Delirium

Delirium is an acute onset of fluctuating consciousness associated with impaired cognition and perception, commonly encountered in elderly patients. Prompt recognition allows early treatment of reversible causes. 4AT is a screening tool for rapid assessment of delirium.

By assessing the use of the 4AT score in Orthogeriatric patients, this quality improvement project aimed to improve assessment and management of delirium with both verbal and written interventions.

Weekly data was collected from Orthogeriatric inpatients across three PDSA cycles including the admission 4AT score, reviewing notes for mention of delirium, acute confusion and cognitive decline and whether the causes were considered and managed.

Cycle one demonstrated that 98% of patients had a 4AT assessment on admission. 38% had a score suggestive of delirium or cognitive impairment. 5.7% of patients had delirium considered at clinical review. 2% had a cause of delirium documented.

Daily board-round announcements to the clinical team highlighted delirium, prompt review of 4AT and screening for causes using the ‘PINCHME’ model.

After cycle 2, 100% of patients had 4AT completed on admission, 55% had evidence that delirium, acute confusion or cognitive decline was considered at review and 50% had a cause for delirium documented.

This project demonstrated an improved awareness of delirium and its causes amongst clinicians through written and verbal interventions. The next steps for sustainable change are to propose the introduction of an automatic online delirium alert in patients scoring ≥4 on 4AT and designing a digital confusion screen proforma to ensure thorough assessment of these patients.

Reported delirium prevalence in inpatients with Parkinson’s disease (PD) varies widely across the literature and is often underreported. Delirium is associated with an increased risk of institutionalisation, dementia, and mortality, but to date there are no comprehensive prospective studies in PD. We aimed to determine delirium prevalence in PD compared to older adults and its associated risk with adverse outcomes. Participants from the ‘Defining Delirium and its Impact in Parkinson’s Disease’ (DELIRIUM-PD) and the ‘Delirium and Cognitive Impact in Dementia’ (DECIDE) studies were included. People with PD (DELIRIUM-PD) or older adults from the Cognitive Function and Ageing Study II – Newcastle cohort (DECIDE) admitted to hospitals in Newcastle were approached to take part. Delirium was assessed prospectively using the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition criteria. Outcomes were determined by medical note reviews and home visits 12 months post discharge. Cox regression or binary logistic regression were used to evaluate the effect of delirium on institutionalisation, dementia, and mortality, independent of covariates. Delirium developed in 66.9% (n=81/121) of PD participants compared to 38.7% (n=77/199) of controls (p<.001). Delirium was associated with a significant increased risk of developing dementia in one year in PD (OR=6.1 (1.3-29.5), p=.024) and in controls (OR=13.4 (2.5-72.6), p=.003). However, in only PD participants, delirium was associated with a significantly higher risk of institutionalisation (OR=10.7 (2.1-54.6), .004) and mortality (HR=3.3 [95% CI 1.3-8.6], p=.014). This is the first comprehensive prospective study of delirium in PD, showing that over two-thirds develop delirium during hospitalisation compared to a third of older adults. Delirium in PD is associated with a significant risk of dementia, institutionalisation, and death in one year.

Background
Current practice for acute delirium presentation is hospital admission whilst the delirium resolves, often including multiple transfers with poor outcomes. This project challenges this practice and allows people to recover at home with a maximum of 6 calls a day and night with carers trained in delirium.

Results
From a previous audit of Pathway 2 beds patients with delirium had poor outcomes, high levels of placement in permanent care and long lengths of stay (21 days).

There have been 192 episodes of care through the Delirium Pathway.80% were from hospital wards and 20% stepped up from community settings.

In 2023, 42% had no ongoing social care support needs and 21% had only the requirement of ongoing domiciliary care needs at home. 2.6% entered long term care with the re-admission rate remaining within the local rate for this cohort of 20-30%. There has been low demand for night care. The average LoS is 15 days.

