Reasons to be cheerful about the future of delirium follow-up services?

Dr Shibley Rahman is an academic physician interested mainly in dementia and frailty. He tweets at @dr_shibley

“Optimism," said Cacambo, "What is that?" "Alas!" replied Candide, "It is the obstinacy of maintaining that everything is best when it is worst.”

― Voltaire, Candide

Despite everything, I remain resolutely an eternal optimist about the future of delirium services. There is much to be said about the negative nature and after-effects of delirium and I don’t deny that. However, in my opinion, there are also good reasons to be cheerful about the future of people who survive at least one episode of delirium.

1. Delirium is common

In a prospective observational study involving 45 UK acute care hospitals (a study which long pre-existed the COVID-19 pandemic), delirium was found to be prevalent and associated with significant adverse outcomes [1]. Delirium was more common in individuals with dementia and frailty. Frailty and delirium are both predictive of several negative health-related outcomes. It’s probably worth pointing out that many of these negative outcomes might be prevented by applying adapted and personalised interventions [2].

It was always pretty likely that delirium would turn out to be the most frequent neuropsychiatric complication of COVID-19 in older people living with frailty [see 3 for a wider discussion]. One recent cohort study of 322 hospitalised and 535 community-based older adults demonstrated that prevalence of probable delirium was significantly higher in frail compared to non-frail older adults with COVID-19 [4]. The glaring gaps in the service provision in delirium care, regardless of aetiology, after a hospital admission existed before the pandemic, but the pandemic arguably offers an opportunity now to address them. Whilst a delirium episode in itself is not a long-term condition, the context of it may well be, and therefore patients might benefit from personalised care and support planning. There is no reason to believe that the delirium following COVID-19 is fundamentally different from any other delirium.

2. My own lived experience

Witnessing my own mum’s hospital admissions a few years ago featuring delirium was a real eye-opener. One blogpost of mine reminisces about the distress I experienced as a carer. In March 2020, at the very onset of the COVID-19 pandemic in the UK, in a blogpost on the BGS blog, I outlined my fear that COVID-19 might rear its ugly head in older adults with frailty, and this could be difficult for family carers like me. I had also long known, from my lived experience, that repeated episodes of delirium requiring hospital admission, could lead to long-term cognitive impairment, as I describe here. It has been known for an extremely long time that there might be some sort of link between delirium and progression to dementia [5]. Only recently in a prospective, population-based cohort study was it shown relatively convincingly that repeated episodes of delirium, more days with delirium and greater severity of delirium could be associated with worse cognitive outcomes [6].

3. Focusing on the issues

For patients requiring acute hospital admission with COVID-19, however, the emphasis seems to have been more on preventing mortality than on the quality of life of ‘survivors’, something that  is perfectly understandable in a pandemic of this scale. A recent dose-response meta-analysis showed that each 1-point increase in the clinical frailty scale was associated with 12% increase in mortality, in a linear fashion [7]. In a cohort of older adults aged 65 years and older admitted to a secondary care hospital with COVID-19, worsening frailty on admission was associated with an increased risk of all-cause mortality [8]. The focus on mortality and frailty for me, anyway, was problematic - focussing on the biological frailty of a person, rather than their surrounding social environment. We know that inequalities matter in frailty; in a group of older community-dwelling women, there was a significant association between socio-economic status and frailty. This association remained strong despite controlling for age, race, chronic disease, insurance status and smoking status [9]. Socio-economic factors could be, and should be, considered when implementing public health interventions to ameliorate the disparities in the impact of COVID-19 on distressed communities [10]. As with before the pandemic, if we are able to identify the patients who are most likely to recover, we can target them for intensive rehabilitation and early discharge planning. Equally, those patients who are at greater risk of dying can be offered the opportunity to have advance care planning discussions and palliative care input, to ensure that unnecessary interventions are minimised [11]. This is crucially important in relation to how frailty is framed at all, where frailty is dynamic and capable of improvement, and only one part of a wider discussion involving assets and resilience [12].

There has historically been an emphasis on mortality in delirium studies too. Delirium has been known to be an important independent prognostic determinant of hospital outcomes including new nursing home placement, functional decline and death - even after controlling for age, gender, dementia, illness severity, and functional status [13]. Delirium can also be an important mediator of the link between frailty and mortality. Although delirium and frailty both contribute to mortality, the relationship between delirium, frailty and mortality is a complicated one [14]. A recent longitudinal observational study in a Sao Paulo tertiary university hospital caring for severe cases of COVID-19 involved a total of 707 patients aged over 50 years admitted to the hospital between March and May 2020. It found that delirium was independently associated with in-hospital death in people over 50 with Covid-19 [15].

