Delirium

Background Delirium is an acute impairment of attention and cognition, precipitated by physiological stressors (Wilson et al., Nature Reviews, Disease Primers, 2020, 6(1)), associated with adverse outcomes (Huraizi et al., Journal of Clinical Medicine, 2023, 12(16), p. 5346) and often under-diagnosed in hospital (Lochlainn, Frewen and Bryant, Age And Ageing, 2018, 47(suppl_5), pp. v1–v12). Integrating early assessment into clinical practice is vital (Hopper et al., Geriatric Medicine GIRFT, 2021). This project assessed compliance with delirium guidelines from the National Institute for Health and Care Excellence (NICE) and Geriatric Medicine Getting It Right First Time (GIRFT), and introduced a cost-effective, easily embedded ward-based intervention to improve adherence. Methods This single-centre, retrospective observational audit was conducted on a 28-bedded Acute Senior Health Unit (ASHU) at our hospital. A previous cohort of trainees demonstrated statistically significant improvement in formal delirium assessment using education-based interventions (Cycle 1; C1). We re-audited the sustainability of this change and consequently introduced a digital admission proforma (Cycle 2; C2) to expand on this work. This incorporated the 4-AT assessment and prompting completion of an electronic assessment. This proforma’s impact was evaluated. All data was anonymised. Results 71 patients were included in C2. Re-audit of C1 showed a decline in patients receiving a formal delirium assessment with 4-AT (56.6% to 8.3%), while delirium diagnoses increased (27.6% to 66.7%). Following proforma introduction, delirium assessment increased (8.3% to 34.0%, p<.05) however this was associated with a concurrent decline in formal delirium diagnoses (66.7% to 44.7%). conclusions an easy-to-access, low-cost digital intervention may be useful tool improve assessment. however, project demonstrates the challenges of sustaining change across multiple cycles and trainee rotations. single is unlikely ‘silver bullet’ aligning practice national guidelines. continual re-audit necessary ensure sustainability.

Introduction

There is limited understanding of long-term delirium care after discharge from hospital for older people. A realist approach was used to investigate the contextual factors and mechanisms of care that influence recovery from delirium. Realist evaluation is fundamentally theory-driven. A preliminary programme theory was used as the foundation for theory testing and refinement, in order to develop the RecoverED intervention.

Method

Realist interviewing techniques were used to obtain real-world and lived experiences of delirium recovery and service use in the community for theory-building and testing. Semi-structured interviews were conducted with a purposive sample of people with delirium (N=7), informal carers (N=14), and healthcare professionals (N=24). Data from the interviews were analysed using a deductive codebook of Context-Mechanism-Outcome (CMO) configurations. Open coding was also performed to identify inductive themes, which were then aggregated to elicit explanatory statements.

Results

There was support for a multicomponent delirium intervention including cognitive and physical rehabilitation, and psychosocial support. The analysis revealed the need for an additional component which focused on improving awareness and understanding about delirium amongst those with lived experience. In the context of insufficient knowledge about delirium, people experienced increased fear and anxiety among other negative outcomes. Offering a focused educational component as part of the intervention is expected to contribute to recovery outcomes. This was associated with CMOs identifying the need for positive relationships with staff, improving communication with staff and sense-making through staff emotional support.

Conclusion(s)

The preliminary programme theory was refined based on the realist analysis data. Additional components were included, one of which was targeted education for people with delirium and carers. Following a consultation with an expert panel, the intervention is being tested in a feasibility trial and process evaluation, which will analyse data from multiple sources using realist methods to further refine the intervention

Introduction: The Centre for Perioperative Care recommends the assessment and documentation of delirium using a validated tool such as the 4-AT in older people undergoing surgery.

Aim: This quality improvement project (QIP) aimed to improve the assessment and documentation of delirium in patients aged 65 and above following vascular surgery in a tertiary centre.

Methods: Patients aged ≥65 years who had undergone vascular surgery were identified and data was collected with access to the electronic patient record system. Analysis was carried out using Microsoft Excel and SPSS. Following baseline measurements taken in August 2023, 1 plan-do-study-act (PDSA) cycle was completed between September 2023-January 2024.

Baseline measures: Baseline data collected between August 1-31st 2023 identified 51 patients, of which delirium was screened using the 4-AT tool in 39.2% (n=20), on average 90 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review (100%,n=51). There were clinical concerns of post-operative delirium documented in 7 patients, with the 4-AT documented in 5 of those cases.

Intervention: Interventions included stakeholder discussions to identify key barriers in the assessment and documentation of delirium, multidisciplinary team education and poster reminders across the ward. These were introduced between November-December 2023.

Results: Post-intervention results reviewed between 10th-31st January 2024 showed that the 4-AT was used to screen for delirium in 61.9% of patients (n=13), on average 45 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review. In addition, 2 patients developed delirium post-operatively with the 4-AT reported in both cases.

