Alasdair MacLullich Professor of Geriatric Medicine University of Edinburgh

1. Delirium and unnecessary new institutionalisation of older people: could intermediate care help prevent this? Alasdair MacLullich Professor of Geriatric Medicine University of Edinburgh

2. Outline Background Definition(s) Causes Diagnosis and management Delirium and intermediate care Conclusions

3. Background

4. Background > 30% geriatrics inpatients > 20% of 12.5M inpatients/yr over 65 in USA • morbidity & mortality • length of stay impedes rehabilitation  risk of new institutionalisation • risk of long-term cognitive impairment

5. Background Distressing for patients and carers Underdiagnosed and undertreated Cost = £€$ Billions

6. Natural history of delirium

7. Resolved delirium Delirium then decline Patterns of delirium Cognition Persistent deficits Worsening of dementia

8. Definition(s)

9. “acute confusional state” “toxic psychosis” “ICU psychosis” “post-operative psychosis” “metabolic encephalopathy” “acute brain failure” “organic brain syndrome” “cerebral insufficiency” “dysergastic reaction” “subacute befuddlement” “a bit muddled” “not themselves” “confused” “agitated” “a bit knocked off” “vague” “poor historian” “non- compliant” “obtunded” “flat” Delirium: many formal and informal terms

10. DSM-IV definition • (1) A disturbance of consciousness (reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention), • (2) A change in cognition (eg. memory impairment) or a perceptual disturbance, and • (3) Acute onset of hours to days, and tendency to fluctuate. • (4) Evidence of general medical or drug aetiology

11. Causes

12. Direct brain insults • Hypoxia • Hypercapnia • Hypercalcaemia • Hypoglycaemia • Drugs, esp. some classes • Stroke • Traumatic brain injury • etc.

13. Aberrant stress responses • Infection • Myocardial infarction • Acute renal failure • Psychological stress • etc.

14. Diagnosis

15. Core features • Acute onset/fluctuating course • Inattention • Additional features • Other cognitive deficits, eg. in memory • Poor comprehension / disorganised thinking • Altered arousal • Psychotic features • Sleep-wake cycle disturbance

16. Clinical approach Is there mental status impairment? Duration of mental status impairment? Chronic impairment (?dementia) Delirium and chronic impairment (?dementia) Delirium

17. Assessment tools for delirium Standard cognitive tests Abbreviated Mental Test Orientation-Memory-Concentration Test MMSE Additional tests of attention digit span serial 7s days of week / months of year backwards Specific delirium scales Delirium Rating Scale Memorial Delirium Assessment Scale Confusion Assessment Method (CAM) Assessment of chronic cognitive impairment Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE)

18. IQCODE (indicator of dementia)

19. Clinical approach: STEP A Is there mental status impairment? Cognitive screening with tests AMT, MMSE, OMC, etc., plus bedside tests of attention + Additional information Patient’s account, clinical examination, informant history

20. Clinical approach: STEP B Duration of mental status impairment? History Patient’s account, informant history, OT/SW assessment +/- Formal testing Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

21. Subsyndromal delirium: prognosis Marcantonio et al, JAGS 2005

22. Persistent delirium Cole et al., Age and Ageing 2009

23. Persistent delirium • + • Misdiagnosis • = • Risk of unnecessary institutionalisation • (misdiagnosed as: ‘cognitive impairment’, ‘dementia’, • ‘unable to cope’, ‘confused’, ‘doesn’t initiate’, ‘loss of motativation’, ‘poor self-care’, ‘unable to manage ADLs’, ‘low mood’, etc.)

24. Differential diagnosis • Dementia • Onset mostly much slower • Attentional deficits less prominent • Dementia with Lewy Bodies shares some features • Depression • Onset slower • Cognitive impairment may be less severe • Attentional deficits are less severe • Flat affect

25. Management

26. Initial assessment • If delirium suspected, treat as a medical emergency • ( ~ 20% are dead in one month) • Nursing / medical input early • All members of the healthcare team can pick up early signs

27. Detailed assessment • First line: wide net to find predisposing and precipitating factors • (Comprehensive Geriatric Assessment) • Neuro examination • Nutritional status • Infection screening • Routine bloods including TFTs and B12/folate • Further Ix • CT +/- MRI • LP • EEG • Vasculitis screen • etc.

28. Treatment of delirium Complex! Requires specialist geriatrics input in most if not all cases Requires a team approach

29. Treatment of delirium Treat precipitating factors Reduce impact of predisposing factors Reduce distress (patients and carers) Manage agitation Prevent complications Rehabilitation Follow-up (document, 3x risk dementia at 2y)

30. Delirium and long-term cognitive impairment

31. Barrough, The Method of Physik, 1601

32. Memory decline in AD patients with and without delirium Fong, T. G. et al. Neurology 2009;72:1570-1575

33. Follow-up Delirium is a marker for current and future dementia If current dementia excluded, high risk patients should be monitored (GP/OP clinic) Not standard practice, but growing Registers of ‘at-risk’ patients

34. Prevention Multicomponent Interventions Oyxgenation Rapid recognition and treatment of medical problems (eg. UTI) Rx or prevention of dehydration General reduction of pharmacological burden on brain, esp BDZs Treatment of pain Correction of sensory deficits (vision aids, amplifiers) Early mobilisation Treatment of constipation Avoidance of urinary catheter Staff and family education Basically: excellent multidisciplinary geriatrics care!

35. Delirium and intermediate care

36. Delirium and intermediate care Delirium is the major blindspot in healthcare and research! Especially true of intermediate care Pubmed search Oct 11: “delirium” + “intermediate care”: 4 results Not included in National Dementia Strategy (DoH) 2 hits on entire DoH website More hits on SHOW, but no main webpage

38. Caplan study • RCT of home rehabilitation in delirium (>6 days acute LOS) • Compared with rehab ward • No delirium on enrolment • Home rehab patients had significantly less delirium • Home rehab patients showed greater satisfaction • Home rehab was cheaper

39. Potential roles of intermediate care Accurate diagnosis Frequent monitoring Rehabilitation Allowing time for recovery Diagnosis of dementia (>50% of older patients with delirium) Avoidance of unnecessary institutionalisation!

40. How to implement? Diagnosis in the hospital Requirement for referral: cognitive assessments Diagnosis in intermediate care Ongoing monitoring Severity scoring Standardised care protocols Like dementia care but more dynamic: potential for recovery

41. How to implement? Diagnosis in the hospital Requirement for referral: cognitive assessments Diagnosis in intermediate care Ongoing monitoring Severity scoring Standardised care protocols Like dementia care but more dynamic: potential for recovery

42. Advantages over acute hospital environment Less chaotic Consistent staff/home care team Quieter Less interruptions at night Potentially closer to real life Potential for longer-term rehabilitation ? More stimulating environment ? Closer to family

43. Some potential disadvantages Additional transition Slower access to acute care if pt deteriorates Variable access to specialist input May not have access to appropriate level of MDT Staff training?

44. Conclusions

45. Conclusions Delirium is common and serious Delirium is underdetected and undertreated Delirium can persist for weeks or months But persistent delirium can resolve Accurate diagnosis and good management are essential More studies are required Ample knowledge on good practice ready to go now

46. www.europeandeliriumassociation.com