Annals of Delirium Volume 14 Oct 2014

European Delirium Association 2014 www.europeandeliriumassociation.com 1

Annals of Delirium Care Volume 14, October 2014

Guest Editorial

Recently I gave a talk entitled Clinical care of delirium: where are we now and where are we going? at the British Geriatrics Society (Scotland Division) conference. I included a timeline of some of the landmarks in the expansion of the field thinking in particular of tangible effects on clinical practice in the UK. These landmarks included delirium appearing in DSM-III, the publication of specific delirium assessment scales, several key papers on risk factors and prevention, the Who Cares Wins report in 2005, the founding of the European Delirium Association in 2006, and key UK National Institute of Health and Clinical Excellence (NICE) documents on delirium: the Guidelines (2010) and Quality Standards (2014). In Scotland we have also had additional national impact from both the Scottish Delirium Association (founded 2011), a group of clinicians focused on providing pragmatic resources, and strategic government involvement from Healthcare Improvement Scotland since 2012. These and many other developments are now clearly having positive effects on the quality of routine care of delirium. We can be encouraged that delirium is now no longer generally overlooked, and is now coming to be recognised as a major problem in modern healthcare.

Ongoing improvements in delirium care will come from activity in many domains. Working to increase awareness of delirium among professionals, policy-makers and the public remains a priority because it is essential to producing mainstream change. As an example, in the UK the decision by the governmental bodies NICE and Healthcare Improvement Scotland to make delirium a focus of activity was strongly influenced by the engagement of a relatively small number of professionals (several

involved in the EDA) with an interest in delirium. The resources and implementation expertise of such policy-makers massively amplifies the adoption of good practice recommendations from expert groups in the field. Positive effects are now being seen in mainstream healthcare in the UK. Continued efforts at raising awareness, such as distributing the Scottish Delirium Associations Factsheet for Hospital Managers (see www.scottishdeliriumassociation.com), will likely yield large dividends.

Education of healthcare practitioners is another domain where harnessing the scale and authority of major providers is essential. Through engagement with relevant policy-makers, delirium is now featuring more prominently in curricula and in online training programmes. This required not only that the educational resources were produced, but also that national providers were approached about disseminating these resources. So our efforts in delirium education, tackling attitudes, skills, and knowledge, should not only be made in local and national educational events but also at the level where we can reach those not attending such events.

Implementation is a domain of healthcare which is rapidly developing, especially as proven improvement methodologies become more commonly employed. It is pleasing to see that several delirium meetings now include reports of the use of such methodologies in delirium; indeed there is a workshop on this in the EDAs next annual meeting in Cremona, Italy. Work on how we join up research findings with pragmatic implementation strategies will likely be an important growing area in the field.

Alongside raising awareness, providing education, and implementing what we know to be best practice, the field also needs an expanding programme of high quality research. There are too many issues to list here, but examples are the mechanisms underpinning delirium, the detailed epidemiology (especially addressing long-term outcomes), further development of measurement tools, and clinical trials of prevention and treatment strategies.
http://www.europeandeliriumassociation.com/http://www.scottishdeliriumassociation.com/


The EDA is active in all the above domains, and the programme of our forthcoming meeting in Cremona reflects this. Alessandro Morandi (Chair), Giuseppe Bellelli and other members of the scientific committee have put together a strong, highly varied and exciting programme with multiple international speakers and workshops. We also have even more space dedicated to new research presentations: this year we have had the largest ever number of abstract submissions for oral presentations and posters. Full details of the programme can be seen here: http://www.overgroup.eu/eda2014/. It is great to see the enormous achievements and rapid expansion of the American Delirium Society. This year also marked the inaugural meeting of the Australian Delirium Society, which was another huge success. We look forward to ongoing productive work with our sister international organisations, and hopefully many collaborative visits to our respective continents!

Please do promote the work of EDA our forthcoming meetings in Cremona and London (2015) as well as our website. Look out for an expansion of the website in 2015 (led by Stefan Kreisel and Daniel Davis), as we aim to put together a major centralised source of materials for delirium awareness-raising, education, clinical implementation, and science.

Resources and links referred to above can be found at: www.scottishdeliriumassociation.com

NICE Delirium Guidelines: https://www.nice.org.uk/guidance/cg103

NICE Delirium Quality Standards: http://www.nice.org.uk/guidance/qs63

Alasdair MacLullich Professor of Geriatric Medicine

University of Edinburgh, and President of the European Delirium Association

Developing delirium recognition and assessment in palliative

care: an update on the DePAC project

Annmarie Hosie The University of Notre Dame Australia Correspondence to: [email protected]

Introduction

Delirium is an acute neurocognitive condition [1] that is prevalent, distressing and debilitating for hospitalised patients, yet frequently under-recognised and under-prioritised in many clinical practice settings [2], including inpatient palliative care. [3] Fortunately, there is growing awareness of the need to build the palliative care delirium evidence-base and better align medical and nursing care with emerging evidence. [4]

Nurses are integral to optimal recognition and assessment of delirium by virtue of their 24-hour presence at the bedside and professional responsibilities. [5] However, nurses have variable delirium recognition capabilities. [6, 7] Various strategies have been recommended to engage nurses in better delirium recognition and assessment practices across care settings, including: use of validated tools, building their delirium capabilities using an array of educational approaches, and integration of cognitive and delirium assessment into ward rounds, routine documentation and patient handovers. [6-9] In order to better target strategies to enhance palliative care nurses delirium practices first requires exploration of: 1) impetus for change; 2) contextual factors that influence nurses delirium capabilities; 3) nurses perspectives of their experiences in delirium care; and 4) the barriers and enablers to changing individual and organisational practices.

This paper provides a brief overview of a research project exploring these factors in Australia.
http://www.europeandeliriumassociation.com/http://www.overgroup.eu/eda2014/http://www.scottishdeliriumassociation.com/https://www.nice.org.uk/guidance/cg103http://www.nice.org.uk/guidance/qs63mailto:[email protected]


Aim

The Delirium in Palliative Care Project (The DePAC Project) aims to determine how nurses can better recognise, assess and respond to patients delirium symptoms within palliative care inpatient settings.

Conceptual framework

Knowledge translation (KT) is the conceptual framework underpinning this doctoral research project. Knowledge translation is defined as a dynamic and systematic process by which knowledge moves more rapidly into practice, strengthens the health system and improves peoples health. [10] This conceptual framework was selected because it acknowledges the challenges of translating evidence into practice, and allows for a better understanding local health care context and the factors that impact on specialist palliative care service and nurse capacity to integrate delirium evidence into practice.