Conclusions: This QIP has demonstrated a marked improvement in compliance with national guidelines on the assessment of delirium, highlighting the impact of multidisciplinary education in improving the perioperative clinical pathway for older people undergoing surgery. Future PDSA cycles will focus on improving the documentation of 4AT in the post-operative surgical review.

Introduction

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

Methods

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

Results

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. 151 met inclusion criteria and were included in the final review. Much of the literature focusing on hospitalised participants (n=140) explored MLTC as a risk factor for delirium (n=125). Fewer studies explored the impact of MLTC on delirium presentation (n=5), duration (n=3) or outcomes (n=6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n=107/151) and Confusion Assessment Method (n=88/151), respectively.

Conclusion

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Introduction: Delirium affects up to 50% of older individuals within hospital environments, with a notable occurrence in 30% of those aged 65 and above in emergency departments. This QIP aimed to enhance the early recognition of delirium by implementing the 4AT assessment and optimize assessments and investigations by implementing the Delirium Bundle.

Methodology: A survey involving 39 doctors was conducted to evaluate their comprehension of delirium and awareness of the Delirium Bundle. PDSA 1 involved retrospective data analysis of medical records for patients admitted with delirium and used as a preliminary baseline to evaluate how the delirium bundle is being utilized. PDSA 2 integrated multiple teaching sessions and the implementation of the Delirium Bundle, assessing the effectiveness of these interventions.

Results: In PDSA 1, twenty-nine patients were identified. None of the patients had a 4AT assessment done. Twenty patients (69%) had a hematological screen done, eight patients (27%) had an ECG done, twenty patients (69%) had a CXR done, eighteen patients (62%) had an MSU test done, eight patients (28%) had cultures done, and twenty-three (79%) had a CT head scan done. In PDSA 2, thirty patients were identified. Seven patients had a 4AT assessment done, sixteen patients (53%) had a hematological screen done, nineteen patients (63%) had an ECG done, twenty-two patients (73%) had a CXR done, fifteen patients (50%) had an MSU test done, fourteen patients (47%) had cultures done, and 20 patients (67%) had a CT head scan done.

Conclusion: The implemented changes showed effectiveness with increased 4AT assessments and enhanced confusion screening. Improvements in assessments and investigations for diagnosed delirium patients were evident. To further enhance efforts, future initiatives include incorporating the 4AT assessment in clerking booklets, conducting continuous teaching sessions, and displaying posters in relevant wards.

Introduction 

The National Hip Fracture Database (NHFD) is the mandatory national clinical audit for patients presenting with hip fracture. Since 2007, the NHFD has made admission cognitive assessment using the Abbreviated Mental Test Score (AMTS) routine for people presenting with this injury. In 2024, the NHFD plans to replace the AMTS with the 4A test (4AT), so all patients are additionally assessed for delirium on presentation. This study aims to compare the AMTS and 4AT for this patient group, so the NHFD and our local team can anticipate the consequences of this change in patient assessment.

Methods

The clerking house officer completed both AMTS and 4AT for patients admitted consecutively under the ‘femur fracture pathway’ to University Hospital Wales between August-October 2023. We classified an AMTS < 8 and 4AT = 1-3 as suggestive of cognitive impairment. A 4AT ≥ 4 also indicated possible delirium.

Results

A total of 100 patients were included, 65 female and 35 male. 4AT was normal (0) in 67/75 patients with normal AMTS (8+). 4AT was abnormal (1+) in 24/25 patients with abnormal AMTS (<8). Screening with 4AT highlighted possible delirium in 15 patients (15%) which may not have been identified by AMTS. Four questions from AMTS form the ‘AMT-4’ sub-domain of 4AT. AMT-4 was normal (0) in 73/75 patients with a normal AMTS, and abnormal (1+) in 22/25 patients with an abnormal AMTS (sensitivity 0.88, specificity 0.97).

Conclusion

The 4AT provides invaluable training in delirium recognition for junior doctors, and highlights aspects of cognition (such as delirium) missed by the AMTS whilst being a quick, user-friendly tool. The AMT-4 subdomain of 4AT proved remarkably consistent with full AMTS results. Our findings are being integrated into local clerking protocols and used by the NHFD in its redesign of cognitive screening nationally.

Introduction: Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness. This has serious consequences including the increased risk of dementia, death, length of hospital stay and increased chance of new admission to long term care. Therefore, prompt identification and management is essential. NICE recommends the use of the 4AT score in identification of delirium to improve subsequent management.

Methodology: A retrospective descriptive study was done identifying all patients admitted to Wigan infirmary who received a 4AT during the 1/4/22- 30/9/22. Patients were excluded if aged 64 4AT score of 1-3 (a score over 4 is positive for delirium) and had multiple admissions. This reduced the sample size to 275 from 8648 patients, of these data was collected from the individual electronic records from the first 110 patients.

