Delirium

Delirium in hip fracture patients admitted from home is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation and readmission to acute services: The IMPACT Delirium study

RS Penfold1,2, AJ Hall2,3,4, A Anand5, ND Clement2,4, AD Duckworth4,6, AMJ MacLullich1,2

1. Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK 

2. Scottish Hip Fracture Audit, Edinburgh, UK 

3. Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK 

4. Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK 

5. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK 

6. Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK 

Aim 

Delirium is associated with adverse outcomes following hip fracture, but specific associations in patients admitted directly from home are less well studied. Here we analysed relationships between delirium in patients admitted from home with: (i) mortality; (ii) total length of hospital stay; (iii) need for post-acute inpatient rehabilitation, and (iv) hospital readmission within 180 days. 

Methods 

This study utilised routine clinical data in a consecutive sample of hip fracture patients aged ≥50 years admitted to a single large trauma centre between 01/03/20-30/11/21. Delirium was prospectively assessed as part of routine care by the 4’A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, level of social deprivation, and American Society of Anesthesiologists grade.  

Results 

A total of 1821 patients (mean age 80.7 years; 71.7% female) were admitted, with 1383 (mean age 79.5; 72.1% female) directly from home. 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1734): 14.1% (189/1340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20 day longer total length of stay (p<0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (Odds Ratio (OR) 1.69, 95% Confidence Interval (CI) 1.13-2.54; p=0.013), requirement for post-acute inpatient rehabilitation (OR 2.82, CI 1.99-4.00; p<0.001), and readmission to hospital within 180 days (OR 1.77, CI 1.01-3.11; p=0.046). 

Conclusions 

Delirium affects 1 in 7 patients with a hip fracture admitted directly from home and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. 

Introduction

Delirium remains under-recognised. We wished to improve recognition of delirium on our assessment wards.

Methods

Data was collected prospectively on two admissions wards between 18/10/21 and 30/01/23 initially weekly, and then periodically to assess for the presence of a 4AT assessment by post take ward round.

• PDSA 1 -Departmental meeting to raise awareness and creating of an improvement team including doctors and ward managers.
• PDSA 2 -Teaching ward nurses “How to” do a 4AT and education sessions for nurses on delirium. Online guide on 4AT
• PDSA 3 -Adding 4AT to the admissions checklist performed by nurses.

Results

On ward A, 4AT completion rates improved from 15.4% to 35% with a step change in completion rates with 6 points above the baseline. On ward B, 4AT completion rates improved from 14.8% to 24.5% with a step change improvement but with wider variability.

Conclusions

Ward teams felt that education and inclusion of the 4AT to the admissions checklist would result in significant improvement. Whilst a statistically significant improvement did occur, 4AT completion rates are still lower than desired and there was still some resistance to completion from both medical and nursing teams.

Ward A had a few nurses who took up admission 4AT completion enthusiastically, with strong local leadership from the ward manager. The nursing leadership of the wards changed during the time of the project, and consultant cover was at lower levels than has been the case historically.

We have now added 4AT to the “ward metrics” so wards will be measured on compliance. We have launched a trust-wide delirium improvement plan, supported by senior management. We plan for routine electronic collection of 4AT completion rates. In addition, we have designed a delirium care plan to link 4AT assessment to prevention and management 

Background

NICE and SIGN guidelines recommend screening of inpatients at risk of delirium using the 4AT (www.the4at.com) and communication of delirium to patients’ General Practitioners (GP). The aim of this audit was to establish whether delirium is currently being screened and documented, as recommended, in our Orthopaedic Trauma unit.

Methods

Data was collected by two junior doctors across four days (14/11/2022, 29/11/2022, 08/12/2022, 05/02/2023). Trauma and orthopaedic inpatients over the age of 65, who were more than four days post-surgery were included. Each patients’ medical notes, nursing notes, and drug Kardex was reviewed. Subsequently, all discharge letters available up until 8/2/23 were reviewed and documentation of delirium recorded.

Results

Forty patients were included in the study, of which, 29 (72.5%) were screened using the 4AT on both day-one and day-four post-operation. Of these 29 patients, 13 had delirium documented. Nine had a positive 4AT score and four had a negative 4AT score. One patient had documented delirium without a 4AT assessment. Of the 14 patients who had delirium documented, eight had delirium recorded on their discharge letter and four were yet to be discharged at the time of final data collection. Potential reasons for not using the 4AT included expressive dysphasia, review completed by a senior doctor using continuation rather than the proforma pages used by junior doctors, and documented confusion (unclear whether acute or chronic).

Conclusion

As per NICE and SIGN guidelines all patients with indicators for delirium (i.e. older trauma patients) should be screened for delirium using the 4AT. This audit identified a delirium screening rate of 72.5% in our unit. The majority of patients with delirium (8/10) had it documented on their discharge letter and thus was communicated to their GP. Further work to raise delirium awareness and confidence in delirium management in our unit is planned.

