Delirium

Introduction 

Delirium complicates 10% of admissions. A delay in diagnosis can lead to permanent cognitive decline, care home placement and death. Watford General Hospital’s (WGH) delirium liaison service receives fewer referrals than expected from areas with vulnerable patients such as ITU. This audit sought to understand why and what effect this might have on outcomes. 

Method The audit team reviewed notes for all >75-years-old in WGH on a single day, looking for delirium risk factors, evidence of delirium and, if present, a diagnosis and management plan. Outcomes were reviewed at 90 days. 

Results Of 216 patients, 44% had evidence of delirium. 40% were missed, with only half of those diagnosed having a delirium-centred plan. Pareto analysis revealed 50% of >75-yr-olds on only four of twenty wards and 50% of delirium present on those same four wards. 90-day outcomes revealed: - Delirium is associated with higher mortality (OR 2.28) - Longer length of stay (LOS) (+3 days). - LOS was longer if delirium was missed (average 28.5 days) - Frailty is a predictor of delirium (OR 3.26) and mortality (OR 2.5) Subgroup analysis showed that, even when compared to other geriatrician led CGA based care, orthogeriatric patients with delirium had significantly higher rates of diagnosis (100% vs 53%), management (100% vs 35%), lower mortality (OR 0.55), comparable LOS, and fewer than half as many readmissions. 

Conclusions Delirium is concentrated on a small number of medical and orthopaedic wards. Orthogeriatric patients have significantly higher rates of diagnosis, delirium-focused plans, lower mortality and readmission rates. This data suggests that a best practice pathway, akin to that for hip fractures, mandating delirium screening for at-risk, especially frail, patients on high-risk medical wards may improve outcomes. This data has allowed us to develop a focused improvement plan based on a time-critical pathway. 

Introduction:

It is important to identify delirium on admission as delirium increases patient mortality and also is linked to an increased length of hospital admission (1). Delirium is identified through a scoring system such as 4AT (2) and should be done on all patients over 65, with new confusion, or reduced mobility (3) as per NICE guidelines. The aim of the QIP is therefore to bring the department in line with NICE guidelines and increase the number of patients in the over 65 cohort having a cognitive assessment, and in particular looking at those with confusion and falls as these can be presenting symptoms of delirium(3).

NICE guidelines state that all over 65s should have a cognition screen on admission to identify delirium and particularly those with symptoms of delirium (3).

This completed two cycle QIP aimed to improve the proportion of patients over 65 who presented with a fall, new confusion, or both fall and new confusion, who had a documented completed cognition screen on admission to CDU from Eastbourne ED.

Method:

From a random 2 week interval of CDU admissions, we identified those aged over 65. Using their clerking documentation we identified those presenting with fall, new confusion, or both. We assessed if they had an accepted completed cognition screen (MMSE, MOCA, 4AT, AMTS, SQuID) documented in their clerking. This required reading through the entirety of the clerking as there was no dedicated place for a cognition screen to be documented. This was repeated post intervention.

For cycle 1, a 4AT box with the four questions which generated a score was added to the electronic clerking proforma. For cycle 2 we organised and delivered in person teaching sessions for the junior doctors within the department. Juniors were recruited to act as 'delirium champions' and encourage a culture of delirium awareness through discussion at board rounds and within the department on a daily basis. The high turnover of A&E staff and the highly varied rota's posed a challenge to the efficacy of in person teaching sessions. To ensure the educational element was delivered to all, we created posters to educate on the presenting symptoms of delirium, the importance of early identification, and screening tools to use such as the 4AT box.

Results:

For CDU admissions for all over 65s, the percentage with a completed cognition screen increased from 0.02% to 5.10% after cycle 1, and increased further to 11.25% after cycle 2. For those admitted to CDU aged >65 with new confusion only (no falls), the percentage with completed cognition screen increased from 9.09% to 25.00% in cycle 1 and to 66.67% in cycle 2. For those aged >65 presenting with fall only (no confusion), the percentage increased from 0.00% to 4.35% in cycle 1 and to 26.32% in cycle 2. For those aged >65 with both fall and new confusion, the percentage increased from 0.00% to 11.76% in cycle 1 and to 33.33% in cycle 2.

Conclusion:

Including a 4AT prompt on the clerking proforma improved cognition screening for those with symptoms of delirium. However, clerking proforma changes alone are insufficient and much greater improvement was achieved through the combination of proforma changes (4AT box) and departmental educational initiatives. It is additionally important to consider a variety of educational initiatives in a department such as A&E with high staff turnover and varied rota's which can limit engagement with traditional in person teaching sessions.

References:

1. Anand, A. et al. (2022). Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and Home Time: Two-centre study of 82,770 emergency admissions. Age and Ageing, 51(3). Available at: https://doi.org/10.1093/ageing/afac051.
2. Jeong, E., Park, J. and Lee, J. (2020). Diagnostic test accuracy of the 4AT for delirium detection: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(20), p. 7515. doi:10.3390/ijerph17207515.
3. NICE (2010). Recommendations: Delirium: Prevention, diagnosis and management in hospital and long-term care: Guidance (2010) NICE. Available at: https://www.nice.org.uk/guidance/cg103/chapter/Recommendations#assessment-and-diagnosis (Accessed: 07 January 2024). Last updated: 18 January 2023

Background: This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction: Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method: An initial audit measured delirium prevalence using 4AT in patients aged >65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. Staff answered questionnaires relating to delirium awareness and screening. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented, and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results: 36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion: Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.

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

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.