Results: The average age of patients within the sample is 81, average 4 AT score of 6 and the average CSF was 5. There was a diagnosis of delirium in 32 (29%), and 'confusion' in 10 (15%), a past medical history of dementia in 49 (45%) and cognitive impairment/ suspected dementia in a further 10 (9%), PD was found in 9 (8%) of patients. A basic blood test screen to identify a cause for delirium was done in 50 (45%) of patients. DNA CPR was present in 59 (54%) of patients, and a DOLS in 43 (39%) during the admission reviewed. Patients were on a significant number of medication (mean of 10 on discharge) and had an average of 3 ward moves. Length of stay was 20.3 days and 51 (46%) were deceased within a year of admission.

Conclusion: Embedding 4AT in electronic records improves recognition of delirium. Further work will be undertaken to improve management of this condition once it is recognised.

Introduction

The Mental Capacity Act is designed to protect patients who may lack the mental capacity to make decisions about treatment. At the Nuffield Orthopedic Centre (NOC) in Oxford, nurses obtain a baseline AMTS during the pre-operative assessment clinic. Following on from this, any patient over 64 years old that is seen by the orthogeriatrics team will have a post-op AMTS done to assess for cognitive impairment. If the AMTS is less than 8, or the patient is clinically believed to be delirious, then an MCA form will be completed for the decision to accept treatment. The aim of this QI project was to widen this practice to all the junior doctors at the NOC.

Method

AMTS and MCA data were collected from one month of inpatients >64 years old at the NOC. The AMTS were analysed and the patients with post-op AMTS of <8 were identified and checked for MCA form completions. The data was presented to junior doctors at the NOC, and a repeat cycle was performed to assess if the practice was being implemented.

Results

Data collected from 10/01/23 – 10/02/23 (n=125) showed that out of 10 patients meeting the AMTS criteria, only 4 had MCA forms completed. Once the QI projected was presented on 25/05/23, data collected from 12/06/23 – 15/07/23 showed that out of 5 eligible patients, 4 of them had MCA forms completed.

Conclusion

Prior to this QI project, only 40% of eligible patients from the collected data were having MCA forms completed by junior doctors at the NOC. Following the presentation to raise awareness, the data collected shows that this figure had increased to 80%. In conclusion, this QI project has been a success and should be repeated every 4 months to account for each new rotation of junior doctors.

The 4AT Score is a simple tool recommended by NICE to help detect Delirium in everyday practice. In QEH Gateshead, clerking sheets include this score however it is frequently missed by admission doctors.
Our QIP standard was that all patients >65 should be screened for Delirium in accordance with NICE Guidance and to improve this. Clerking sheets were audited to assess completion of 4AT scores.
Improvement Methodology included prompt cards on working computers, posters in handover rooms, verbal reminders and quick teaching after morning handover.
Run charts shows improvement in patients >65 screened for Delirium in both wards with non-random pattern / signal of change after interventions with too few runs, or crossings of the median line according to statistical table.
Our QIP highlights that posters and prompt cards are helpful tools that can aid as reminders, however may cause cluttering of workspace.
Next steps include further cycles without interventions to assess for compliance.
If targets are still not met we could consider liaising with IT department regarding incorporating checkbox on electronic patient system.

Introduction
Mittens are used to facilitate necessary interventions safely in patients who lack the mental capacity adhere to them. A serious incident (SI) occurred at our Trust when a patient, with delirium, developed pressure ulcers to their wrists as a result of prolonged use of mittens. A subsequent investigation revealed that there had been inadequate skin checks and insufficient documentation, from the medical team, directing the use of mittens.

Method
A multidisciplinary QIP was initiated: • For the Medical team: An electronic “Mittens Request Form” was created. This included fields to document a mental capacity assessment, the best interest decision and a link to apply for Depravation of Liberty Safeguards. There was also a prompt to prescribe mittens on the electronic drug chart. • For the Nursing team: A pre-existing electronic mittens checklist form was updated to confirm that a daily skin check had been completed. The outcomes of the SI report and changes above were communicated to the department. After the QIP, a notes review was completed for all patients over the age of 65 years who had a mittens checklist completed before and after the interventions. Notes were assessed for documentation of a mental capacity assessment, communication of a best interest decision, prescription of mittens and completion of a daily skin assessment.

Results
Documentation of a capacity assessment improved from 9% to 47%. Communication with relatives improved from 0% to 35%. Prescription of mittens, on the drug chart, improved from 0% to 24%. Documentation of a daily skin assessment Increased from 0% to 94%

Conclusions
This QIP brought about improved documentation of best interest decisions related to mittens and ensured regular skin checks. The next stages will involve expanding the QIP to other departments within the hospital and reinforcing messaging about communication with relatives and prescription of mittens.