Setting

This research was conducted in Australia, where specialist palliative care inpatient units admit patients with complex needs related to life limiting illness, for the purposes of symptom management, respite and/or terminal care [11]. Despite the call for palliative care to broaden its remit to non-malignant life limiting illness, the majority of Australian inpatient units continue to serve a predominately advanced cancer population [12].

Methods

The DePAC Project is a three-phase sequential transformative mixed method design, composed of a series of sub-studies (Figure 1).[13] These studies have been configured to allow examination of delirium recognition and assessment in palliative care units from a multifaceted perspective, using a variety of qualitative and quantitative methodologies.

Results

Phase 1 - Scoping the problem

Study 1: A systematic review of delirium prevalence, incidence and implications for screening in palliative care inpatient settings identified eight studies (1996 -2008) of predominately advanced cancer populations (98.9%). [14] Studies screening patients at least daily for delirium reported higher incidence (32.8%45%), while delirium prevalence was 13.3%42.3% at admission, 26%62% during admission, and 58.8%88% in the weeks or hours preceding death. The conclusions emerging from this systematic review found that delirium occurrence rates in palliative care inpatient settings support the need for routine screening in clinical practice. However, to support this practice change there is a need to establish which delirium tools and processes are most feasible, valid and acceptable for palliative care patients and their families. [14]

Study 2: A cross sectional study prospectively measured 24-hour delirium point prevalence in inpatients (n=47) of two palliative care units, using the Nursing Delirium Screening Scale (NuDESC) [15], Memorial Delirium Assessment Scale (MDAS) [16] and the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) [1] diagnostic criteria for delirium. Results revealed that this cohort was primarily an older (mean age 74 years (SD +10) and advanced cancer population (96%), with only two patients (4%) considered by clinicians to be in their last days or hours of life. [17] Sixteen patients (34%) screened positive for delirium, with a fifth (19%) meeting the full DSM-5 diagnostic criteria for delirium (n=9). These results are similar to that reported in the systematic review [14] and support the need for routine processes for delirium recognition and assessment within Australian inpatient palliative care services.
http://www.europeandeliriumassociation.com/


Study 3: An environmental scan examining organisational capacity to recognise and assess delirium in palliative care inpatient settings is currently underway, with initial data obtained through structured group interviews with key personnel of three metropolitan palliative care inpatient units. Preliminary data indicate that policies and procedures guiding delirium practice and routine screening and assessment processes are absent within this setting. However, there are opportunities for future practice change strategies to be incorporated into existing systems; for example: through routine daily delirium symptom screening [18] and structured clinical handover using ISBAR (Identify, Situation, Background, Assessment and Recommendation), a mnemonic designed to improve safety and consistency in the transfer of patient information. [19]

Phase 2 Exploring palliative nurses delirium experiences, perceptions and capabilities

Study 4: A series of semi-structured interviews using the critical incident technique explored inpatient palliative care nurses:

a. delirium recognition and assessment capabilities; [20] and

b. perceptions of the barriers and enablers to delirium recognition and assessment for palliative care inpatients. [21]

In brief, palliative care nurses experience a range of emotions when caring for patients with delirium symptoms, including empathy, puzzlement and distress. These nurses acknowledged the need to improve their delirium knowledge and expressed a preference for locally delivered education that is relevant to the palliative care context. They believed that integrating delirium guidance, routine systems and screening tools would better support their practice. Ambiguous terminology, such as terminal agitation or terminal restlessness, impeded nurses understanding, communication and assessment of delirium. Findings revealed a need for team communication that is more consistently respectful, structured and explicitly focused on patients delirium status. [20, 21]

Study 5: A mixed methods study exploring the feasibility and acceptability of the NUDESC in the palliative care inpatient setting resulted in bedside nurses applying the tool for 100% of inpatients at two palliative care inpatient units at least once during eight 24-hour periods. Per shift, a 97% completion rate was achieved. Additionally, the perspectives of nurses who had used the NuDESC (n=19) were obtained through rapid focus groups, with thematic content analysis and integration of data soon to be finalised and reported.

Phase 3: Narrowing the evidence-practice gap

Study 6: A Quality Improvement Initiative adopted a Plan-Do-Study-Act [22, 23] approach, to identify and test small steps to develop palliative care interdisciplinary practice and systems in delirium recognition and assessment in one palliative care unit. These steps included: 1) implementation of the NuDESC; 2) addition of tick-box prompts for nurses to document and communicate a positive NuDESC score to the doctor and nurse in charge; 3) bedside guidance on delirium assessment, communication and non-pharmacological intervention. Testing of change revealed that while nursing staff achieved a high rate of completion of the NuDESC, a positive NuDESC score did not consistently lead to documentation of interdisciplinary communication, delirium assessment, delirium diagnosis nor care planning for patients.

Final steps

This program of research is in the final stages of data analysis and writing up. These data will inform the development of a model to guide future practice development and research initiatives related to delirium care of patients receiving palliative care, which will be disseminated widely.

Conclusions

The DePAC project has provided important insights into the barriers and enablers shaping palliative care nurses delirium screening and assessment practices. Better understanding of the impetus for practice


change, as well as the context in which nurses practice, will enable the development of more tailored interventions to address the barriers and harness the enablers that will change individual and organisational practices in delirium recognition and assessment within palliative care inpatient settings.

Acknowledgements

The author gratefully acknowledges the contribution of Professor Jane Phillips, Professor Patricia Davidson, Associate Professor Meera Agar and Professor Elizabeth Lobb in The DePAC Project design, conduct and dissemination, and all managers and nurses who have supported and participated in this research.

References

1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)2013, Arlington, VA: American Psychiatric Publisher.

2. National Clinical Guideline Centre for Acute and Chronic Conditions, Delirium: diagnosis, prevention and management, NICE Clinical Guideline 103, 2010, National Institute for Health and Clinical Excellence: London.

3. Fang, C.K., et al., Prevalence, detection and treatment of delirium in terminal cancer inpatients: A prospective survey. Japanese Journal of Clinical Oncology, 2008. 38(1): p. 56-63.

4. Lawlor, P.G., et al., An Analytic Framework for Delirium Research in Palliative Care Settings: Integrated Epidemiological, Clinician-Researcher and Knowledge User Perspectives. Journal of Pain and Symptom Management, 2014(0).

5. Nursing and Midwifery Board of Australia, National Competency Standards for the Registered Nurse, 2006, Nursing and Midwifery Board of Australia: Melbourne.

6. Steis, M.R. and D.M. Fick, Are nurses recognizing delirium? A systematic review. Journal of Gerontological Nursing, 2008. 34(9): p. 40-49.

7. Agar, M., et al., Making decisions about delirium: A qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology. Palliative Medicine, 2012. 26(7): p. 887-96.

8. Brummel, N.E., et al., Implementing delirium screening in the ICU: Secrets to success. Critical Care Medicine, 2013. 41(9): p. 2196-2208.

