Delirium: partnership approaches to improving care Alasdair MacLullich Professor of Geriatric Medicine Consultant in Geriatric Medicine University of Edinburgh 1

What is delirium? Severe, acute neuropsychiatric syndrome Cognitive impairments Reduced or increased level of consciousness Psychotic features are common Resolves in 80% Mainly affects older people in hospital

Delirium is common and serious >120 patients per 1000-bedded hospital 1 in 5 dead in a month  New institutionalisation Strong marker of dementia Accelerates existing dementia; linked with new onset dementia Distressing High healthcare and social costs

Distress in delirium “No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.” New York Times, June 20, 2010 4 4

Challenges Delirium affects 1 in 8 hospital patients; outcomes are poor Many staff do not know about delirium Detection levels are low (<30%) Treatment is complex Public & policy-maker awareness is low Etc.

delirium care: multiple domains Policy makers Funders Public Improving delirium care: multiple domains Systems of care Senior clinical staff Junior clinical staff Hospital managers 6

Scottish Delirium Association Founded 2011 Pragmatic, clinical focus ~20 in core group Meetings every three months Representatives in most Scottish Health Boards Inter-disciplinary Good collective experience of clinical care improvement work

2012: decision that delirium would be a key focus of OPAC work Approached SDA members with a view to collaborative working  Close working relationship since

Collaboration Joint shaping of main goals Educational resources & events Dissemination Ongoing review process

Detection of delirium Yet <20% of delirium is formally detected Triggers delirium management Crucial diagnostic information to patients and carers Urged by policy-makers Yet <20% of delirium is formally detected

4AT delirium test Rapid, simple test for routine clinical practice Developed in Edinburgh in 2010-2011 for local use www.the4AT.com website generated additional interest Used in various UK and international sites But not widely implemented (no delirium tool is) Adopted by HIS as part of delirium improvement work 13

4AT as part of HIS delirium package kg

Clinical management of delirium Delirium is a medical emergency Early assessment for life-threatening triggers is crucial Complex: multiple aspects Systematic approach is best

New Delirium Care Bundle: overview

Delirium Care Bundle Berwick quote

New educational resources Video summaries Learnpro module to be launched this year

Information for patients and carers

Impact of collaborative work Greatly increased awareness 4AT tested and potentially adopted in multiple sites Higher level of delirium detection in test sites New care bundle implemented in test sites New educational resources for healthcare staff New patient information leaflet

Conclusions Delirium care improvement = complex Multiple elements HIS / academic /clinical collaboration has allowed progress on several fronts Increased awareness but also capacity to do multi-site testing  Big step forward in delirium care in Scotland 22