[NICE Guideline] Delirium: prevention, diagnosis and management Clinical guideline [CG103]

NICE | March 2019 | Delirium: prevention, diagnosis and management Clinical guideline [CG103]

NICE has updated this clinical guideline, the guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long-term residential care or a nursing home. It also covers identifying people at risk of developing delirium in these settings and preventing onset. It aims to improve diagnosis of delirium and reduce hospital stays and complications.

In March 2019 NICE removed the use of olanzapine for the treatment of delirium in people who are distressed or considered a risk to themselves or others.

Full details from NICE 

Older patients spared dementia and falls by NHS tech roll-out

Digital checks that can prevent dementia and falls in older people are among a range of tools being made available in hospitals across the country, as part of the NHS Long Term Plan | Via NHS England

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One in eight hospital patients is affected by delirium, which can make people unsteady on their feet, increases the risk of developing dementia and can result in longer hospital stays or admission to a care home.

However, these problems can be avoided through timely and effective care, with a scheme in Salford increasing the number of patients correctly diagnosed with delirium by 34%, through the introduction of screening for all over-65s who are admitted to hospital. Doctors and nurses run through a symptoms checklist on a mobile computer or handheld device.

The new electronic assessment tool for delirium has increased screening of over 65-year-olds on admission to hospital and has increased assessment of those who become newly confused when they are in hospital, with the number of identified cases per year having risen by 34% and the length of stay for these patients has reduced by 11%, saving an estimated £1.7m in the first year. Readmissions for delirium patients has also reduced from 15% to 13% saving an estimated £101,000 for the same period.

The scheme is just one of a series that is being rolled out across the country through the adoption of toolkits, known as blueprints, that allow any NHS hospital to implement improvements quicker and more easily to transform care and improve services for patients and staff.

Full detail at NHS England

Dementia patients “suffering in silence”

University College London | September 2018 | Dementia patients “suffering in silence”

A new study from University College London (UCL) reports that one-third of patients with dementia who may also experience delirium (a state of acute confusion) are frequently unable to express that they are in pain.  The study has originality, as it is the first of its kind  in a hospital context. It has been funded by the Alzheimer’s Society and Bupa Foundation, and supported by the terminal illness charity Marie Curie. The research was conducted in two acute hospitals in the UK and followed more than 200 patients over the age of 70 (via UCL).

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At the outset the researchers asked patients if they were in pain. If the patient was then unable to communicate, researchers assessed people for signs of pain in their facial expression and body language. They recorded the number of people who were unable to communicate that they were in pain, and measured delirium with a standard confusion assessment method.

The researchers found that almost half (49%)  of the participants experienced pain at rest, while a quarter (25%)  experienced pain during activity. A little over a  third (35%) of participants who were delirious and unable to self-report pain,  of these patients 33%  experienced pain at rest, and 56% experienced pain during activity.

The odds of being delirious were 3.26 times higher in participants experiencing pain at rest.

Senior Author Dr Liz Samson from the Marie Curie Palliative Care Research Department, UCL Psychiatry says, ” In the UK, almost half of people admitted to hospital over the age of 70 will have dementia. We know that they are a high-risk group for delirium and yet delirium is often under treated.”  She elaborated, “It’s deeply troubling to think that this vulnerable group of patients are suffering in silence, unable to tell healthcare professionals that they are in pain.” (Source: UCL)

Read the full story at UCL

The research findings have now been published in the journal  Age and Ageing, where the full article can be read

Assessment of delirium in hospital for people with dementia

This report published by the Royal College of Psychiatrists provides a full breakdown of results from a national audit focusing on the identification and assessment of delirium in general hospitals.  It also includes key findings, recommendations, and a discussion of results. 