9. Registered Nurses Association of Ontario, Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (With revised 2010 supplement), 2004, Registered Nurses Association of Ontario: Toronto.

10. World Health Organisation, Bridging the KnowDo Gap Meeting on Knowledge Translation in Global Health WHO, Editor 2005: Geneva, Switzerland.

11. Palliative Care Australia, A Guide to Palliative Care Service Development: A population based approach, 2005, p.7, Palliative Care Australia: Deakin West.

12. Palliative Care Outcomes Collaborative, National Report on Patient Outcomes in Palliative Care in Australia, 2013, Centre for Health Service Development, University of Wollongong PCOC Central Cancer and Palliative Care Research and Evaluation Unit, University of Western Australia PCOC West Department of Palliative and Supportive Services, Flinders University of South Australia PCOC South Institute of Health and Biomedical Innovation, Queensland University of Technology - PCOC North.

13. Creswell, J.W., & Plano-Clarke, V. , Designing and conducting mixed methods research2006, Thousand Oaks, California: Sage Publications.

14. Hosie, A., et al., Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review. Palliative Medicine, 2013. 27(6): p. 486-498.

15. Gaudreau, J.D., et al., Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening


scale. Journal of Pain and Symptom Management, 2005. 29(4): p. 368-375.

16. Breitbart, W., et al., The memorial delirium assessment scale. Journal of Pain and Symptom Management, 1997. 13(3): p. 128-137.

17. Palliative Care Clinical Outcomes Collabrative. Clinical Reference Manual Version 3 Dataset. 2012; Available from: http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow137241.pdf.

18. Eagar, K., The Australian Palliative Care Outcomes Collaboration (PCOC) - Measuring the quality and outcomes of palliative care on a routine basis. Australian Health Review, 2010. 34(2): p. 186-192.

19. SA Health. Clinical handover. 2012 September 29 2014]; Available from: http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/clinical+handover.

20. Hosie, A., et al., Palliative care nurses' recognition and assessment of patients with delirium symptoms: A qualitative study using critical incident technique. International Journal of Nursing Studies, 2014. http://dx.doi.org/10.1016/j.ijnurstu.2014.02.005.

21. Hosie, A., et al., Identifying the Barriers and Enablers to Palliative Care Nurses' Recognition and Assessment of Delirium Symptoms: A Qualitative Study. Journal of Pain and Symptom Management, 2014. http://dx.doi.org/10.1016/j.jpainsymman.2014.01.008.

22. NSW Ministry of Health. Plan, Do, Study, Act cycle. 2013; Available from: http://www.health.nsw.gov.au/pfs/Pages/PDSA.aspx.

23. Clinical Excellence Commission. Clinical Practice Improvement. 2014; Available from: http://www.cec.health.nsw.gov.au/programs/clinical-practice.

Figure 1


Older loved ones and delirium: The experiences of family members in Australia

Dr Jenny Day & Professor Isabel Higgins School of Nursing and Midwifery, University of Newcastle, Australia Correspondence to: [email protected]

In this Annals item we provide a summary of research undertaken by the first author for her doctoral studies. Whilst a full report is under review for publication, our aim is to bring the thesis findings to the attention of researchers and clinicians committed to understanding delirium from the perspective of family.

Introduction

In light of the prevalence of delirium (Bruce, Ritchie, Blizard, Lai, & Raven, 2007; Siddiqi, House, & Holmes, 2006), and by virtue of love, a sense of duty, roles or responsibilities, family members of older people are likely to encounter delirium and the changes to their loved ones demeanour that ensue. Family members also become involved in their loved ones care during delirium in order to assist nursing staff to manage their loved ones disruptive behaviours, the increased workload, safety issues and general ward disruption (Dahlke & Phinney, 2008; Hallberg, 1999; Rogers & Gibson, 2002; Segatore & Adams, 2001). Family member involvement is also suggested in clinical guidelines and research as an important way of improving the therapeutic environment for the older person, and preventing, detecting, monitoring or managing delirium (Harding, 2006; Rapp, 2001). Care involvement is, however, despite little being known about the experiences of family members at this time.

Approach & Methods

Guided by phenomenology, the aim of this study was to describe the experiences of family members during their older loved ones delirium. There were 14 family members in this study; twelve daughters and two wives who cared for their loved ones at home, in residential aged care and/or while hospitalised. The older people included 8 mothers, 2 fathers and 2 husbands (n=12) aged 69-100 yrs. Seven had pre-existing early/moderate dementia. Delirium was determined by diagnosis or participant description concordance with recognised delirium identification/diagnosis criteria. Data from in-depth interviews over 19 months, field notes and reflections, and media depictions were analysed. Data interpretation was thematic, informed by the phenomenologies of Merleau-Ponty (1945/2002) and Sartre (1943/2003).

Findings

Changing family portraits: Sudden existential absence during delirium depicts the womens experiences during their older loved ones delirium. The notion of existential absence reveals how the women suddenly lost the familiar and taken-for-granted presence of their loved one, and experienced the presence of a stranger. The meaning of existential absence for the women is described further by the following theme and sub-themes:

Living the fragility of a loved ones presence:-

Facing a loved one's existential absence, and

Living with a stranger.

During delirium the womens attention was focused on their older loved one; the person they expected to meet and depicted in their family portraits. However, delirium suddenly and markedly altered the very nature of the person the women were with, changing who they experienced as present, or in-person. Delirium was lived as a sudden, imposed and traumatic absence of their mother, father or husband, whilst
http://www.europeandeliriumassociation.com/mailto:[email protected]


the unfamiliar and bizarre ways the person behaved redefined their loved one as a stranger. Though immersed in absence they were called on to be with, and support, a stranger.

Certain qualities characterised the nature of the absence experienced by the women; it was unexpected, distressing and pervasive. Unlike other losses some women had experienced during their loved ones dementia, experiencing absence during delirium was a shock; it was unforeseen rather than anticipated, sudden rather than insidious, unpredictable rather than predicable. Their older loved ones absence came quickly and without explanation and was incongruous with their loved ones continued corporeal presence. No matter if their loved ones delirium lasted for a short time or persisted, absence was difficult for the women to comprehend; their loved ones absence was unrelated to their loved ones physical death and seemed to break the unity of their older loved ones corporeal presence and self.

The second theme and sub-themes add further insights into the womens experience of existential absence:-

Living life holding on:-

Waiting for a loved one,

In the dark,

On the fringe but centre stage,

On thin ice, and

Keeping secrets.

