Associate Professor Dianne Wynaden RN, PhD 9th September 2008 Delirium Associate Professor Dianne Wynaden RN, PhD 9th September 2008

Other team members Mr Malcolm Hare – Fremantle Hospital Ms Sunita McGowan – Fremantle Hospital Ms Gaye Speed – Fremantle Hospital Mr Ian Landsborough – Curtin Ms Shirley McGough – Curtin Ms Lynn Moore – Curtin/Fremantle

Background Increasing number of “confused” elderly patients in acute care setting led to many questions being asked around how to provide quality care High acuity, high cost, stress on health professionals, the patient and relatives

Background Implementation of dedicated rooms with permanent specialling facilities including the use of: Music Fiddle blankets Clock Non-slip mats etc 1950s furniture

Financial Cost So What? 10% of all hospitalised patients will suffer from a delirium Up to 89% in high risk groups (dementia) 50% or more of delirium goes unrecognised Financial Cost The economic impact of delirium is substantial, rivalling the health care costs of falls and diabetes mellitus

Cost of specialling/medical care Cost of complications Increased length of stay Higher level of care on discharge

Emotional cost Health Cost Patient / family/ carer stress Impact on nursing staff Decreased quality of life Health Cost Increased mortality Increased morbidity Loss of function

Why study delirium? International research: Medical and nursing staff not good at recognising delirium No definitive treatment Most effective treatment is PREVENTION

Why study delirium? Cost effective interventions to prevent delirium require identifying risk factors and addressing them systematically in each patient

Difficulty separating diagnoses Dementia Delirium Dementia with superimposed delirium Depression and dementia Made worse when: Inconsistent baseline information available when patient is admitted to the acute care setting

“Ad hoc” diagnosis of dementia based on unexplored assumptions Confusion is seen as a diagnosis rather than a symptom of an underlying problem

Differential Diagnosis Delirium Dementia Depression Onset Acute Chronic and insidious Coincides with life changes, sometimes abrupt. ALTERNESS Altered level of consciousness Alertness may fluctuate Varies May be unaffected MOTOR BEHAVIOUR Fluctuates; lethargy or hyperactivity May vary Psychomotor behaviour may be agitated or retarded or unaffected ATTENTION Impaired and Fluctuates Usually normal Usually normal, but may be distractible

Delirium Dementia Depression AWARENESS Impaired, reduced Normal Clear DURATION Hours Months to years At least preceding 2 weeks – to months PROGRESSION Abrupt Slow but stable Varies ORIENTATION Fluctuates in severity, usually impaired May be impaired May be selective disorientation MEMORY Recent and immediate impaired Recent impaired Selective or patchy impairment

Delirium Dementia Depression THINKING Disorganised, distorted, incoherent, slow or accelerated. Difficulty with abstraction, thoughts impoverished, difficulty finding words, poor judgement Intact, but may voice hopelessness and self depreciation PERCEPTION Distorted, illusions, delusions and hallucinations, difficulty distinguishing reality Misperceptions often present Intact; delusions, hallucinations absent except in severe cases STABILITY Variable, hour to hour Fairly Stable Some variability

Delirium Dementia Depression EMOTIONS Irritable, aggressive, fearful Labile. Apathetic, Irritable Flat, unresponsive, or sad; may be irritable SLEEP Nocturnal confusion Often disturbed; nocturnal wandering and confusion Early morning awakening OTHER FEATURES Physical cause may not be obvious Past history of mood disorder

What is delirium? Short-term disturbance of consciousness (Acute organic psychosis or acute confusional state) Characterised by acute onset, fluctuating course and inattention and either disorganised thinking or altered level of consciousness Must have a medical cause

What is delirium? Must not be better explained by pre-existing or evolving dementia Can occur at any age - dependent on risk factors Most commonly recognised delirium (DTs) – withdrawal from alcohol – screening for patients routinely

Types of delirium Hyper-alert - Most commonly recognised Hyper-vigilance Agitation Hallucinations Difficulty holding/shifting attention Hypo-alert - Most commonly linked to increased mortality/morbidity Lethargic, difficult to rouse Difficulty gaining attention

Types of delirium Mixed Fluctuates between features of both

Presentation of Delirium Fluctuating course often worse in early morning or night Visual hallucinations Persecutory delusions Impaired cognition and memory

Predisposing Risk Factors Age (> 65years old) Dementia Multiple Medications Sensory Impairment (Visual/Hearing) Dehydration

Predisposing Risk Factors Chronic physical illness Substance Use (including alcohol) Depression Neurological impairment Functional disability

* Precipitating Risk Factors Severe acute illness Changes to electrolyte or acid base Alterations in oxygenation Liver or kidney failure Hypoglycaemia

*Precipitating Risk Factors Malnutrition Alcohol or Benzodiazepine withdrawal Surgery, particularly cardiac and orthopaedic Immobility

* Precipitating Risk Factors Stroke Pain Infection Heart failure Multiple medications

Precipitating Risk Factors Use of catheters, particularly urinary Multiple medications Acute fracture Invasive procedures Use of restraints Iatrogenic events

Focus of program of research Keeping elderly people healthy in the acute care setting- major focus on confusion and particularly delirium

Prevalence of confusion A prevalence audit was conducted to identify how many confused patients were in the hospital. To be counted in the audit as “confused” patients had to be: Identified by staff as being confused, having a delirium, “being a bit off” or appearing depressed; and, These or other descriptors had to be documented in the patient’s notes.

Prevalence of confusion A total of 1209 patients were covered in the four audits over four weeks on 15 medical and surgical wards at two hospitals. Of these 183 patients (15%) were identified as confused: - 107 females and 76 males. - Mean age of 80.5 years. This rate is consistent with international research.

