Presentation on theme: "Associate Professor Dianne Wynaden RN, PhD 9th September 2008"— Presentation transcript:
1Associate Professor Dianne Wynaden RN, PhD 9th September 2008 DeliriumAssociate Professor Dianne Wynaden RN, PhD9th September 2008
2Other team members Mr Malcolm Hare – Fremantle Hospital Ms Sunita McGowan – Fremantle HospitalMs Gaye Speed – Fremantle HospitalMr Ian Landsborough – CurtinMs Shirley McGough – CurtinMs Lynn Moore – Curtin/Fremantle
3BackgroundIncreasing number of “confused” elderly patients in acute care setting led to many questions being asked around how to provide quality careHigh acuity, high cost, stress on health professionals, the patient and relatives
4BackgroundImplementation of dedicated rooms with permanent specialling facilities including the use of:MusicFiddle blanketsClockNon-slip mats etc1950s furniture
5Financial Cost 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 unrecognisedFinancial CostThe economic impact of delirium is substantial, rivalling the health carecosts of falls and diabetes mellitus
6Cost of specialling/medical care Cost of complicationsIncreased length of stayHigher level of care on discharge
7Emotional cost Health Cost Patient / family/ carer stressImpact on nursing staffDecreased quality of lifeHealth CostIncreased mortalityIncreased morbidityLoss of function
8Why study delirium? International research: Medical and nursing staff not good at recognising deliriumNo definitive treatmentMost effective treatment is PREVENTION
9Why study delirium?Cost effective interventions to prevent delirium require identifying risk factors and addressing them systematically in each patient
10Difficulty separating diagnoses DementiaDeliriumDementia with superimposed deliriumDepression and dementiaMade 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
12Differential Diagnosis DeliriumDementiaDepressionOnsetAcuteChronic and insidiousCoincides with life changes, sometimes abrupt.ALTERNESSAltered level of consciousnessAlertness may fluctuateVaries May be unaffectedMOTOR BEHAVIOURFluctuates; lethargy or hyperactivityMay varyPsychomotor behaviour may be agitated or retarded or unaffectedATTENTIONImpaired and FluctuatesUsually normalUsually normal, but may be distractible
13DeliriumDementiaDepressionAWARENESSImpaired, reducedNormalClearDURATIONHoursMonths to yearsAt least preceding 2 weeks – to monthsPROGRESSIONAbruptSlow but stableVariesORIENTATIONFluctuates in severity, usually impairedMay be impairedMay be selective disorientationMEMORYRecent and immediate impairedRecent impairedSelective or patchy impairment
14DeliriumDementiaDepressionTHINKINGDisorganised, distorted, incoherent, slow or accelerated.Difficulty with abstraction, thoughts impoverished, difficulty finding words, poor judgementIntact, but may voice hopelessness and self depreciationPERCEPTIONDistorted, illusions, delusions and hallucinations, difficulty distinguishing realityMisperceptions often presentIntact; delusions, hallucinations absent except in severe casesSTABILITYVariable, hour to hourFairly StableSome variability
15DeliriumDementiaDepressionEMOTIONSIrritable, aggressive, fearfulLabile. Apathetic, IrritableFlat, unresponsive, or sad; may be irritableSLEEPNocturnal confusionOften disturbed; nocturnal wandering and confusionEarly morning awakeningOTHER FEATURESPhysical cause may not be obviousPast history of mood disorder
16What is delirium?Short-term disturbance of consciousness (Acute organic psychosis or acute confusional state)Characterised by acute onset, fluctuatingcourse and inattention and either disorganised thinking or altered level of consciousnessMust have a medical cause
17What is delirium?Must not be better explained by pre-existing or evolving dementiaCan occur at any age - dependent on risk factorsMost commonly recognised delirium (DTs) – withdrawal from alcohol – screening for patients routinely
18Types of delirium Hyper-alert - Most commonly recognised Hyper-vigilanceAgitationHallucinationsDifficulty holding/shifting attentionHypo-alert - Most commonly linked toincreased mortality/morbidityLethargic, difficult to rouseDifficulty gaining attention
19Types of deliriumMixedFluctuates between features of both
20Presentation of Delirium Fluctuating course often worse in early morning or nightVisual hallucinationsPersecutory delusionsImpaired cognition and memory
21Predisposing Risk Factors Age (> 65years old)DementiaMultiple MedicationsSensory Impairment (Visual/Hearing)Dehydration
26Precipitating Risk Factors Use of catheters, particularly urinaryMultiple medicationsAcute fractureInvasive proceduresUse of restraintsIatrogenic events
27Focus of program of research Keeping elderly people healthy in the acute care setting- major focus on confusion and particularly delirium
28Prevalence 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, havinga delirium, “being a bit off” or appearingdepressed; and,These or other descriptors had to bedocumented in the patient’s notes.
30Prevalence 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.
31Possible 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
32The 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.
33Discussion PointsPrevalence 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 thepoor rates of recognition of delirium.
34Discussion PointsManaging confused patients in now the norm and many staff just accept this level of acuityImproved 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.
35Discussion PointsManagement 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.
36Discussion PointsHealth 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).
37Nurses’ 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 managementof delirium was also low.
40Qualitative study on nurses caring for patients with delirium Qualitative study conducted at two hospitalsTwo main themes emergedInability to differentiate confusionManaging confused patients
41Inability to differentiate confusion Three subthemes:Caring for so many confused patientsFeeling helpless and frustratedLack of education and training toassess confused and deliriouspatients
42Managing confused patients Three subthemes:Safety issuesAttitudes of staffThe environment
43Where 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.
44Where 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 contextClinical pathways attachedto risk assessment tool
45Where 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 inassessment
46Where 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.
47Where 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.
48Assessing and Managing Old Age Psychiatric Disorders Mini Mental State Examination/Abbreviated Mental Test/ AMT4Geriatric Depression ScaleConfusion Assessment Method/ Delirium Rating Scale
49ABBREVIATED MENTAL TEST (AMT) .Question1. 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 Street4. 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.
50AMT4 What is your age? What is your date of birth? What place is this? What year is this?A score of 3 or < indicatescognitive impairment
52Geriatric 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 severeTEXT FOR YOUR RECORDS - click here:
53Confusion 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?
54Feature 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 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])
55Thank you Associate Professor Dianne Wynaden School of Nursing and MidwiferyCurtin University of TechnologyGPO Box U1987Perth, WA 6845(08)