The women experienced having little control over what was happening and lived life holding on to their memories of their loved one and, filled with uncertainty, they waited and hoped for their loved ones return. Waiting, the women felt isolated and yet central to their loved ones care. Consigned to being an onlooker through the staffs relationship with them, the women watched on and felt helpless to control the stranger they were with. Rather than finding reassurance and relief in the presence of

healthcare staff, the women were distressed, troubled and frustrated. Their experience of the stranger was theirs alone; it was hidden and went unacknowledged by health care staff. The women yearned for the loved one they knew; the one depicted in their family portraits and recalled from their memories.

The women sought explanations that would help them to come to grips with their loved ones absence and the strangers presence, particularly how long they would need to endure the strangers presence. Lived was the inadequacy of medical categories in explaining their experiences. Like being left In the dark, not understanding their experience added to the uncertainty which permeated the womens experiences and made it harder for them to know what to do and maintain hope for their loved ones return.

The women who experienced an end to an episode of delirium also experienced the ever-present possibility their loved one would suddenly transform and be absent once more, this possibility engendering apprehension. When their loved one was well the possibility of deliriums return kept the women wary, watchful and on guard. Like living On thin ice, these women were never sure when their loved one would suddenly leave again. These women also endured Keeping secrets. Though all women experience the stranger, some find the stranger is not recalled by their loved one after delirium passes. They realise they hold privileged knowledge of a time when their loved one was a stranger. Keeping the stranger a secret shields their loved one from the likely distress of knowing they were not themselves; that their behaviour was out of control and at times unspeakable. Keeping secrets reveals the close ties between family members but they are also a burden the women bear.

Conclusion

The analysis and interpretation of experiences shared by the women in this study reveals that their experiences were profound; distressingly dominated by the existential absence (Sartre, 1943/2003) of their older


loved one. It reveals that reaching beyond knowledge of delirium as a condition to its existential meaning for family members enriches our understanding of human experiences during this condition. Based on Cohen et al.s (2000) argument that understanding the meaning of experiences for several people provides a sensitive basis upon which a caring relationship can be built, it is hoped that these findings invite readers to appreciate what delirium is like for family members and to respond with compassion and sensitivity.

Implications for Practice

Understanding family member experiences of absence and their feelings of distress invites healthcare staff to provide meaningful support and appropriately include family members in their older loved ones care. For example, opportunities for family members to express feelings or concerns, providing information or explanations and talking about how they are coping with the changes they perceive may be interventions which are supportive and of benefit. Together with information about delirium, it may be beneficial to include explanations about what family members experience and how to cope or respond during care. Better understanding of the impact of delirium on family members can assist in acknowledging and ensuring the wellbeing of family members during an older loved ones delirium.

Acknowledgement

Sincere thanks to John Young and the Editors for permission to use the poem titled My Fathers Delirium, published in the March 2012 Annals, in my thesis.

References

Bruce, A., Ritchie, C., Blizard, R., Lai, R., & Raven, P. (2007). The incidence of delirium associated with orthopedic surgery: A meta-analytic review. International Psychogeriatrics, 19(2), 197-214. doi: 10.1017/S104161020600425X

Cohen, M., Kahn, D., & Steeves, R. (2000). Hermeneutic phenomenological research: A practical guide for nurse researchers. California: Sage.

Dahlke, S., & Phinney, A. (2008). Caring for hospitalised older adults at risk for delirium: The silent, unspoken piece of nursing practice. Journal of Gerontological Nursing, 34(6), 41-47.

Hallberg, I. (1999). Impact of delirium on professionals. Dementia and Geriatric Cognitive Disorders, 10(5), 420-425.

Harding, S. (2006). Delirium in older people: An Australian government initiative. Candberra: Australian Department of Health and Ageing, Commonwealth of Australia.

Merleau-Ponty, M. (1945/2002). Phenomenology of perception (C. Smith, Trans.). London: Routledge.

Rapp, C.G. (2001). Acute confusion/delirium protocol. Journal of Gerontological Nursing, 27(4), 21-33.

Rogers, A., & Gibson, C. (2002). Experiences of orthopaedic nurses caring for elderly patients with acute confusion. Journal of Orthopaedic Nursing, 6(1), 9-17. doi: 10.1054/joon.2001.0210

Sartre, J.P. (1943/2003). Being and nothingness: A phenomenological ontology (H. E. Barnes, Trans.). New York: Routledge.

Segatore, M., & Adams, D. (2001). Managing delirium and agitation in elderly hospitalised orthopaedic patients: Part 2 - interventions. Orthopaedic Nursing, 20(2), 61-75.

Siddiqi, N., House, A., & Holmes, J. (2006). Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age and Ageing, 35(4), 350-365. doi: 10.1093/ageing/afl005


Delirium Prevention in Psychiatry a new Paradigm

Dr Simon Thacker Derbyshire Healthcare NHS Foundation Trust Correspondence to: [email protected]

Dementia is the heartland of Old Age Psychiatry and has achieved a high national profile in the UK.1 In contrast, delirium barely enters public discourse. The prevalence of delirium in hospitals and care homes is remarkable and of the same order of magnitude as dementia unsurprising given that age and a pre-existing dementia are the largest risk factors for delirium.2,3 The publication of NICE Delirium Guidelines has been a major advance in the promotion of delirium management4 but evidence is lacking that specific programmes of delirium-care improve outcomes.5 Conversely, there is some limited evidence that multicomponent interventions aimed at preventing delirium reduce its incidence and improve outcomes.6,7

Why is Delirium Prevention not taken more seriously in Community Psychiatry?

Prevalence studies of delirium in any setting are fraught by the problem of distinguishing delirium from dementia.8 A Swedish epidemiological study of very elderly people found that 52% of PWD had experienced delirium within the previous month compared to 5% of those without dementia.9 Moreover, there is evidence from cohort follow-up that delirium in the very elderly increases the risk of subsequent dementia by 9-fold. 10

People with dementia (PWD) who are living in their own homes and in receipt of care from community mental health teams are also likely to be at high risk of delirium. Behavioural and psychological symptoms in dementia (BPSD) create obstacles to care that render the patient vulnerable to comorbidities that contribute to delirium such as falls,

nutritional deficits and polypharmacy. Conversely, delirium can plausibly generate non-cognitive features that become chronic and constitute BPSD.

Delirium is often triggered by acute physical events and rightly remains the domain of primary care and geriatricians but unless psychiatry co-owns the delirium agenda, the cross-over of skills from the management of BPSD will fail to influence Delirium Prevention (DP).

Integrated Care for the Frail Elderly

Community care of the frail elderly must embrace both delirium and dementia by recognising their reciprocity. Unfortunately, the requirement for dual skills and current organisational divisions are at odds. Transformational change into Integrated Care is an NHS driver aimed at healing the schism but clear ideas of the mechanism for this are lacking.11 Is raising the profile of delirium a way to bridge the divide between mental health and physical health approaches to the care of the elderly?