Whilst not all economics is classical and not all of the field of economics concerns rationality, the time is now ripe for good qualitative and quantitative studies into the quality of ‘survivorship’ after a COVID-19 delirium episode. In one study, long-term, health-related quality of life following delirium survivors in intensive care was not affected by delirium [16].

4. A need to reform delirium follow-up services

Even if you survive delirium in a hospital admission, there needs to be some sort of follow up because of the potential for serious long-term consequences. In a new Commentary in Age and Ageing that I wrote with Kit Byatt (@Laconic_doc), we proposed that the needs of older patients who have experienced delirium, including from COVID-19, could be addressed through a new model of post-acute delirium care that combines early supported discharge, including discharge-to-assess, with community-based follow up to assess for persistent delirium and early new long-term cognitive impairment [17].

With the implementation of follow-up delirium care as we describe, we believe there is potential for the harmful long-term effects of delirium to be reduced.

References

[1] Geriatric Medicine Research Collaborative. Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC Med. 2019 Dec 14;17(1):229.

[2] Bellelli G, Moresco R, Panina-Bordignon P, Arosio B, Gelfi C, Morandi A, Cesari M. Is Delirium the Cognitive Harbinger of Frailty in Older Adults? A Review about the Existing Evidence. Front Med (Lausanne). 2017 Nov 8;4:188. doi: 10.3389/fmed.2017.00188.

[3] Oldham MA, Slooter AJC, Cunningham C, Rahman S, Davis D, Vardy ERLC, Garcez FB, Neufeld KJ, de Castro REV, Ely EW, MacLullich A. Characterising neuropsychiatric disorders in patients with COVID-19. Lancet Psychiatry. 2020 Nov;7(11):932-933.

[4] Zazzara MB, Penfold RS, Roberts AL, Lee KA, Dooley H, Sudre CH, Welch C, Bowyer RCE, Visconti A, Mangino M, Freidin MB, El-Sayed Moustafa JS, Small KS, Murray B, Modat M, Graham MS, Wolf J, Ourselin S, Martin FC, Steves CJ, Lochlainn MN. Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults. Age Ageing. 2021 Jan 8;50(1):40-48.

[5] Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015 Aug;14(8):823-832.

[6] Richardson SJ, Davis DHJ, Stephan BCM, Robinson L, Brayne C, Barnes LE, Taylor JP, Parker SG, Allan LM. Recurrent delirium over 12 months predicts dementia: results of the Delirium and Cognitive Impact in Dementia (DECIDE) study. Age Ageing. 2020 Dec 16:afaa244.

[7] Pranata R, Henrina J, Lim MA, Lawrensia S, Yonas E, Vania R, Huang I, Lukito AA, Suastika K, Kuswardhani RAT, Setiati S. Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis. Arch Gerontol Geriatr. 2020 Dec 15;93:104324.

[8] Aw D, Woodrow L, Ogliari G, Harwood R. Association of frailty with mortality in older inpatients with Covid-19: a cohort study. Age Ageing. 2020 Oct 23;49(6):915-922.

[9] Szanton SL, Seplaki CL, Thorpe RJ Jr, Allen JK, Fried LP. Socioeconomic status is associated with frailty: the Women's Health and Aging Studies. J Epidemiol Community Health. 2010 Jan;64(1):63-7.

[10] Hawkins RB, Charles EJ, Mehaffey JH. Socio-economic status and COVID-19-related cases and fatalities. Public Health. 2020 Dec;189:129-134.

[11] Pocock LV, Sharp DJ. Acute hospital admission of the frail older person: an opportunity to discuss future care. Age Ageing. 2017 Nov 1;46(6):878-879.

[12] Rahman S. The two cultures of health and social care might perhaps be brought together by assets. Aging Med (Milton). 2018 Sep 19;1(2):117-119.

[13] Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998 Apr;13(4):234-42.

[14] Dani M, Owen LH, Jackson TA, Rockwood K, Sampson EL, Davis D. Delirium, Frailty, and Mortality: Interactions in a Prospective Study of Hospitalized Older People. J Gerontol A Biol Sci Med Sci. 2018 Mar 2;73(3):415-418.

[15] Garcez FB, Aliberti MJR, Poco PCE, Hiratsuka M, Takahashi SF, Coelho VA, Salotto DB, Moreira MLV, Jacob-Filho W, Avelino-Silva TJ. Delirium and Adverse Outcomes in Hospitalized Patients with COVID-19. J Am Geriatr Soc. 2020 Nov;68(11):2440-2446.

[16] Fontela PC, Abdala FANB, Forgiarini SGI, Forgiarini LA Jr. Quality of life in survivors after a period of hospitalization in the intensive care unit: a systematic review. Rev Bras Ter Intensiva. 2018;30(4):496-507.

[17] Rahman S, Byatt K. Follow-up services for delirium after COVID-19-where now? Age Ageing. 2021 Jan 22:afab014.