The medical and environmental principles of delirium management are well known and are basically the same as for prevention

Preventing delirium is preferred over treating delirium Cochrane review, Siddiqi N et al, 2009

DELIRIUM ↔ DEMENTIA Dementia is the most important RISK FACTOR FOR DELIRIUM (Lindsay 2002); Delirium ACCELERATES dementia (Fong et al, 2009) Delirium increases the RISK FOR DEMENTIA (OR = 8,7 95% CI, 2,1-35) (Fick et al, 2002) Delirium prevention has the potential for primary and secondary prevention of dementia

DELIRIUM ↔ DEMENTIA Dementia is an independent predictor of underrecognition of delirium, together with : Presence of the hypoactive form of delirium, Age 80 and older, Vision impairment (Inouye et al, 2001)

INCIDENT DELIRIUM IN DEMENTIA = DELIRIUM SUPERIMPOSED ON DEMENTIA= DSD Delirium prevention is an effective secondary prevention strategy for dementia patients, targeting this population makes empirical sense and may deliver important benefits.

EPIDEMIOLOGY Delirium affects as much as 50% of the 65+ in hospital and 60-89% of patients with dementia 11 codes for delirium are included in the ICD 9 23 codes for delirium in ICD 10 But only 3% of delirium cases are coded in medical records (Inouye, 2012)

COSTS OF DELIRIUM It costs more than $164 billion /year in USA $ per delirious patient in Europe Delirium increases hospital costs by 2500 $ per patient. (Leslie 2008). Despite its high prevalence and cost, delirium is undetected and untreated in 32-67% of elderly hospitalized patients (Zaubler et al, 2013).

DSD OUTCOMES AND COSTS for patients with dementia who develop delirium are worse than for those who do not develop this condition: accelerates trajectory of cognitive decline (Fong 2009) increases rates of re-hospitalization and institutionalization (RR= 9.3) (fick 2000) increases rates of mortality (RR=5.4) (rockwood 1999)

DELIRIUM PREVENTION Delirium is PREVENTABLE in 30-40% of cases, but few hospitals are implementing interventions in a systematic manner.

Delirium-friendly hospital Staff aware that delirium affects 1 in 8 of their patients Staff with basic knowledge of delirium Delirium screening is routine Delirium information for patients and families are available Basic delirium prevention measures are in place (Maclullich, 2013)

Despite its high prevalence and cost, delirium is undetected and untreated in 32-67% of elderly hospitalized patients (Zaubler et al, 2013). Higher detection of delirium in routine hospital practice is a major priority

DELIRIUM PREVENTION PREVENTION / TREATMENT pharmacological non-pharmacological

PHARMACOLOGICAL PREVENTION Prophylactic administration of citicoline (Diaz 2001) and donepezil (Liptzin 2005) did not prevent delirium compared with placebo. Prophylactic haloperidol was not effective in preventing delirium but did reduce its severity and duration, and also decreased length of hospital stay (Kalisvaart 2005).

NON-PHARMACOLOGICAL PREVENTION – NICE (National Institute for Health and Clinical Excellence) Guidelines in UK, 2010 – HELP (Hospital Elder Life Program) Guidelines in US, 1999 The recommendations made comprised measures that are essentially basic aspects of good care, yet they were able reduce delirium incidence by more than one third

HELP PROGRAM (Inouye et al, 1999) It is an innovative hospital-based program to prevent delirium in hospitalized older adults. It uses a multidisciplinary team and trained lay volunteers to deliver interventions to older adults. Currently operating in more than 150 hospitals and eight countries.

HELP PROGRAM (Inouye et al, 1999) Responsible: Elder Life Specialist Screening: within 48 hours from hospital admission Inclusion criteria: 70 years and over, at least one risk factor for delirium present Exclusion criteria: intubation, aphasia, terminally ill,expected discharge within 48 hours after admission Daily visitor program Mobilization program Feeding assistance Targeting delirium risk factors

TARGETING DELIRIUM RISK FACTORS Six evidence-based delirium risk factors: 1.Cognitive impairment 2.Sleep deprivation 3.Immobility 4.Visual impairment 5.Hearing impairment 6.Dehydration 7.Plus the recent add-on of PAIN (Fong et al, 2011)

HELP PROGRAM - Effective Proved effective in reducing: – Incidence of delirium (OR=0.60, 95%CI, ) – Duration – Severity – Care costs Not only for delirium prevention but also for delirium treatment (Rubin et al, 2006; Rubin et al, 2011).