Facing the Fear

Dementia has become the most feared disease of later life.12 The thrust towards early diagnosis is creating an expectation that services will exist to support PWD but these interventions are predominantly social and can leave many people feeling short-changed that medical carers have abandoned them.13 DP constitutes a multicomponent medical paradigm that seeks to engage and empower carers by providing a formulation of dementia as a risk factor for a greater catastrophe i.e delirium. 14

The Derbyshire Ambition

1) Delirium prevention should be an explicit part of all care plans for people with dementia on the wards and within community mental health teams for the elderly (CMHTEs). A simple checklist is necessary but insufficient without raising the profile of delirium through training and education.


2) Delirium awareness should be part of post-diagnostic counselling for PWD and their carers. Our local 3rd sector providers for dementia support have included delirium in their programmes.

3) Delirium training should be part of nursing undergraduate courses in Mental Health. This has been achieved at the University of Derby.

4) Initiation and regular refreshment of delirium training for Old Age Psychiatry staff. Liaison Psychiatry staff have already commenced this programme within the general hospital but we aim to appoint a Band 8 delirium practitioner to pump-prime the Mental Health Trust.

5) Nurses within CMHTEs should have attachments to the Liaison Team at the general hospital to embed awareness of the diagnostic challenges presented by delirium and the deliriogenic potential of the general hospital environment. Carefully considered, therapeutic risk-taking is crucial here the benefits of discharge back to a familiar setting may outweigh the safeguards provided by an institutional setting.

6) Under the auspices of the Delirium Practitioner, delirium training for primary care staff is to run alongside that for dementia.

Research questions

1) What factors lead to patients with dementia who have been referred to mental health services attending hospital for reasons other than discrete pathology such as hip fracture? The Liaison Team is providing daily screening the Medical Assessment Unit at the general hospital for those patients who are known or have been referred to mental health services (usually because of suspected dementia) to provide information to general hospital staff and identify lacunae in services that might have avoided the crisis.

2) We have audited admissions to the general hospital of patients initially noted to have both delirium and urinary tract infection (UTI) and found that undiagnosed dementia is commonly unmasked by delirium.

UTI was not substantiated in over 50% of cases and 60% died or were readmitted within 6 months. 50% were referred to memory services because of a suspected underlying dementia. More research on the factors that lead to this sort of presentation is required. Would earlier diagnosis of dementia or better assessment of the potential for delirium within primary care have avoided the acute presentation?

3) Is DP an acceptable way of selling cognitive assessment to older people who are reluctant to be referred for memory services?

4) Is delirium-risk best assessed within primary care thereby avoiding burdensome memory clinic appointments for frail elderly people? For many of these, dementia can be considered as a geriatric syndrome and a risk factor (for delirium) rather than a disease in need of extensive high-tech investigation. This model has parallels with the Gnosall model of primary care memory services and merits further investigation.15

5) Community mental health team work is focused on BPSD but a simultaneous focus on DP and BPSD might increase the credibility and acceptability of DP by spotlighting the potential acuity of decompensation within dementia. Again further investigation of this approach is warranted.

Summary

The prevention of delirium attenuates morbidity within dementia and may even have a preventive role against dementia. Psychiatry in the United Kingdom now has a firm grasp of the dementia agenda. The skills of psychiatric teams within general hospitals and thenceforth in the community can help realise the potential to stop delirium in some of our most vulnerable elders.


References

1. Living well with dementia: A National Dementia Strategy. Department of Health 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_094051.pdf

2. Ryan D, O'Regan N, O Caoimh R, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open 2013; 3:e001772 (doi:10.1136/bmjopen-2012-001772)

3. Siddiqi N, Clegg A, Young J. Delirium in care homes. Reviews in Clinical Gerontology 2009; 19(4):309-16.

4. NICE clinical guidelines. Delirium: diagnosis, prevention and management. Updated July 2010. www.nice.org.uk/guidance/CG103/PublicInfo

5. Goldberg SE, Bradshaw SE, Kearney F, Russell C, Whittamore K, Foster PER, Mamza J, Gladman JRF, Jones RG, Lewis SA, Porock, D, Harwood RH on behalf of the Medical Crises in Older People study group. Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial). BMJ 2013;347:

6. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. Journal of the American Geriatrics Society 2001; 49(5):516-22.

7. Inouye, Help Hope article Inouye SK, Bogardus ST, Jr., Charpentier PA, Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999; 340(9):669-76.

8. Davis DH, Kreisel SH, Muniz Terrera G, Hall AJ, Morandi A, Boustani M, Neufeld KJ, Lee HB, Maclullich AM, Brayne C. The epidemiology of delirium: challenges and opportunities for population studies. Am J Geriatr Psychiatry 2013;21(12):1173-89

(doi: 10.1016/j.jagp.2013.04.007).

9. Mathillas et al. Thirty-day prevalence of delirium among very old people: A population-based study of very old people living at home and in institutions . Archives of Gerontology and Geriatrics 2013; 57:298304.

10. Davis DH, Muniz Terrera G, Keage H, Rahkonen T, Oinas M, Matthews FE, Cunningham C, Polvikoski T, Sulkava R, MacLullich AM, Brayne C. Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain 2012 135(Pt 9):2809-16.

11. Monitor. Enabling Integrated Care in the NHS. Last updated 8th September 2014. https://www.gov.uk/enabling-integrated-care-in-the-nhs

12. Donnelley, P. We fear dementia more than cancer. Daily Mail 4th August 2014. http://www.dailymail.co.uk/health/article-2715049/We-fear-dementia-cancer-Two-thirds-50s-fear-brain-condition.html

13. Prakash A, Thacker S. The audacity of hope tyranny or liberation in dementia care. Geriatric Medicine 2014 http://www.gmjournal.co.uk/the_audacity_of_hope_tyranny_or_liberation_in_dementia_care_25769811827.aspx

14. Siddiqi N, Young J, Cheater FM, Harding RA. Educating staff working in long-term care about delirium: The Trojan horse for improving quality of care? Journal of Psychosomatic Research 2008; 65:261-6.

15. Jolley D, Greaves I, Greaves N, Greening L. Three tiers for a comprehensive regional memory service. Journal of Dementia Care 2010; 18(1):26-9.
http://www.europeandeliriumassociation.com/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_094051.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_094051.pdfhttp://www.nice.org.uk/guidance/CG103/PublicInfo


Delirium and early Mobilisation

Nydahl, P., RN BScN,1 Guenther, U., MD DESA EDIC,2 Krotsetis, S., RN CCRN MSc 3

1 Nursing Research, University Hospital of Schleswig-Holstein, Kiel

2 Consultant Anaesthesiologist, Clinic of Anesthesiology & Intensive Care Medicine, Bonn University Medical Centre, Bonn, Germany.