Delirium symptoms significantly improved at discharge and stayed improved; pre-discharge the median 4AT score was 7, at first pathway assessment (generally within 24 hours of arrival home), the median 4AT score was 2 and at exit of pathway the median 4AT score was 1.

Patients and carers reported that the discharge home felt safe and that home was the best place for recovery: 89% of patients and 76% of carers felt it was safe to return home; 94% of patients; and 93% of carers felt that home was the best place for recovery.

Conclusion
This pathway has demonstrated that discharging patients with an acute delirium with supportive home care is safe, effective, and reduces admissions to long term care

Introduction Delirium is a common, reversible condition with significant morbidity. Guidelines facilitate diagnosis and management (NICE Delirium Guidelines [CG103]). Previous audits in an acute frailty ward identified areas for improvement in assessment of delirium. In this cycle, a novel admission proforma was implemented to promote adherence to current guidelines. Methods This is a continuation of a previous quality improvement project representing cycles three and four. An admission proforma was co-developed with patients and the multidisciplinary team (MDT), primarily to prompt staff to complete delirium assessments. Adherence was audited and the proforma was modified based on feedback. An equivalent audit was then conducted on the updated proforma. The audit period occurred over several resident doctor changeovers. Primary outcomes; completion of delirium assessments, positive diagnosis of delirium and use of the new proforma. Secondary outcomes; completion of resuscitation and clinical frailty score (CFS) forms and the relationship between length of stay (LOS) and delirium or CFS. Results  The initial admission proforma was used in 86% of admissions. After its introduction, 53% of patients had completed delirium assessments and the prevalence of delirium was 25%. Resuscitation forms were completed in 86% of patients, 60% of patients had completed CFS. Diagnoses of delirium were associated with increased LOS. CFS of 6/7 was associated with an increased LOS and a diagnosis of delirium. The modified proforma was used in 94% of admissions. Completion of delirium assessments improved to 79% and diagnoses of delirium to 43%. Completion of resuscitation forms and CFS improved to 93% and 79% respectively. The difference in LOS between patients with and without delirium was statistically significant. Conclusion This study shows the efficacy of an admission proforma, as low-cost MDT-based intervention, improving and sustaining adherence to guidelines and improving documentation and assessment of other elements of a comprehensive geriatric assessment. 

Introduction 

Delirium is a common presentation in frail, older, hospitalized patients (approximately 25% of admissions, with 50%+ on surgical wards), with a high mortality (approximately 22% during the hospital stay) with more associated, avoidable deaths than sepsis. Delirium is underdiagnosed. The National Institute for Health and Care Excellence (NICE) recommend using a validated screening tool on all patients at risk or showing evidence of delirium. “Getting it Right First Time, Geriatric Medicine” recommends all patients aged 75 or more, should be assessed using the 4AT tool (a validated delirium screening tool). 

Method 

A delirium pathway was developed in University Hospital Morecambe Bay Trust to embed these recommendations. A program of learning events was devised to target all grades of doctor along with a poster with the byline “Test it, Type it, Treat it”, included in multiple presentations and in trust screensavers. 

Results 

Before the education program, the Frailty Intervention Team (FIT) assessed patients for potential early discharge used the 4AT in 80.85% of patients with a diagnosis of delirium coded in 11.12%. In patients not seen by FIT (nFIT) the 4AT usage was 25.18%, with a delirium diagnosis rate of 9.11% Following the education program FIT 4AT usage was 96.12% with 18.69% diagnosed with delirium. The nFIT cohort completed 4AT in 33.63% of patients with 12.63% diagnosed with delirium. Analysis with Statistical Process Control charts showed that after the education program the use of 4AT by inpatient teams improved (p<0.05), but not in the Emergency Department (ED). 

Conclusion 

FIT assessed and diagnosed more patients than nFIT both before and after the intervention, with both groups showing improvement following the educational package. There is scope for improvement and further education events are planned, especially with ED, engagement of the ward “frailty champions” and possibly mandating the electronic 4AT.

