Delirium facts and figures Daniel Davis Senior Clinical Researcher Consultant in Geriatric Medicine University College London Dementia Friendly Hospitals Dementia Action Alliance 24th November 2015

Overview What is delirium Why is it important How to diagnose delirium How to manage delirium It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk. 2

What is delirium?

A neuropsychiatric syndrome DSM-IV: Disturbance of consciousness Change in cognition Acute Physiological precipitant Cognitive decompensation under stress conditions Psychiatrists – describe it, Physicians naturally recognise the inverse nature of delirium: PREDISPOISING FACTORS PRECIPITATING FACTORS (this is actually borrowed from psychiatric formulation) There is evidence for this ... Inouye, Marcantonio But the KEY MESSAGE is that any research into delirium must account for BOTH these factors: from an EXPLANATORY point of view in order to assess whether it is the DELIRIUM PER SE (or underlying predis / precip factors) that is driving the adverse outcomes

Range of delirium severity Normal function Range of abnormalities of cognition: quantifiable Range of abnormalities of level of arousal Range of delirium severity It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk. ‘Untestable’ with most cognitive tests Coma 5

Subtype Mixed Hyperactive Hypoactive Wandering, aggressive Hyper-alert, agitated Strong Difficult to reason with Pulling at lines Easily recognised Often medicated Hypoactive Quiet, bewildered Sleepy, innattenitve “off-legs” Highest mortality – HR 1.6 Most often unrecognised More common Mixed Geront Series A: 2007; 62: 174-179

Why does delirium matter?

Why delirium matters Common 15% hospital Serious 20% mortality Marker for dementia 60% underlying Costly £13k / admission Distressing 15% prevalence in those aged 65 years and older, admitted to general medical beds 20% mortality in 3m = similar to anterior STEMI As a marker for dementia, individuals with delirium are an enriched source of persons with underlying dementia £13k per admission comes from the NICE economic analysis, and accounts for the short- and long-term complications of delirium. There may be a perception that patients are amnestic for delirium. That is a myth. Recall of delirium symptoms after the event can approach a PTSD-like disorder. Delirium is undoubtedly distressing for relatives. There is also evidence that delirium is distressing for care staff.

Diagnosis and management

Action plan Diagnose Precipitating and predisposing Optimise environment Treat specific symptoms It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk. 11

Initial approach [1] Assess arousal [2] Test cognition [3] Acute onset and/or fluctuating course? 12

Screening tests Confusion Assessment Method 4 “A”s Test Nursing Delirium Screening Scale Delirium Observational Screening Scale Recognising Acute Delirium As Routine

Causes Precipitants Infections Drugs (on/off) Specific organ failures Pain Bladder Bowels Predisposing Dementia Frailty Mobility

Management (+)/- Prevent Treat +/(-) Pharmacological +   Prevent Treat Pharmacological  +/(-)  (+)/- Non-pharmacological  +