Most effective treatment is PREVENTION

9. Why study delirium? • Cost effective interventions to prevent delirium require identifying risk factors and addressing them systematically in each patient

10. Difficulty separating diagnoses • Dementia • Delirium • Dementia with superimposed delirium • Depression and dementia Made worse when: • Inconsistent baseline information available when patient is admitted to the acute care setting

11. “Ad hoc” diagnosis of dementia based on unexplored assumptions • Confusion is seen as a diagnosis rather than a symptom of an underlying problem

12. Differential Diagnosis

16. What is delirium? • Short-term disturbance of consciousness (Acute organic psychosis or acute confusional state) • Characterised by acute onset, fluctuating course andinattentionand either disorganised thinking oraltered level of consciousness • Must have a medical cause

17. What is delirium? • Must not be better explained by pre-existing or evolving dementia • Can occur at any age - dependent on risk factors • Most commonly recognised delirium (DTs) – withdrawal from alcohol – screening for patients routinely

18. Types of delirium Hyper-alert - Most commonly recognised Hyper-vigilance Agitation Hallucinations Difficulty holding/shifting attention Hypo-alert - Most commonly linked to increased mortality/morbidity Lethargic, difficult to rouse Difficulty gaining attention

19. Types of delirium Mixed Fluctuates between features of both

20. Presentation of Delirium • Fluctuating course often worse in early morning or night • Visual hallucinations • Persecutory delusions • Impaired cognition and memory

21. Predisposing Risk Factors • Age (> 65years old) • Dementia • Multiple Medications • Sensory Impairment (Visual/Hearing) • Dehydration

22. Predisposing Risk Factors • Chronic physical illness • Substance Use (including alcohol) • Depression • Neurological impairment • Functional disability

23. * Precipitating Risk Factors • Severe acute illness • Changes to electrolyte or acid base • Alterations in oxygenation • Liver or kidney failure • Hypoglycaemia

24. *Precipitating Risk Factors • Malnutrition • Alcohol or Benzodiazepine withdrawal • Surgery, particularly cardiac and orthopaedic • Immobility

25. * Precipitating Risk Factors • Stroke • Pain • Infection • Heart failure • Multiple medications

26. Precipitating Risk Factors • Use of catheters, particularly urinary • Multiple medications • Acute fracture • Invasive procedures • Use of restraints • Iatrogenic events

27. Focus of program of research Keeping elderly people healthy in the acute care setting- major focus on confusion and particularly delirium

28. Prevalence of confusion A prevalence audit was conducted to identify how many confused patients were in the hospital. To be counted in the audit as “confused” patients had to be: • Identified by staff as being confused, having a delirium, “being a bit off” or appearing depressed; and, • These or other descriptors had to be documented in the patient’s notes.

30. Prevalence of confusion A total of 1209 patients were covered in the four audits over four weeks on 15 medical and surgical wards at two hospitals. Of these 183 patients (15%) were identified as confused: - 107 females and 76 males. - Mean age of 80.5 years. This rate is consistent with international research.

31. Possible causes of confusion Of the 183 patients 132 (72%) displayed features consistent with delirium: • 58 patients (44%) = Possible delirium superimposed on a confirmed dementia. • 48 patients (36%) = Diagnosed delirium that may or may not be hospital acquired. • 26 (20%) = Possible delirium or organic brain disorder

32. The remaining 51 (28%) of the 183 patients: • 29 (57%) = Behaviour related to confirmed dementia. • 15 (29%) = Behaviour related to organic brain disorder that may or may not resolve. • 7 (14%) = Behaviour related to probable unconfirmed dementia.

33. Discussion Points • Prevalence rates probably under estimated. Most causes of confusion are related to delirium. • Care of patients would be greatly facilitated if consistent use of the term delirium and not ill defined synonyms such as confusion were used. This would reduce diagnostic imprecision which often leads to the poor rates of recognition of delirium.

34. Discussion Points • Managing confused patients in now the norm and many staff just accept this level of acuity • Improved documentation on patient’s cognitive state is needed. Again, confusion is a poor descriptor to use as it is difficult to measure change over a period of time.As a result, staff may not identify the cause and continue to just manage the resulting behaviours.

35. Discussion Points • Management is often compounded by a lack of baseline data on the patient’s level of cognitive functioning --- approximately 60% of patients in the audit came from home with no accompanying cognitive assessment.

36. Discussion Points • Health professionals’ level of knowledge of the causes of confusion is also questionable. A study of nurses’ knowledge of delirium and associated risk factors demonstrated this (Hare, Wynaden, McGowan & Speed, 2006).

37. Nurses’ level of knowledge of delirium and associated risk factors • Questionnaire sent to 1100 non-casual nursing staff 338 returns (30.7%). • Poor level of recognition of risk factors particularly things like dementia, gender, hypoactive form of delirium. • Level of knowledge of management of delirium was also low.

40. Qualitative study on nurses caring for patients with delirium • Qualitative study conducted at two hospitals • Two main themes emerged • Inability to differentiate confusion • Managing confused patients

41. Inability to differentiate confusion Three subthemes: • Caring for so many confused patients • Feeling helpless and frustrated • Lack of education and training to assess confused and delirious patients

42. Managing confused patients Three subthemes: • Safety issues • Attitudes of staff • The environment

43. Where to from here? • Educational program in area of confusion/ delirium • Assessment of cognition in the elderly should have the same importance as physical assessment in all health professional undergraduate curricula.

44. Where to from here? • Develop a risk assessment tool to predict delirium in the same way as we predict risk for falls. • Test tool in the Australian context • Clinical pathways attached to risk assessment tool

45. Where to from here? • Improve baseline cognitive assessment documentation for patient’s admitted from home/ residential care. • Coordinated approach to specialist assessment AMT, MMSE; CAM, Delirium Rating Scale – prevent people being labelled as having dementia – cultural diversity taken into account in assessment

46. Where to from here? • Nurse practitioner/ specialist in ageing to assess and manage issues in acute care situation - High impact and high cost of not accurately assessing patient – co-morbidity and mortality.

47. Where to from here? • Elderly friendly hospitals. • Educate elderly people “how to survive” hospitalisation. • Improved discharge planning to ensure family and carers understand the experience of hospitalisation particularly when the patient has experienced a delirium.

48. Assessing and Managing Old Age Psychiatric Disorders • Mini Mental State Examination/ Abbreviated Mental Test/ AMT4 • Geriatric Depression Scale • Confusion Assessment Method/ Delirium Rating Scale

49. ABBREVIATED MENTAL TEST (AMT) . Question 1. How old are you? 2. What is the time (nearest hour)? • Address for recall at the end of test – this should be repeated by the patient, eg. 42 West Street 4. What year is it? 5. What is the name of this place? 6. Can the patient recognise two relevant persons (eg. nurse/doctor) 7. What was the date of your birth? 8. When was the second World War? 9. Who is the present Prime Minister? 10.Count down from 20 to 1 (no errors, no cues) TOTAL CORRECT (0 or 1 for each question) Score less than 8 indicates cognitive impairment. Source: Hodkinson HM. (1972). Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing, 1:233-8.

50. AMT4 • What is your age? • What is your date of birth? • What place is this? • What year is this? A score of 3 or < indicates cognitive impairment