3 Nursing Research, University Hospital of Schleswig-Holstein, Lbeck

Correspondence to: [email protected]

Introduction

For several decades patients in Intensive Care Units (ICU) were assumed to benefit from bed rest and deep sedation. Mental and physical immobilisation was supposed to protect patients and reduce their risks for complications1. During the last decade, though, bed rest has been shown to be associated with a higher risk for several undesirable effects. Prolonged immobility increases the risk for an extended rehabilitation process and many secondary complications in ICU patients, including muscle wasting, insulin resistance, orthostatic intolerance, pressure sores, contractures, pneumonia, prolonged weaning from ventilator etc. These conditions result in serious consequences like ICU acquired weakness and neurological as well as psychological complications: delirium, anxiety, depression and posttraumatic stress disorder2-4. Hence, to reduce the consequences of prolonged bed rest, early rehabilitation and mobilisation is now recommended for the treatment of mechanically ventilated ICU patients4.

Early mobilisation is a stepwise, interdisciplinary approach, starting after initial stabilisation. Patients are mobilised in a sitting position, sit on the edge of the bed or in a chair, are standing, marching, walking with mechanical ventilation. Example videos can be seen on www.mobilization-

network.org. Early mobilisation of mechanically ventilated patients has been shown to be safe, even with an endotracheal tube in place5, and was associated with reduced length of stay and ventilator days6,7; moreover, it improves physical outcome8. Early mobilisation is also recommended for the treatment of delirious patients9, while at the same time, delirium is seen as a barrier to mobilisation by clinicians10. Hence, questions arise about the impact and feasibility of early mobilisation on delirious patients.

Early mobilisation and delirium: evidence

Early mobilisation has got an impact on delirium of mechanically ventilated ICU patients. proved In a randomized controlled trial with medical, mechanically ventilated patients Schweickert et al.8 showed the effects of early mobilisation within the first 72h compared to usual care. The intervention was conducted by additional occupational Therapists and physiotherapists during daily wake up and spontaneous breathing trial - the control grouponly receiving daily wake up & breathing trials. The intervention group (n=49) showed significant better self-care competencies, shorter time of mechanical ventilation and shorter length of stay in the ICU than the control group (n=55). Patients in the intervention group had shorter time of delirium than control (2d vs 4d, p=0.02). Delirious days on ICU were 33% vs. 55% (p=0.02), assessed with the CAM-ICU.

Needham et al.7 conducted a quality improvement project to reduce sedation and improve mobility of medical ICU patients. Compared to the 4-month pre-project period (n=29), patients in the project group (n=30) had significantly more physical therapy (93% vs 59%, p = 0.004), were more out of bed (sitting or more: 78% vs 56%, p = 0.03), had a reduced length of stay in the ICU (4.9 vs 7.0 days, p = 0.02) and had more delirium free days on the ICU (53% vs 21%, p = 0.003), detected with the CAM-ICU.

Balas et al.11 implemented the ABCDE approach (daily wake up trial, daily spontaneous breathing trial, delirium assessment and early mobilisation).


In a before/after cohort study on a medical and surgical ICU (before: n=146, after: n=150), after adjustment of co-factors the approach lead to a significant reduction in ventilator days (24d vs 21d, p=0.04), doubled the odd of being mobilised out of bed (OR 2.11, 95%CI 1.29-3.45, p=0.003) and reduced the odd of delirium by half (OR 0.55, 95% CI 0.33-0.93, p=0.03).

These well done studies with a low risk of bias proved the impact of early mobilisation on delirium, despite being critically ill or being mechanically ventilated. How can this effect be explained?

Early mobilisation and the brain

As Hopkins et al.12 discussed, the impact of early mobilisation on the delirious brain is not fully explained nor proven, but one can use hints from other studies. Animal studies13,14 found that physical activity promoted new blood vessel formation and neurogenesis. In elderly humans, physical exercise has been shown to be associated with increased cerebral blood flow, oxygen extraction and glucose metabolisation15. In patients suffering from dementia, a prospective study following more than 4000 healthy elderly people for 5 years demonstrated that physical activity was associated with lower incidence of cognitive decline and dementia16. In patients already presenting with dementia, physical exercise was confirmed by a meta-analysis to still have moderate beneficial effects on cognition17. Recent data suggest that physical exercise also prevents physical impairment and cognitive decline in ICU patients8, but further and well powered studies are needed to prove the impact18. According to Hopkins et al.12, early mobilisation increase resistance to brain injury by facilitation of synaptic transmission and promotion of neurogenesis and angiogenesis. Early mobilisation thereby preserves cognitive function and decreases depression and anxiety12.

Feasibility

Despite of the latter evidence based recommendations, clinicians may see limited feasibility to facilitate early mobilisation in hospitalised delirious patients, in particular in the group of critically ill patients19. Evidence based protocols and safety criteria can be adapted to the culture and sample of patients of different ICUs5,20,21. Common concerns of clinicians are safety of early mobilisation of delirious patients, lack of staff and others. In general, early mobilisation is safe with a low rate of complications. In a current systematic review including 453 mechanically ventilated patients who were mobilized for 3613 times out-of-bed, the rate of unplanned pulling out of tubes or lines was 0.3% (n=10)22, but presence and in- or exclusion of delirium was not consistently demonstrated in the included studies. Clinicians may fear the safety of tubes and lines, when mobilising delirious patients, especially in the case of a hyperactive delirium. Based on our clinical experiences, patients with a hyperactive delirium often improved after being mobilised out of bed. Besides an anticipatory planning, individual safety and risk assessment and interdisciplinary collaboration, a trustful and understandable communication with the hyperactive delirious patient is essential.

In the context of safety issues the question arises how many personnel are needed to safely mobilise a critically ill patient, for example suffering from a hyperactive delirious episode? Has a nurse patient ratio, or the presence of a 7-days-a-week physical therapist (PT), an influence on the frequency or quality of a targeted early mobilisation? Morris et al. (2008)21 were able to present results whereupon a mobility team could significantly reduce the ICU stay (p= 0,027) respectively the length of hospital stay (p=0,006) in the investigated sample. The economical benefit of additional staff for early mobilization has been proven7,21,23. Outside the setting of early mobilisation with specifically trained teams, the discussion remains controversial. In a one day point prevalence study in Germany, including 116 ICUs and 783 patients, no relationship between staff-patient-ratio and out-of-bed mobilisation was found10. In contrast, another study from Germany24, exploring consequences of reduced staffing in


German ICUs, reported reduced mobilisation on 532 ICUs, if less nurses were present. These contrary results can be explained with a sample bias within the studies (only those ICUs with enough or spare staff participated). On the other hand, Thomsen25 proved that patients are more mobilised if they are transferred to an ICU where early mobility has a high priority. Attitude, knowledge and cooperation seem to be important factors to overcome the barriers to early mobilisation26.

