Delirium

Associate Professor Dianne Wynaden RN, PhD9th September 2008

Other team members

Mr Malcolm Hare – Fremantle HospitalMs Sunita McGowan – Fremantle HospitalMs Gaye Speed – Fremantle HospitalMr Ian Landsborough – Curtin Ms Shirley McGough – CurtinMs 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

So What?

10% of all hospitalised patients will suffer from a deliriumUp to 89% in high risk groups (dementia)50% or more of delirium goes unrecognised

Financial CostThe 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

Patient / family/ carer stressImpact on nursing staffDecreased quality of life

Health Cost

Increased mortalityIncreased morbidityLoss 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:1. Inconsistent baseline information

available when patient is admitted to the acute care setting

2. “Ad hoc” diagnosis of dementia based on unexplored assumptions

3. 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 recognisedHyper-vigilanceAgitationHallucinationsDifficulty holding/shifting attention

Hypo-alert - Most commonly linked to increased mortality/morbidity

Lethargic, difficult to rouseDifficulty gaining attention

Types of delirium

MixedFluctuates 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.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%Q

35 -

Per

cept

ual

Dis

turb

ance

s

Q34

- D

istr

acti

on

Q36

- S

leep

/Wak

e

Q29

- A

ggre

ssio

n

Q15

- H

ow lo

ng

Q30

- A

lcoh

ol

Q11

- S

edat

ion

Q33

- B

ehav

iour

Cha

nges

Q09

- F

luct

uati

on

Q12

- R

ecal

l

Q28

- L

etha

rgy

Q13

- M

MSE

Q31

- M

orta

lity

Q10

- D

epre

ssio

n

Knowledge

% Incorrect

% Correct

% Unsure

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%Q

25 -

Deh

ydra

tion

Q19

- ID

C

Q21

- P

oor

Nut

riti

on

Q16

- A

ge

Q27

- O

besi

ty

Q18

- N

umbe

r of

Med

s

Q32

- F

amil

y D

emen

tia

Q22

- D

emen

tia

Q14

- N

OF

Q24

- D

iabe

tes

Q26

- H

eari

ng D

efic

it

Q17

- V

isua

l Def

icit

Q20

- G

ende

r

Q23

- G

ende

r - M

ale

Risk Factors

% Incorrect

% Correct

% Unsure

Qualitative study on nurses caring for patients with delirium

1. Qualitative study conducted at two hospitals

2. 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)?

3.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

1. What is your age?2. What is your date of birth?3. What place is this?4. What year is this?

A score of 3 or < indicatescognitive impairment

MMSE

See MMSE PDF

Geriatric Depression ScaleDATE:           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    moderate12 -  15    severe

TEXT FOR YOUR RECORDS - click here:

Confusion Assessment Method (Diagnostic Algorithm)

Feature 1: Acute Onset or Fluctuating CourseThis 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: InattentionThis 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 thinkingThis 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 tosubject?

Feature 4: Altered Level of consciousnessThis 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 MidwiferyCurtin University of Technology

GPO Box U1987Perth, WA 6845

d.wynaden@curtin.edu.au(08) 92662203