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Delirium:
developing and implementing a
multi-component intervention
Dr. Duncan Forsyth Consultant Geriatrician
Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
Cambridge, England
Engaging with management
Psychiatric illness in older people in general hospitals:
– Is common
– Affects outcomes
– Is often unrecognised
– Is often inappropriately treated
Length of stay
Mortality
Costs
Our core business
Age Cardio-vascular disease
Gender Cerebral pathology
Living alone Respiratory disease
Smoking Alcohol
No clock Bed moves
Isolation Precipitating illness
Sensory deprivation ITU
Poor nutrition / dehydration Tubes & catheters
Drugs Restraints
Limited or not modifiable
Define at risk individuals
More modifiable
Define interventions / preventative strategy
Patient Disease
Environment Ilness
What have we done?
• Nurse education and support
• Support of LOAP
• Junior doctor awareness of cognitive problems
• Carer involvement
• Dementia friendly staff and environment
– Day room to be functional for confused patients
– Colour coded ward bays
– Dementia friendly signage
– Coloured toilet seats
– Better seating
– Watering hole
– Artwork
Formalised Training • Alongside the environmental changes training was provided.
• A specialist dementia nurse was appointed. The specialist mental health nurses designed a teaching package which ensures that staff are aware of strategies to use when working with people living with dementia that are admitted to an acute ward and are able to utilise the environment and the resources to improve the patients experience.
• Training was delivered over 8 sessions each of 20 minutes and each session was repeated as necessary so that all ward staff might attend.
• Session 1 Dementia.
• Session 2 Person Centred Care.
• Session 3 Behaviour as communication.
• Session 4 Behaviour as communication.
• Session 5 Meaningful activities.
• Session 6 Depression.
• Session 7 Delirium.
• Session 8 Dementia/Delirium.
Before
After Dementia Friendly Environment
Before After
Before After
Before After
Before After
Environmental risk factors
• Moving room
• No clock local audit data
• No glasses
• Others not conclusive
Preventing delirium • Orientation
• Hydration
• Nutrition
• Constipation
• Infection
• Pain
• Polypharmacy
• Improve mobility
• Reduce sensory impairment
• Avoid sleep deprivation
• Reduce bed moves
• Maintain consistency of staff » Inouye 1999, Marcantonio 1999 and 2001
NB: Multicomponent intervention trials
provide low quality evidence for
reducing:
• Incidence of delirium
• LOS Gustafson 1991
Wanich 1992
Landefeld 1995
Inouye 1999
Harari 1997
Marcantonio 2001
Bogardus 2003
Lundstrom 2005
Wong 2005
Delirium prevention Inouye et al. NEJM 1999
• 852 patients aged > 70 admitted to general medical wards.
One patient from intervention unit matched with two
patients from usual care units
• Intervention consisted of standardized protocols for
cognitive impairment, sleep deprivation, immobility, visual
impairment, hearing impairment, and dehydration
• Intervention group
– Less delirium - 9.9% vs 15% of usual care group
– fewer days of delirium and fewer episodes of delirium
– No difference in LOS
Treatment of delirium
• Cornerstones
– Early recognition
• Missed in < 2/3
– Elimination or correction of underlying causal factors
• Multifactorial causation
• Multicomponent interventions
– Symptomatic and supportive care
Causes of delirium (precipitants)
D rugs
E ndocrine
M etabolic
E nvironmental
N eoplasm
T rauma
I nfection
A poplexy
(stroke)
D rugs: CNS active drugs particularly anticholinergics, polypharmacy, withdrawal (antidepressants, alcohol and benzodiazepines)
I nfection & Intracranial pneumonia, urinary tract, skin
Stroke, subdural, epilepsy
M etabolic glucose, calcium, ammonia, hypoxia, low cardiac perfusion
E lectrolytes sodium, dehydration
All may be associated with immobility – remember restraining
Treatment of delirium
• Moderate quality evidence that attention to:
– Orientation
– Hydration / nutrition
– Medication management
– Early mobilisation
• Reduce
– Length of delirium
– LOS
• But NOT
– Institutionalisation rates » Pitkala 2006 and 2008
Preventing / manging delirium • Orientation
• Hydration
• Nutrition
• Constipation
• Infection
• Pain
• Polypharmacy
• Improve mobility
• Reduce sensory impairment
• Avoid sleep deprivation
• Reduce bed moves
• Maintain consistency of staff » Inouye 1999, Marcantonio 1999 and 2001
NB: Multicomponent intervention trials
provide low quality evidence for
reducing:
• Incidence of delirium
• LOS Gustafson 1991
Wanich 1992
Landefeld 1995
Inouye 1999
Harari 1997
Marcantonio 2001
Bogardus 2003
Lundstrom 2005
Wong 2005
• Hyperactive – Agitation, plucking at bedclothes
– Deranged sleep pattern (day-night reversal)
– Persecutory delusions and visual hallucinations
– Wandering
– Aggression, labile mood, euphoria
• Hypoactive – Apathy, poor motivation, poor engagement, no trouble
– Diagnostic confusion