Delirium is a neuropsychiatric syndrome characterised by an acute fluctuation in attention and cognition and affects approximately one quarter of older patients admitted to hospital (1) (2). Delirium results in increased length of stay, increased risk of long-term cognitive impairment, increased mortality, and results in significant patient and carer distress (3) (4) (5). Electronic patient records for adults admitted to the Frailty Acute Medical Unit (fAMU) at Huddersfield Royal Infirmary from 2022 to 2024 were reviewed to assess whether delirium was identified, and whether this was discussed with patients’ carers. Interventions were implemented with the aim of improving communication about delirium early in admission amongst staff and carers. This included raising awareness via World Delirium Day, educational posters, carer leaflets and certificate incentives for staff. Data collection was repeated following each new intervention introduced. As a result, there was an increase in the frequency of conversations had with carers. Through facilitating discussions about delirium, the aim is to improve carers’ recognition and understanding. This would enable earlier supported discharges into a more familiar or appropriate environment utilising the Virtual Frailty Ward. Better understanding also leads to reduced delirium-related distress amongst carers (3). Carers can take a more active role in the prevention and management of delirium; identifying common triggers, regular reassurance, reorientation to time and place, and redirection. Future work should focus on the relationship between improved carer communication and its impact on reducing patients’ length of stay.

Bibliography

1. The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study. Gibb K, Seeley A, Quinn T et al. 2020, Age Ageing, no.49, pp. 352–60.

2. Delirium. Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AM, Slooter AJ, Ely EW. : Nature Reviews Disease Primers., 2020 , Vol. 6.

3. Distress in delirium: causes, assessment and management. . Williams, S.T., Dhesi, J.K. & Partridge, J.S.L. : Eur Geriatr Med, 2020, Vol. 11.

4. Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies. . Davis DH, Muniz-Terrera G, Keage HA et al. : JAMA Psychiatry, 2017, Vol. 74.

5. Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. Geriatric Medicine Research Collaborative. : BMC Med, 2019, Vol. 17.

Introduction: Delirium is a common and serious complication in frail older patients undergoing emergency hip fracture surgery, often resulting in prolonged hospital stays, increased morbidity, and a greater risk of long-term cognitive decline. Recognizing and managing delirium effectively is critical in improving patient outcomes. However, initial assessments indicated variability in the confidence and capability of surgical postgraduate doctors to assess and manage delirium appropriately. A baseline survey revealed that 50% of staff were not familiar with hospital delirium guidelines, and 62% rated their confidence in managing delirium as 3 out of 5. Additionally, over one-third of staff inappropriately used the AMT10 as a delirium screening tool, and many lacked confidence in interpreting the 4AT score.

Method: To address these gaps, we implemented a multipronged educational program to improve staff knowledge and confidence in delirium assessment and management. This approach included formal teaching sessions, the display of delirium infographics in ward areas, and the dissemination of key information via email and WhatsApp. The program emphasized the appropriate use of the 4AT for screening and highlighted common delirium triggers and their management.

Results: Post-intervention analysis showed an improvement in both the confidence and accuracy of delirium assessment among staff. All staff were able to use the 4AT correctly, and everyone reported increased confidence in assessing delirium. Management practices revealed that pain, infection, constipation, and electrolyte abnormalities were generally well-addressed in patients. However, there remained a lower frequency of medication reviews, along with insufficient attention to nutrition and hypoxia as potential contributors to delirium.

Conclusion: Our educational intervention significantly enhanced staff confidence and competence in detecting and managing delirium in the trauma and orthopaedic ward setting. Following these improvements, the next phase of our project is to introduce a standardized delirium care bundle in the surgical setting. This care bundle aims to establish a structured approach to delirium management, thereby minimizing delirium-related complications and improving overall patient care.

Introduction: Delirium is a common and reversible neurobehavioral condition with significant morbidity and mortality ramifications. Consequentially, clear guidelines exist pertaining to its swift identification and management. However, studies suggest adherence to these guidelines is poor. This audit evaluates compliance to the National Institute for Health and Care Excellence’s (NICE) delirium guidelines in an Acute Senior Health Unit (ASHU) and presents a single centre experience of low-cost ward-based interventions for improving 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, an acute neuropsychiatric syndrome, affects one in four hospitalised older adults. Effective management requires timely detection using validated tools and a structured approach to causes and sequelae. There is limited evidence on contextual factors surrounding assessment tool implementation and delirium management. The primary aim of this study was to describe the use of validated delirium assessment tools across Scotland, with a secondary aim of describing protocols for delirium management and barriers to implementation.

Methods:

This was a secondary analysis of national Scottish data from a global point-prevalence study conducted on World Delirium Awareness Day, March 15, 2023. Data were collected via an anonymous survey distributed through social media and professional networks, covering inpatients in acute hospitals, including ICUs, at two timepoints (8am/8pm). The survey collected data on the presence of delirium, delirium assessment tools used, management protocols, and barriers to effective delirium care.

Results:

A total of 120 survey responses were received from 13 hospitals, reporting on 3257 patients at 8am and 2436 patients at 8pm. Most respondents were doctors (72.5%). The most frequently reported assessment tool was the 4AT (75%), and 14.2% of units reported using personal judgement rather than a validated tool. The overall delirium prevalence was 22.3% at 8am and 23.2% at 8pm, with the highest rates observed in geriatric units. Most units had delirium management protocols, but reported barriers to implementing delirium assessment and management including staff shortages, lack of time and insufficient training.

Conclusion:

This study highlights widespread use of the 4AT for delirium assessment in Scotland. There is variation in existing delirium management protocols, and significant barriers remain to effective implementation. Findings emphasise need for ongoing awareness, education, and resources to improve delirium care. Future research should focus on developing delirium management protocols and exploring context-specific barriers to improve patient outcomes.