Another important issue is early mobilisation during the night. Sufficient sleep quality reduces the incidence of delirium27 and early mobilisation may be reduced to daytime activities. Delirious patients have a disturbed sleep rhythm. One can argue that early mobilisation may also happen during the night, if a patient is restless and cannot sleep, e.g. sitting on the edge of the bed for a couple of minutes. Clinicians expect patients to sleep at night, but one has to know that (in Germany) one in three suffers from sleep disorders (Fed. Bureau of Statistics, 2013). At home, these persons would stand up, walk around, watch tv or the like: for those persons it is common to get up during the night. If early mobilisation reduces incidence of delirium, one can conclude that mobilisation during the night might help (one third of) delirious patients to reduce the tension, particularly those patients suffering of a hyperactive delirium. It may help patients to re-orientate and to get back to a regular wake-sleep-cycle. Future research may focus on the hypothesis of early mobilisation during the night, whether it has an influence on sleeping quality and delirium, subsequent use of benzodiazepines and restraints.

A trustful, understandable interaction, and possible presence of relatives may be important factors. The approach of early mobilisation, which combines the need of family members to be integrated into the care of their critically ill relatives26 and to provide a more familiar surrounding for the delirious patient requires participation of families or friends into a mobilisation procedure. Rosenbloom-Brunton et al. (2010)28 conducted a study regarding the feasibility of family participation in a delirium prevention in elderly hospitalised patients. The researchers evaluated that 57% of the interviewed relatives (n=15) estimated the participation in an

early mobilisation protocol as moderately difficult to perform. Of course, families need detailed teaching and constant monitoring.

In order to support patients and family members and to promote a culture of willingness to implement tools of a successful delirium management, such as an early mobility approach, into daily practice, the entire therapeutic team needs a valid knowledge regarding the clinical picture, prevention and management of delirium29. Furthermore institutional engagement and support of the therapeutic team seems crucial to constitute a structural framework30.

Recommendations/Conclusions

Early mobilisation is recommended for the rehabilitation, prevention and management of delirium in critically ill patients. The impact of early mobilisation on the delirious brain cannot be explained in detail, yet. The approach is safe and reduces the delirium rate. Further research is needed to evaluate the participation of next of kin and to prove the impact of early mobilisation during the night on hyperactive, delirious patients.

References

1. Kress, J.P. (2013). Sedation and Mobility: Changing the Paradigm. Crit Care Clin. 29 (1): 67-75.

2. Brower, R.G. (2009).Consequences of bed rest. Crit Care Med 37 (10): 422-428.

3. Desai, S. V., Law, T. J. & Needham D. M. (2011). Long-term complications of critical care. Crit Care Med (39) 2: 371-379.


4. Needham, D.M., Davidson, J., Cohen, H., et al. (2012). Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med. 40 (2): 502-9.

5. Bailey, P., Thomsen, G.E., Spuhler, V.J., et al. (2007). Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 35 (1): 139-45.

6. Morris, P.E., Goad, A., Thompson, C., et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med.: 36 (8): 2238-43.

7. Needham, D.M., Korupolu, R., Zanni, J.M., et al. (2010). Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil 91:536-542.

8. Schweickert, W.D., Pohlman, M.C., Pohlman, A.S., et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 30; 373 (9678): 1874-82.

9. Page, V.J., Casarin, A. (2014). Missing link or not, mobilise against delirium. Crit Care. 31; 18 (1): 105.

10. Nydahl, P., Bartoszek, G., Ruhl, P.A. et al. (2014). Early Mobilization of Mechanically Ventilated Patients: A One-Day Point Prevalence Study in Germany. Crit Care Med 42: 1178-1186.

11. Balas, M.C., Vasilevskis, E.E., Olsen, K.M. et al. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 42 (5): 1024-36.

12. Hopkins RO, Suchyta MR, Farrer TJ et al. (2012). Improving post-intensive care unit neuropsychiatric outcomes: understanding cognitive effects of physical activity. Am J Respir Crit Care Med. 186(12):1220-8.

13. Swain RA, Harris AB, Wiener EC et al. (2003). Prolonged exercise induces angiogenesis and increases cerebral blood volume in primary motor cortex of the rat. Neuroscience 117:1037-1046.

14. Rhyu IJ, Bytheway JA, Kohler SJ et al. (2010). Effects of aerobic exercise training on cognitive function and cortical vascularity in monkeys. Neuroscience 167:12391248.

15. Churchill JD, Galvez R, Colcombe S et al. (2002). Exercise, experience and the aging brain. Neurobiol Aging 23:941955.

16. Laurin D, Verreault R, Lindsay J et al. (2001). Physical activity and risk of cognitive impairment and dementia in elderly persons. Arch Neurol 58:498504.

17. Heyn P, Abreu BC, Ottenbacher KJ (2004). The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil 85:1694-1704.

18. Brummel NE, Girard TD, Ely EW et al. (2014). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med. 2014 Mar;40(3):370-9.

19. Devlin, JW, Pohlman, AS (2014). Everybody, Every Day: An Awakening and Breathing Coordination, Delirium Monitoring/ Management, and Early Exercise/Mobility Culture Is Feasible in Your ICU. Critical Care Medicine 42 (5): 1280-1281.

20. Stiller, K. & Phillips, A. (2003). Safety aspects of mobilising acutely ill inpatients. Physiotherapy Theory & Practice 19 (4): 239-57.

21. Morris, PE. Goad, A., Thompson, C. et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med.36(8): 223843.

22. Nydahl, P., Ewers, A., Brodda, D. (2014). Complications related to early mobilisation of mechanically ventilated patients on Intensive Care Units. Nursing in Critical Care, in press.


23. Lord RK, Mayhew CR, Korupolu R. (2013). ICU early physical rehabilitation programs: financial modeling of cost savings. Critical Care Medicine 41(3):717-24.

24. Isfort, M., Weidner, F., Gehlen, D. (2012). Nursing-Thermometer 2012 (German: Pflege-Thermometer 2012). www.dip.de, 12.8.2014

25. Thomsen, G.E., Snow, G.L., Rodriguez, L. et al. (2008). Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 36 (4): 1119-24.

26. Engel, H.J., Needham, D.M., Morris, P.E. et al. (2013). ICU Early Mobilization: From Recommendation to Implementation at Three Medical Centers. Crit Care Med 41:S69-S80.

27. Kamdar BB, Yang J, King LM, et al. (2013). Developing, Implementing, and Evaluating a Multifaceted Quality Improvement Intervention to Promote Sleep in an ICU. Crit Care Med 41:800809.