Introduction 

Malaysia is transitioning from an ageing to an aged nation. According to the Department of Statistics Malaysia (DOSM), 7.4% of Malaysia's population was aged 65 years or older in 2023, projected to exceed 15% by 2030. Frailty is increasingly prevalent, affecting 11% of adults aged 50–59 years and escalating to 51% among those aged 90 years or older, based on global data. A local pilot study in March 2024 in general medical wards highlighted common frailty-related issues, including deconditioning (36%), delirium (17%), and a 12-month readmission rate of 46%. 

Objectives 

To introduce a user-friendly, standardized frailty care bundle to support non-geriatric-trained healthcare personnel in detecting common issues related to frailty syndrome early and implementing appropriate interventions. 

Methods 

A multidisciplinary team comprising geriatricians, medical practitioners, pharmacists, nurses, therapists, dieticians, and medical social workers developed a care bundle focusing on three key components: (1) screening tools for identifying acute functional decline, sarcopenia, and delirium; (2) protocolized management pathways; and (3) a discharge planning checklist. The bundle is designed for ease of use in general medical wards by non-geriatric-trained personnel. 

Results 

The care bundle will be piloted in 2025 across general medical wards. Nurses and doctors will screen patients aged 65 and older for deconditioning and delirium upon admission, notifying geriatrician as needed. Early physiotherapist referrals will address deconditioning, and a structured delirium checklist will guide targeted management. The discharge checklist includes caregiver identification, discharge planning, medication reconciliation, equipment assessment, and welfare support. 

Conclusion 

Frailty amidst an ageing population poses significant clinical and economic burdens, including higher readmission rates and healthcare costs. A standardized frailty care bundle offers a systematic approach to optimizing elderly care, improving outcomes, and addressing ageing challenges. Future audits will assess its effectiveness in reducing readmissions, functional decline, and healthcare costs.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by frightening or traumatic events. Delirium is a state of acute confusion associated with acute illness, surgery, and hospitalisation. Delirium is known to be associated with a risk of PTSD in patients in the Intensive Care (ICU) setting. However, there is limited information on the prevalence of delirium in older adults outside of Intensive Care. Therefore we undertook a systematic review to ascertain the prevalence of PTSD in elderly patients after an episode of delirium on a general ward.

METHODS: The systematic review was conducted using MEDLINE (1946-10/01/2024), Embase (1974- 10/01/2024), and PsycINFO (1806- 10/01/2024) to identify studies. Studies were eligible if they included adults aged ≥ 65 years, admitted to an acute hospital, diagnosed with delirium using a validated screening tool, (e.g. 4AT, CAM-ICU) and subsequently screened for PTSD at any point following discharge with a validated screening tool (e.g. the PTSS-14). The exclusion criteria excluded ICU cohorts and terminal illness with < 3 months life expectancy. Two researchers (SM, NM) independently reviewed all studies with any disparities resolved though a 3rd researcher (AM)

RESULTS: After removal of duplicates, the search identified 1042 titles from which only 3 eligible studies were identified. All 3 studies were in older patients after surgical procedures (n=132 participants in total). Two of the studies reported no association between delirium and the subsequent risk of PTSD. However, the largest study (n=77) reported a significant independent association between delirium and the 3-month risk of PTSD.

CONCLUSION: The current body of research on the prevalence of PTSD following episodes of in-patient delirium in older adults is limited. The findings of this review highlight the need for further research. A prospective cohort study on Geriatric Medicine wards is being planned.

Introduction

Delirium has a significant impact on morbidity and mortality. It is also associated with an increased level of institutionalisation at discharge and increased length of stay. Therefore, a diagnosis of delirium should always be considered with an assessment of risk factors. The aim of this project was to ensure 100% of patients on Geriatric wards have a diagnosis of delirium considered via the 4AT as per NICE guidelines.

