1. THINK DELIRIUM Matt Lambert Clinical Lecturer and Specialty Registrar in Geriatric Medicine and Stroke mlambert@nhs.net

2. What I’m going to talk about Why am I here talking about delirium? Why is it important? How do we diagnose delirium and how bad are we at it? How should we be managing delirium? How can we do better?

3. What I’m going to talk about Why am I here talking about delirium? Why is it important? How do we diagnose delirium and how bad are we at it? How should we be managing delirium? How can we do better?

4. Dear Receiving Doctor, Re: Mrs Connie Fused 0101240125 Thank for admitting this 89 year old lady with confusion. She has a history of vascular dementia, TIAs, OA of her hips, depression and AF. She has recently been treated for recurrent UTIs. She normally lives alone with a carer once daily. Over the last few days her carers have noticed that she has become more confused and is incontinent of urine. Her medication consists of aspirin, simvastatin, bendrofluazide, co-codamol 30/500, citalopram, levothyroxine and tolterodine. Thank you for assessing her. Yours sincerely, GP

5. Patient experience

6. Delirium Matters ◦ Loss of independence ◦ Higher chance of being admitted to institutionalised care - 83% of those with persisting delirium at discharge, 68% with resolved delirium, 42% in those who never had delirium. [1] 1.McAvay GJ, van Ness PH, Borgardus ST et al. Older adults discharged from hospital with delirium: one year outcomes. J Am Geriatr Soc. 2006: 54: 1245-50.

7. Delirium Matters ◦ Increased risk of mortality ◦ In patients who are admitted with delirium, mortality rates are 10-26% [1] ◦ Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge. [2] 1.McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12- month mortality. Arch Intern Med. Feb 25 2002;162(4):457-63. 2. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. May 1999;156(5 Suppl):1-20.

8. Delirium Matters ◦ Morbidity ◦ In patients who are elderly and patients in the postoperative period, delirium may result in a prolonged hospital stay, increased complications, increased cost, and long-term disability. [1] 1. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc. Jun 2005;53(6):963-9.

9. Delirium Matters Partly preventable and treatable Indicator of dementia ~2/3 of patients with delirium also have dementia Common 15% of adult acute general hospital patients 25% of acute geriatric patients Post hip fracture surgery: 40-60% 7% of everyone >65 will develop delirium annually

10. What I’m going to talk about Why am I here talking about delirium? Why is it important? How do we diagnose delirium and how bad are we at it? How should we be managing delirium? How can we do better?

11. Recognition Often unrecognised Fluctuation nature Overlap with dementia Lack of formal cognitive assessment Underappreciation of its clinical consequences Failure to consider the diagnosis important

12. Local Audit-AMU 20 case notes reviewed Inclusion – 75 years or older, been admitted for minimum of 8 hours Exclusion – referred with “delirium”

13. Local Audit-AMU Results All patients had potential precipitant or risk factor identified (6 had 1, 11 had 2, 3 had all 3) 7 patients had no cognitive screening performed 13 had a change in function or cognition documented 3 of these did not have a cognitive screen Delirium was likely in 11 patients Only diagnosed in 4 Delirium possible in further 3 patients Only excluded in 1 case

14. Local Audit-ASRU 5 sets of notes All met criteria suggestive of delirium 4 had existing dementia 4 had polypharmacy None had cognitive screening None had function formally tested None were described as “confused” or similar

15. Possible Conclusions Delirium under recognised Lack of awareness? Low on priorities? Not seen as a diagnosis? No system in place to look for delirium/cognitive impairment

16. Diagnosing Delirium “Acute confusion” “Acute confusional state” “Confusion” “Agitation” “Toxic psychosis” “Off the legs” “A bit knocked off” “Non-compliant with examination” “Disorientated in TPP” “Acute brain failure” “Global brain dysfunction” “Unable to obtain history” “Vague” “UTI” “not themselves today” Think Delirium

17. Tools to help diagnosis Confusion assessment method (CAM) 4AT

18. CAM Does the patient have: Inattention Symptoms that are acute AND fluctuating Disorganised thinking OR altered level of consciousness

19. Who has the delirium?

20. 4AT tool www.the4AT.com

21. What I’m going to talk about Why am I here talking about delirium? Why is it important? How do we diagnose delirium and how bad are we at it? How should we be managing delirium? How can we do better?

22. Delirium is a Medical Emergency A marker of: physiological stress acute illness It is not “normal”! Do ABC

23. What’s the cause?

24. Management 1.Treat precipitating factors 2.Decrease impact of predisposing factors 3.Decrease distress (patients and carers) 4.Manage agitation 5.Prevent complications 6.Follow up –review meds, cognition, rehabilitation

25. What I’m going to talk about Why am I here talking about delirium? Why is it important? How do we diagnose delirium and how bad are we at it? How should we be managing delirium? How can we do better?

26. Aims Increase recognition and diagnosis of delirium Encourage everyone to take it seriously and manage it fully

30. Plans Audit Audit management of patients with delirium Audit detection and management in wards 5/6 and RVH. Tests of change Trial delirium pathway in AMU initially for usability then role out more widely Being trialled on ASRU and ward 17 Education Delirium week Re-audit Re-audit diagnosis and management of delirium after change introduced.

31. Any Questions?