28. Rosenbloom-Brunton, DA, Henneman, EA, Inouye SK. (2010). Feasibility of Family Participation in a Delirium Prevention Program For The Older Hospitalized Adult. Gerontol Nurs. 36(9): 2235.

29. Balas, MC. et al. (2013). Implementing the ABCDE Bundle into Everyday Care: Opportunities, Challenges and Lessons Learned for,Implementing the ICU Pain, Agitation and Delirium (PAD),Guidelines. Critical Care Medicine. 41(901): S116S127.

30. Carrothers, KM. et al. (2013). Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs. Critical Care Medicine. 41 ( 9) (Suppl.): S129.

EDA and ADS working together

Following the publication of the DSM-5 criteria the EDA and American Delirium Society collaborated on an opinion piece, which was recently published in Current Controversies in Psychiatry. The paper comments in the particular on the loss of the term consciousness i.e. the change from DSM-4, which described delirium as a disturbance in consciousness and attention, to DSM-5, to a disturbance in attention and awareness. Furthermore DSM-5 adds the statement that the disturbance does not occur in the context of a severely reduced level of arousal such as coma.

The concern is that The risk of misinterpreting these revised criteria is that clinicians may focus inappropriately on inattention and testability, erroneously overlooking the de facto disturbance in consciousness (that is, delirium) that comes with altered arousal.

The emphasis in DSM-V is in the detection of inattention. A substantial proportion of patients present with reduced levels of arousal severe enough to affect their ability to be tested for inattention. Those patients, rather than being correctly identified as delirious, may be classed as obtunded or stuporose. Reduced arousal may indeed be a result of delirium. Separating reduced arousal, short of coma, into those patients who can be demonstrated to have inattention and those who cannot be tested due to their lack of response is not clinically useful and given the degree of fluctuation in delirium, impractical.

The summary states that patients who have impaired arousal such that they cannot engage in cognitive testing or interview must be understood to effectively have inattention. This is consistent with the current evidence base and the realities of clinical practice. This unique opinion piece is freely available to read in its entirety on open access.

http://www.biomedcentral.com/1741-7015/12/141

Valerie Page Editor
http://www.europeandeliriumassociation.com/http://www.biomedcentral.com/1741-7015/12/141


Young Delirium Researchers Meeting

On 11th and 12th of September this year 15 researchers in delirium met in Birmingham, UK. The meeting had the intention of bringing together early career researchers working in the field of delirium in an informal yet constructive way. By presenting current and future projects to peers we were able to highlight challenges as well as a good practice in delirium research. These included recently funded work looking at anaesthetic type and delirium in hip fractures, ongoing work in screening for delirium using different tools and potential projects looking at cognitive outcomes in delirium in population based cohorts. Delegates included medical students, neuropsychologists, nurses and both doctoral students and early post-doctoral researchers. Updates in biomarker work, animal studies, assessment scales and cognitive outcomes were presented as well as a presentation on inflammageing as a possible driver of delirium. This was all done through seminar style presentations and importantly over drinks and a meal later on. By meeting as a group of peers, without the potentially intimidating presence of senior researchers, it allowed perhaps more unguarded questioning and discussion which was very constructive.

One of the difficulties in organising the meeting was attempting to identify everyone who may have liked to come, and future meeting would hope to ensure we include as many people as possible. In a relatively small but emerging field this collaboration provides a good peer level support network.

From our meeting the group identified 4 research priorities:

1) Clarify and operationalise measures for assessing delirium severity and the core symptoms of arousal and inattention.

2) Describe the natural history of delirium with respect to cognitive, functional and inflammatory outcomes- from community settings through all care settings, especially hospitals and care homes. This will need collaboration with other disciplines including epidemiology and health economics.

3) Embed basic and translational research alongside clinical research projects to improve understanding of the pathophysiology and understanding of any conclusions seen

4) Improve collaboration with all clinical disciplines including, but not exclusively nursing, physiotherapy, occupational therapy and speech therapy.

People left the meeting feeling refreshed and enthusiastic about the future with new project ideas and collaborations in the pipeline; so its main aim was met.

Thomas Jackson

On behalf of delegates:

Leonna Bannon Emma Cunningham Daniel Davis Roanna Hall John Hazeldine Kirsty Hendry Daisy Moran Sarah Richardson Liz Sapey Alina Schwarz Joyce Yeung


9th Annual Meeting of the European Delirium Association

November 6th - 7th, 2014 Cremona (Italy)

http://www.overgroup.eu/eda2014/

The Conference Planning Committee of the American Delirium Society invites you to submit proposals for presentation at ADS 5th Annual Meeting, May 31 - June 2, 2015. Follow this link to the Call for Proposals page on our website: https://www.americandeliriumsociety.org/conference-events/call-for-proposals Click here to go directly to the downloadable form: https://www.americandeliriumsociety.org/files/Call_for_Proposals_2015_v1.pdf Key dates:

November 24, 2014: Deadline for Submission of Oral Presentation Abstracts

December 15, 2014: Email Notification of Status Sent to Abstract Submitters

March 2, 2015: Deadline for Poster Abstract Submissions

April 15, 2015: Early Registration Deadline (Presenters must register by this date)

May 31 - June 2- 2015: American Delirium Societys 5th Annual Meeting Baltimore, MD

____________________________________________________________________________________
http://www.europeandeliriumassociation.com/http://www.overgroup.eu/eda2014/https://www.americandeliriumsociety.org/conference-events/call-for-proposalshttps://www.americandeliriumsociety.org/conference-events/call-for-proposalshttps://www.americandeliriumsociety.org/files/Call_for_Proposals_2015_v1.pdfhttps://www.americandeliriumsociety.org/files/Call_for_Proposals_2015_v1.pdf


ADVANCE NOTICE

________________________________________________

EDA 2015

10th Scientific Conference

Dates: 2nd 4th September 2015

Venue: Guys Campus of Kings College London

We will be hosting the conference in conjunction with the British

Geriatrics Society Dementia and related disorders Specialist Interest

Group (BGS Dementia SIG).

Contact for further information: [email protected]

_______________________________________________________________________________

Guidelines for authors

Annals of Delirium Care is a publication of the European Delirium Association which seeks to advance knowledge in the field of delirium. It is published three times a year (March, July, November). We especially welcome opinion pieces, reviews and research articles in the field.

Please send your ideas for contributions to the next Annals to [email protected], [email protected] or [email protected] .

Production Manager: Anne Maule, Newcastle upon Tyne, UK
http://www.europeandeliriumassociation.com/mailto:[email protected]:[email protected]:[email protected]:[email protected]

Date post:	25-Sep-2015
Category:	Documents
Upload:	vika-ratu
View:	217 times
Download:	1 times

Annals of Delirium Volume 14 Oct 2014

Documents