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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

10. 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

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

12. 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

13. 4AT delirium test Rapid, simple test for routine clinical practice
Developed in Edinburgh in for local use
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

14. 4AT as part of HIS delirium packagekg

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

16. New Delirium Care Bundle: overview

17. Delirium Care Bundle
Berwick quote

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

20. Information for patients and carers

21. 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

22. 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