Introduction

Frailty is defined as “a condition characterised by loss of biological reserves, failure of physiological mechanisms and consequent increased risk of experiencing a range of adverse outcomes, including hospitalisation, longer length of inpatient stay, and delirium” [1-4]. We aim to investigate the association between baseline frailty and functional recovery amongst hospitalized older adults and its association with inpatient delirium.

Method

Retrospective analysis of patients admitted to a Geriatrics ward from August to November 2022. Interactions between clinical outcomes with age, length of stay (LOS), discharge destination, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated plus incidence of inpatient delirium.

Results

In total, 58 patients reviewed, mean age 78.8 (±15.1) years, 43 (74%) woman. 79% were admitted from their own home with 56% same discharge destination and 9% inpatient mortality. Median LOS in hospital was 13 days with 8 days on the Geriatrics ward. Mean CFS on admission compared to discharge was (4.9 vs 5.7 (p<0.001)), with no significant difference in CCI. There was a significant association between CFS and LOS, both overall and on the Geriatrics ward (P<0.001). 17 patients (29%) developed delirium, with increased LOS (45 days vs 9 (P<0.001)), increased CFS both on admission (5.9 vs 4.4 (p=0.002)) and discharge (7.4 vs 5.0 (p<0.001)) and were less likely to be discharged to their own home (33.3% vs 84.8% (p<0.001)).

Conclusion

Frailty is a powerful predictor for possible risk of deconditioning and is associated with longer acute hospital stay in our more vulnerable patients. The coexistence of frailty and delirium significantly increased the risk of a prolonged hospital stay. This indicates that a multidisciplinary approach to provide a comprehensive geriatric assessment, is necessary to decrease LOSand the incidence of adverse outcomes as during this time period we had limited specialist therapy staff on the ward

Introduction

Delirium is a common condition in older hospitalised patients causing high morbidity and mortality. The neurobiological basis for delirium is uncertain and, for numerous reasons, research in this area has been limited. Several recent studies have demonstrated that functional neuroimaging in delirium is achievable and has suggested that a brain region termed the default mode network (DMN), may play a cardinal role in delirium pathogenesis. We set out to develop a pilot study to demonstrate that it is feasible to undertake functional magnetic resonance imaging (fMRI) scans in older patients with acute delirium.

Methods

Observational pilot study obtaining a fMRI scan of inpatients in an Australian, tertiary hospital, geriatric ward. Eligible patients diagnosed as delirious by a geriatrician were compared against non-delirious controls. Informed consent was obtained. A novel scanning paradigm was developed. Sequences assed brain structure and functional networks in resting state and during a simple task of sustained attention and response inhibition.

Results

11 participants have been scanned. 6 participants were delirious: mean age 81 years (range 77 – 85 years), 3 female. 5 participants were non-delirious: mean age 83.4years (range 79 -90 years), 2 female. 10 of the 11 participants completed the full imaging protocol, including task engagement. Head movement during scanning, was generally within acceptable limits. Data demonstrates considerable cortical atrophy and ventricular enlargement consistent with age. Preliminary fMRI analyses show a variable pattern of cortical recruitment during task engagement in delirious patients.

Conclusions

These findings show it is ethically and logistically feasible to engage elderly patients with acute delirium into a high end structural and functional imaging study.

Introduction

“Pathway three delirium” is a short-term placement in a care home specific to North Yorkshire, for patients diagnosed with delirium during hospital admission, who are medically fit but have not recovered cognitively enough for discharge home. The goal is to allow extra time to recover from delirium, to allow return to patients’ own homes. At this placement, patients are followed up by the acute hospital liaison team.

Aims

To assess final discharge destinations after pathway three delirium placement.

To analyse characteristics between discharge groups.

Methods

We analysed electronic records of patients on this pathway between August 2020 and November 2021. Data was gathered on age, gender, prior cognitive impairment, visual impairment, hearing impairment, living alone, requiring package of care, and alcohol misuse.

Results

64 patients were included, 39 females (61%), 25 males (39%), average age of 83.7 years.

20 (31%) were discharged home, 26 (41%) remained in residential or nursing homes, 10 (16%) were readmitted to hospital, 8 (12%) discharge location was unknown or “other”.

Average age of those discharged home was 82.65yo, those discharged to residential/nursing homes: 83.88yo, and those readmitted: 85.8yo.

80% of those discharged home were women, compared to 61% of the total group and 50% of those who remained in nursing/residential care.

The discharged home group contained 80% patients who lived alone, versus 58% in the residential/nursing home group, and 30% in readmitted. 25% of the home group had a care package pre-admission: versus 46% in the residential/nursing home group, and 38% across all groups.

Cognitive impairment, sensory impairment and alcohol intake showed no apparent difference across destination.

Conclusions

These findings show that this short-term delirium placement enables some patients to return to their own home. Analysis suggests that younger patients, women and those with apparently less social support were more likely to go home.

Background: Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Our aims: improve delirium detection using the 4AT screening tool as a validated approach, Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Methodology: Plan Do Study Act (PDSA) methodology was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results: Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion: Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway.Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.