HELP PROGRAM – Cost-effective $ 831 saved per intervention patient for acute hospital costs $ 9446 saved per patient per year in long-term nursing – home costs (Fong,2011) Nevertheless adapted HELP programs have been implemented only in two European hospitals (SPAIN, Vidan et al, 2009) (FRANCE, Andro et al, 2012)

HELP in dementia to prevent delirium Only one study evaluated the effectiveness of a preventive intervention- the HELP protocol- in a demented hospitalized population (Andro et al, 2012): The risk reduction of DSD was 66% (RRR 0,34 95%CI 0,15-0,78)

NICE Guidelines (NICE,2010) NICE guidelines includes 13 recomendations to prevent delirium in at-risk patients. EFFECTIVE: -reduced incidence of delirium of about one third COST-EFFECTIVE: -net monetary benefit of £8180 for surgical patient, and of £2200 for medical patient (O’Mahony et al, 2011)

NICE Guidelines (NICE,2010) Staff must become familiar with the person at risk, avoid moving persons within room/ward Delirium risk assessment within 24hours of hospitalization Tailored multicomponent intervention package should be delivered by trained staff Address cognitive impairment and disorientation: clock, calendar, talking to the person at risk explaining where they are, who they are, and facilitating regular visits from family and friends. Address dehydration Assess (and address)for hypoxia Address infection Address limited mobility Assess (and address) for pain Medication review Address poor nutrition Address sensory impairment Promote good sleep patterns (reducing noise, nursing and medical procedures during sleeping hours)

NICE Guidelines cost £377 per patient EFFECTIVE: Reduced the risk of developing delirium RR = 0.66 (95%CI, ) COST-EFFECTIVE: £510 reduction in hospital costs per patient and £2200 savings over the remaining lifespan (Akunne et al, 2012)

DELIRIUM IN DEMENTIA (DSD) Treatment The recommended intervention is a non-pharmacological multicomponent approach maximizing family support and orienting communication, minimizing medication use, ensuring adequate hydration, and attending to sensory needs such as vision and hearing impairment (Fick et al, 2002)

DELIRIUM IN DEMENTIA – Managing 1.Assess for the most common causes of delirium (medications, infections, dehydration) 2.Prevent injuries and delirium complications (falls, skin breakdown, aspiration) 3.Avoid sedative and hypnotics 4.Remove tubes, catheters 5.Provide non-pharmacologic sleep aids

DELIRIUM IN DEMENTIA – Managing 6. Provide sensory aids (eyeglasses and hearing aids) 7.Maintain mobility 8.Schedule regular visits to the toilet 9.Monitor hydration, nutrition, and swallowing 10.Provide discharge teaching (counsel and educate family about delirium) (Fick, 2008)

PREDICTORS of DELIRIUM SEVERITY A prospective controlled study with 444 hospitalized patients with delirium found that: Number of room changes Absence of a clock or watch Absence of reading glasses Presence of a family members Medical or physical restraints Pain were significantly related to delirium severity (Inouye,2013)

DELIRIUM IN DEMENTIA – Treatment Only 16 studies of pharmacological delirium prevention and treatment, focused on antipsychotic and sedating drugs: haloperidol was not effective in preventing delirium but did reduce its severity and duration, and also decreased length of hospital stay (Kalisvaart 2005). Olanzapine reduced the incidence but increased duration and severity Rivastigmine increased duration and mortality Gabapentin under investigation Dexmedetomidine under investigation (Inouye, 2013)

DELIRIUM IN DEMENTIA Pharmacological Treatment Pharmacological approach (HALOPERIDOL) should be confined to patients with severe agitation who risk interruption of essential treatment (e.g., intubation) or self-injury, or have severe distressing psychotic symptoms (e.g., hallucinations, delusions). N.B. Haloperidol and the other antipsychotics carry an increased risk of stroke in elderly patients with dementia and prolongation of QT interval (Fong et al 2011)

KEY POINTS Delirium is one of the foremost unmet medical needs in healthcare. Delirium predicts new-onset dementia and accelerates exisisting dementia. Delirium prevention is effective and cost- effective but implementation in clinical practice is still lacking.

Prophylactic citocoline v. Placebo, Outcome Incident delirium Cochrane Review, 2009

Prophylactic haloperidol v. Placebo, Outcome Incident delirium Cochrane Review, 2009

Prophylactic haloperidol v. Placebo, Outcome delirium duration Cochrane Review, 2009

Prophylactic haloperidol v. Placebo, Outcome delirium severity Cochrane Review, 2009

Prophylactic haloperidol v. Placebo, Outcome length of stay Cochrane Review, 2009

Prophylactic donepezil v. Placebo, Outcome delirium incidence after surgery Cochrane Review, 2009

Proactive geriatric consultation v. Usual care, Outcome delirium incidence Cochrane Review, 2009

Proactive geriatric consultation v. Usual care, Outcome delirium duration Cochrane Review, 2009

Proactive geriatric consultation v. Usual care, Outcome severity-cumulative incidence of severe delirium Cochrane Review, 2009

Proactive geriatric consultation v. Usual care, Outcome institutionalisation at discharge Cochrane Review, 2009

Proactive geriatric consultation v. Usual care, Outcome delirium at discharge Cochrane Review, 2009

Assessment of suspected delirium Inouye, Lancet 2013

Management of suspected delirium Inouye, Lancet 2013

DSD Algorithm Fick, 2008

Cost-effectiveness of multi-component interventions to prevent delirium Akunne, 2012