1. Associate Professor Dianne Wynaden RN, PhD 9th September 2008
Delirium
Associate Professor Dianne Wynaden RN, PhD
9th September 2008

2. Other team members Mr Malcolm Hare – Fremantle Hospital
Ms Sunita McGowan – Fremantle Hospital
Ms Gaye Speed – Fremantle Hospital
Mr Ian Landsborough – Curtin
Ms Shirley McGough – Curtin
Ms Lynn Moore – Curtin/Fremantle

3. 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

4. Background
Implementation of dedicated rooms with permanent specialling facilities including the use of:
Music
Fiddle blankets
Clock
Non-slip mats etc
1950s furniture

5. Financial Cost So What? 10% of all hospitalised patients will
suffer from a delirium
Up to 89% in high risk groups (dementia)
50% or more of delirium goes unrecognised
Financial Cost
The economic impact of delirium is substantial, rivalling the health care
costs of falls and diabetes mellitus

6. Cost of specialling/medical care
Cost of complications
Increased length of stay
Higher level of care on discharge

7. Emotional cost Health Cost
Patient / family/ carer stress
Impact on nursing staff
Decreased quality of life
Health Cost
Increased mortality
Increased morbidity
Loss of function

8. Why study delirium? International research:
Medical and nursing staff not good at recognising delirium
No definitive treatment
Most effective treatment is PREVENTION

9. Why study delirium?
Cost effective interventions to prevent delirium require identifying risk factors and addressing them systematically in each patient

10. Difficulty separating diagnoses
Dementia
Delirium
Dementia with superimposed delirium
Depression and dementia
Made worse when:
Inconsistent baseline information available when patient is admitted to the acute care setting

11. “Ad hoc” diagnosis of dementia based on unexplored assumptions
Confusion is seen as a diagnosis rather than a symptom of an underlying problem

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Types of delirium Hyper-alert - Most commonly recognised
Hyper-vigilance
Agitation
Hallucinations
Difficulty holding/shifting attention
Hypo-alert - Most commonly linked to
increased mortality/morbidity
Lethargic, difficult to rouse
Difficulty gaining attention

19. Types of delirium
Mixed
Fluctuates between features of both

20. Presentation of Delirium
Fluctuating course often worse in early morning or night
Visual hallucinations
Persecutory delusions
Impaired cognition and memory

21. Predisposing Risk Factors
Age (> 65years old)
Dementia
Multiple Medications
Sensory Impairment (Visual/Hearing)
Dehydration

22. Predisposing Risk Factors
Chronic physical illness
Substance Use (including alcohol)
Depression
Neurological impairment
Functional disability

23. * Precipitating Risk Factors
Severe acute illness
Changes to electrolyte or acid base
Alterations in oxygenation
Liver or kidney failure
Hypoglycaemia

24. *Precipitating Risk Factors
Malnutrition
Alcohol or Benzodiazepine withdrawal
Surgery, particularly cardiac and orthopaedic
Immobility

25. * Precipitating Risk Factors
Stroke
Pain
Infection
Heart failure
Multiple medications

26. Precipitating Risk Factors
Use of catheters, particularly urinary
Multiple medications
Acute fracture
Invasive procedures
Use of restraints
Iatrogenic events

27. Focus of program of research
Keeping elderly people healthy in the acute care setting- major focus on confusion and particularly delirium

28. 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.

30. 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.

31. 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

32. 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.

33. 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.

34. 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.

35. 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.

36. 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).

37. 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.

40. Qualitative study on nurses caring for patients with delirium
Qualitative study conducted at two hospitals
Two main themes emerged
Inability to differentiate confusion
Managing confused patients

41. 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

42. Managing confused patients
Three subthemes:
Safety issues
Attitudes of staff
The environment

43. 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.

44. 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

45. 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

46. 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.

47. 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.

48. Assessing and Managing Old Age Psychiatric Disorders
Mini Mental State Examination/
Abbreviated Mental Test/ AMT4
Geriatric Depression Scale
Confusion Assessment Method/ Delirium Rating Scale

49. ABBREVIATED MENTAL TEST (AMT).
Question
1. How old are you?
2. What is the time (nearest hour)?
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.

50. AMT4 What is your age? What is your date of birth? What place is this?
What year is this?
A score of 3 or < indicates
cognitive impairment

51. MMSE
See MMSE PDF

52. Geriatric Depression Scale
DATE:           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    moderate 12 -  15    severe
TEXT FOR YOUR RECORDS - click here:

53. Confusion Assessment Method (Diagnostic Algorithm)
Feature 1: Acute Onset or Fluctuating Course
This 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: Inattention
This 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?

54. Feature 3: Disorganized thinking
This 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 to
subject?
Feature 4: Altered Level of consciousness
This 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])

55. Thank you Associate Professor Dianne Wynaden
School of Nursing and Midwifery
Curtin University of Technology
GPO Box U1987
Perth, WA 6845
(08)