– Most common and misdiagnosed
– Highest mortality
– Prone to pressure sores, malnutrition, dehydration, VTE
• Mixed
Tailor intervention to delirium type
Also observe:
• For incident delirium
• For resolution of prevalent delirium
Addenbrooke’s Hospital | Rosie Hospital
Bay nursing – the issues
Staff feeling stressed and under pressure Staff feeling unsafe in practice Unsafe for patients Too many specialling requests, leading to staff covering the shifts who were not dementia/delirium trained Budget overspend
Bay nursing:
improves staff well being and saves money
Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Cost over 6 months:
Ward 1 2.88% 3.09% 4.46% 5.05% 5.81% 17, 825.04
Ward 2 1.54% 4.94% 3.08% 2.90% 3.94% 14, 207.93
Ward 3 0.79% 5.71% 7.77% 7.27% 10.08% 22, 811.93
Ward 4 1.39% 2.80% 1.83% 0.53% 1.39% 7, 701.54
Ward 5 3.81%
1.59% 2.97%
4.02% 4.18% 14, 711,51
Addenbrooke’s Hospital | Rosie Hospital
Impact of bay nursing on falls
• falls have reduced significantly
• One fall during bay nursing hours (07.45 – 19.15), as a result of reduced staffing
Knock on benefits: •Reduced length of stay
• More appropriate care due to increased likelihood of patients being allocated to most suitable beds in most suitable locations
• Reduced risk of HAI
• Reduced risk of mortality
Addenbrooke’s Hospital | Rosie Hospital
Reduction in specialling
Introduction of delirium ward reduced specialling
• 06/09/09-23/8/2010
– 616 additional shifts to be covered for the purpose of
specialing.
• 06/09/10 – 27/8/2011
– 188 additional shifts to be covered for the purpose of
specialing
• A cost pressure saving of approximately £44,000 based on
the assumption that each shift is 7.5 hours.
Addenbrooke’s Hospital | Rosie Hospital
Additional benefits
Bay nursing has enabled us to improve care, ensuring we give person centred care at high standards. We are now able to provide extra activities, such as:
Patients eating together at a dining table Board games, hair and nails being done Communication between nurses, patients and relatives is a lot more effective
Addenbrooke’s Hospital | Rosie Hospital
Patient and relative feedback
“Bay Nursing gives
staff the chance to get to know us, its
more sociable.” Extracted
from patient experience questionnaire
“I do not need to use my buzzer as staff are always there to help me.” Extracted from patient
experience questionnaire
“My mum is well looked after she is eating so well and gaining weight something we have struggled with as a family for months.” Cherie
(Daughter of a patient)
“You hear so much bad press about dementia care, they need to come to G6 and see there is amazing care going on, my mum is safe and well looked after.” Jean (Daughter of a
patient)
Addenbrooke’s Hospital | Rosie Hospital
Future plans
Occupational therapy to undertake kitchen style assessments on the ward rather than having to wait to book a slot in for a kitchen assessment on level 2 Physiotherapists to gain experience in music and dance therapy to be able to apply this on the ward for patients
Music project
NICE Quality Standards 2014: audited by Jill Christy (Medical Student)
NICE Quality Standards 2014: audited by Jill Christy (Medical Student)
1. Our ‘Dementia Case Finding Tool’ (60% fully completed)
and Frailty CQUIN (96% completed) were useful in
capturing recent changes in behaviour
2. Using proxy measures of food / fluid / bowel charts; pain
scoring, observation charts, medication review and
behaviour charts seemed to identify whether
multicomponent intervention packages are implemented
(96-100% documentation)
However: Medication review documentation poor (70%
documentation).
NICE Quality Standards 2014: audited by Jill Christy (Medical Student)
3. Low levels of antipsychotic prescription (11%)
and compliant (100%) with Trust guidelines -
comparable to a previous audit in 2012
4. 75% of discharge summaries mentioned altered
cognition (only half of these used the term
delirium or delirious). Most reliable reporting was
for those presenting with (prevalent) delirium.
5. We have patient and carer information leaflets
BUT it was unclear whether they were given out.
Can we establish the benefits?
• ↓ Morbidity (falls, HAI. VTE, pressure sores, malnutrition, ADEs)
• ↓ Mortality
• ↓ LOS √
• ↓ Institutionalisation rates (LOS)
• ↑ quality patient care √
• ↓ costs of unnecessary Ix (e.g. CT head scans)
• ↓ costs of specialling √
• ↓ complaints √
• Helps us meet National Dementia Strategy √
• ↓ incidents of aggression towards staff √
Addenbrooke’s Hospital | Rosie Hospital
Good dementia and delirium management simultaneously improves care and costs.
“Good care costs less.” Dr Keith McNeil, Addenbrooke’s CEO
THANK YOU FOR
YOUR ATTENTION
Is there cognitive impairment? MMSE, CLOX1
Duration of cognitive impairment? CAM, IQCODE
Chronic impairment
(?dementia)
Delirium and chronic
impairment (?dementia)
Assess for severity, consider
depression, etc.
?REFERRAL
Cognitive screening algorithm
Delirium
Ix and Rx