Possible causes of confusion Of the 183 patients 132 (72%) displayed features consistent with delirium: 58 patients (44%) = Possible delirium superimposed on a confirmed dementia. 48 patients (36%) = Diagnosed delirium that may or may not be hospital acquired. 26 (20%) = Possible delirium or organic brain disorder

The remaining 51 (28%) of the 183 patients: 29 (57%) = Behaviour related to confirmed dementia. 15 (29%) = Behaviour related to organic brain disorder that may or may not resolve. 7 (14%) = Behaviour related to probable unconfirmed dementia.

Discussion Points Prevalence rates probably under estimated. Most causes of confusion are related to delirium. Care of patients would be greatly facilitated if consistent use of the term delirium and not ill defined synonyms such as confusion were used. This would reduce diagnostic imprecision which often leads to the poor rates of recognition of delirium.

Discussion Points Managing confused patients in now the norm and many staff just accept this level of acuity Improved documentation on patient’s cognitive state is needed. Again, confusion is a poor descriptor to use as it is difficult to measure change over a period of time. As a result, staff may not identify the cause and continue to just manage the resulting behaviours.

Discussion Points Management is often compounded by a lack of baseline data on the patient’s level of cognitive functioning --- approximately 60% of patients in the audit came from home with no accompanying cognitive assessment.

Discussion Points Health professionals’ level of knowledge of the causes of confusion is also questionable. A study of nurses’ knowledge of delirium and associated risk factors demonstrated this (Hare, Wynaden, McGowan & Speed, 2006).

Nurses’ level of knowledge of delirium and associated risk factors Questionnaire sent to 1100 non-casual nursing staff 338 returns (30.7%). Poor level of recognition of risk factors particularly things like dementia, gender, hypoactive form of delirium. Level of knowledge of management of delirium was also low.

Qualitative study on nurses caring for patients with delirium Qualitative study conducted at two hospitals Two main themes emerged Inability to differentiate confusion Managing confused patients

Inability to differentiate confusion Three subthemes: Caring for so many confused patients Feeling helpless and frustrated Lack of education and training to assess confused and delirious patients

Managing confused patients Three subthemes: Safety issues Attitudes of staff The environment

Where to from here? Educational program in area of confusion/ delirium Assessment of cognition in the elderly should have the same importance as physical assessment in all health professional undergraduate curricula.

Where to from here? Develop a risk assessment tool to predict delirium in the same way as we predict risk for falls. Test tool in the Australian context Clinical pathways attached to risk assessment tool

Where to from here? Improve baseline cognitive assessment documentation for patient’s admitted from home/ residential care. Coordinated approach to specialist assessment AMT, MMSE; CAM, Delirium Rating Scale – prevent people being labelled as having dementia – cultural diversity taken into account in assessment

Where to from here? Nurse practitioner/ specialist in ageing to assess and manage issues in acute care situation - High impact and high cost of not accurately assessing patient – co-morbidity and mortality.

Where to from here? Elderly friendly hospitals. Educate elderly people “how to survive” hospitalisation. Improved discharge planning to ensure family and carers understand the experience of hospitalisation particularly when the patient has experienced a delirium.

Assessing and Managing Old Age Psychiatric Disorders Mini Mental State Examination/ Abbreviated Mental Test/ AMT4 Geriatric Depression Scale Confusion Assessment Method/ Delirium Rating Scale

ABBREVIATED MENTAL TEST (AMT) . Question 1. How old are you? 2. What is the time (nearest hour)? Address for recall at the end of test – this should be repeated by the patient, eg. 42 West Street 4. What year is it? 5. What is the name of this place? 6. Can the patient recognise two relevant persons (eg. nurse/doctor) 7. What was the date of your birth? 8. When was the second World War? 9. Who is the present Prime Minister? 10.Count down from 20 to 1 (no errors, no cues) TOTAL CORRECT (0 or 1 for each question) Score less than 8 indicates cognitive impairment. Source: Hodkinson HM. (1972). Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing, 1:233-8.

AMT4 What is your age? What is your date of birth? What place is this? What year is this? A score of 3 or < indicates cognitive impairment

MMSE See MMSE PDF

Geriatric Depression Scale DATE:           TIME (24hr):  Choose the best answer for how you have felt over the past week: Yes / No []   []   1. Are you basically satisfied with your life? []   []   2. Have you dropped many of your activities and interests? []   []   3. Do you feel that your life is empty? []   []   4. Do you often get bored? []   []   5. Are you in good spirits most of the time? []   []   6. Are you afraid that something bad is going to happen to you? []   []   7. Do you feel happy most of the time? []   []   8. Do you often feel helpless? []   []   9. Do you prefer to stay at home, rather than going out and doing new things? []   [] 10. Do you feel you have more problems with memory than most? []   [] 11. Do you think it is wonderful to be alive now []   [] 12. Do you feel pretty worthless the way you are now []   [] 13. Do you feel full of energy? []   [] 14. Do you feel that your situation is hopeless? []   [] 15. Do you think that most people are better off than you are? TOTAL  GDS:   (GDS  maximum score = 15) 0   -     4    normal, depending on age, education, complaints 5   -     8    mild 8   -   11    moderate 12 -  15    severe TEXT FOR YOUR RECORDS - click here:

Confusion Assessment Method (Diagnostic Algorithm) Feature 1: Acute Onset or Fluctuating Course This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? Feature 2: Inattention This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

Feature 3: Disorganized thinking This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4: Altered Level of consciousness This feature is shown by any answer other than “alert” to the following question: Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

Thank you Associate Professor Dianne Wynaden School of Nursing and Midwifery Curtin University of Technology GPO Box U1987 Perth, WA 6845 d.wynaden@curtin.edu.au (08) 92662203