Methods

A Plan-Do-Study-Act methodology was utilised with an initial audit exploring identification and documentation of delirium diagnosis. A Lanyard Prompt Card was then distributed to all physicians with the 4AT score illustrated. A departmental teaching session about Delirium was delivered to all juniors. A re-audit was conducted to assess impact.
 

Results

Of the 41 patients evaluated initially, 50.7% (21) were suspected to be delirious. Of these, 9.5% (2) had been assessed for delirium on the same day delirium was suspected. Of 38 patients, post-intervention audit revealed 36% (14) were suspected to be delirious and of these patients, 43% (6) had a 4AT score on the same day.

Key conclusions

This project revealed 4AT assessments were approximately tripled in patients suspected to be delirious post-interventions. There remains scope for improvement in confidence and skill of documenting assessments to meet the NICE recommendations and potential to explore barriers. Ultimately, we aim to expand across all medical and surgical wards to upskill all MDT members on identification and management of delirium

Background: Delirium is a common and reversible neurobehavioral condition with significant morbidity and mortality ramifications for older patients. Consequentially, clear guidelines exist pertaining to its swift identification and management. However, studies suggest that adherence to these guidelines are poor. This audit aimed to evaluate compliance to the National Institute for Health and Care Excellence’s (NICE) delirium guidelines in an Acute Senior Health Unit (ASHU) and to present a single centre experience of a low-cost ward-based intervention for improving delirium guideline adherence.

Methods: A retrospective observational audit was conducted on patients admitted to ASHU between 01/07/2023 and 30/07/2023. Data on delirium assessments, diagnoses and causes of delirium were obtained through retrospective database searches. Posters and education based multidisciplinary team (MDT) interventions were designed and initiated following grounded thematic literature analysis and ward discussion. A methodically equivalent audit was then conducted between 01/09/2023 and 30/09/23. Data was anonymised and blinded and analysis was performed on SPSS V12.0.

Results: A total of 128 patients were included in the study. Initial audit revealed suboptimal compliance with NICE recommendations. Chi-square test of independence found that patients were statistically more likely to receive a full delirium assessment (1.9% vs 56.6%, p = 0.001) and formal diagnosis (5.8% vs 27.6%, p = 0.002) after the ward-based intervention.

Conclusion: This study provides limited evidence in favour of low-cost MDT based interventions for improving adherence to NICE delirium guidelines and provides a 5-step framework for future studies. This study also explores the potential patient implications of these interventions. A repeat audit should be conducted to ensure lasting and sustainable change is achieved.

Trial registration/clinical trial number: AUDI003614

Introduction: Delirium is common in hospital inpatients, under-recognised, and associated with increased morbidity and mortality. NICE quality standards are that all at-risk adults newly admitted to hospital receive tailored interventions to prevent delirium.

Aims: 1. To reduce time to diagnosis of delirium. 2. For 100% of patients with delirium to have tailored interventions, including behaviour/ bowel/ food charts, medication reviews, and family involvement. 3. To increase junior doctors’ confidence in recognising and managing delirium.

Methods: Two changes were implemented and three cycles of data from inpatients on the geriatric wards were collected over an 8 week period. Qualitative data was also collected from doctors. The first change was teaching delivered to clinicians working in geriatrics. The second was implementing a new Delirium Bedside Bundle which was advertised in posters on the geriatrics wards.

Results: Data was collected from 60 inpatients, of whom 20 were diagnosed with delirium. The time to diagnosis was reduced from 3.5 days in cycle 1 to 1.6 days in cycle 3. There was an increase in documented medication reviews / cessation of sedating drugs from 0% in cycle 1 to 62.5% in cycle 3. There was an increase in family involvement from 60% in cycle 1 to 75% in cycle 3. Data collected from 19 junior doctors showed that confidence in caring for people with delirium increased from 57% to 92%.

Conclusion: Simple interventions such as teaching and implantation of an easy to use Bedside Bundle can positively impact recognition and management of delirium.