Key findings

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Image source: http://www.rcpsych.ac.uk/

A high proportion of patients with dementia admitted as emergencies to hospital did not receive an initial assessment for delirium, even after adjustment

After taking account of the greater number of initial assessments identified by the additional questions included in the questionnaire, we found that 32% of patients with dementia, admitted to hospital as an emergency, did not have an initial assessment or screen for delirium. At just under one third of the sample, this remains a very high proportion of people at high risk of delirium and requires improvement.

Questions about initial screen or assessment for delirium are inconsistently interpreted

Variation is apparent in the approach hospitals take to carrying out and recording the assessment of delirium, as questions about an initial screen or assessment for delirium are inconsistently interpreted. In 219 (10%) casenotes, auditors reported no screen, but questions about specific assessments found that it had taken place.  Following adjustment allowing for responses for the follow up questions, results for individual hospitals improved by an average of 19% with individual hospitals seeing increases ranging from to 64 percentage points.

Over a quarter of patients have no confusion or cognitive tests recorded

37% of patients received no confusion or cognitive tests at all, as well as no initial screen.  Cognitive assessment is an important part of comprehensive assessment which all patients with dementia admitted acutely should receive.

Delirium not included in discharge correspondence

Only 48% of patients whose casenotes recorded possible delirium at admission or after initial screening had this recorded on their discharge letter or summary.  All patients who have delirium during admission to hospital should have this information communicated to their General Practitioner (and Primary Care team) on discharge.

Full report: Assessment of delirium in hospital for people with dementia. Spotlight audit 2017 – 2018

 

Guidance on person centered care for those living with dementia, depression and delirium

Knowing Me! | Life Story Network

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Image source: http://www.lifestorynetwork.org.uk

Knowing Me! offers practical guidance on person centered care for those living with dementia, depression and delirium. The objectives of Knowing Me! are to raise awareness and understanding of the 3D’s, drive improvements in the standards of care, and improve the outcomes that can be achieved for those affected by the 3D’s.

Knowing Me! is not however a stand alone resource aimed at a particular staff group or a particular care environment but should be seen as a complimentary resource to raise the awareness and understanding of the 3Ds.

Knowing Me! builds on the values and principles of person centered care and support to improve the quality of life and provides useful and practical ways improvements can be made to really make a difference.

Full publication: Knowing Me! Dementia, Depression and Delirium – A person
centered education and training resource

Increased risk of dementia in patients who experience delirium after surgery

This study finds those who developed postoperative delirium were three times more likely to suffer permanent cognitive impairment or dementia | ScienceDaily

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Over a ten year period, patients over the age of 65 enrolled at the Mayo Clinic Study of Ageing in Olmsted County Minnesota who were exposed to general anesthesia were included in an investigation involving over two 2000 patients. Their cognitive status was evaluated in regular 15 month periods before and after surgery by neuropsychologic testing and clinical assessment. Out of 2014 patients, 1667 were deemed to be cognitively normal before surgery. Of the 1152 patients who returned for follow-up cognitive evaluation, 109 (9.5%) had developed mild cognitive impairment (pre-dementia) or dementia, and those who had suffered postoperative delirium were three times more likely to be subsequently diagnosed with permanent cognitive decline or dementia. This research is the first to focus on the association between delirium and long-term cognitive decline in patients with normal mental capacity before surgery.

While previous studies have highlighted cognitive decline in the elderly following postoperative delirium, no others have involved such a detailed neuro-cognitive assessment identifying those with normal pre-operative cognitive abilities who go on to develop dementia. In conclusion, researchers believe that postoperative delirium could be a warning sign of future permanent cognitive impairment (dementia) in patients who at the time of surgery were still just above the threshold for registering cognitive decline. Alternatively, postoperative delirium could itself produce injury, which per se accelerates the trajectory of decline into dementia.

The Confusion Care Pathway

The Confusion Care Pathway has been developed by the dementia/delirium working group at London North West Healthcare NHS Trust as a guide to best practice in supporting people with dementia, delirium and/or cognitive impairment and their carers.

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The Confusion Care Pathway (CCP) starts with the need to recognise confusion. A confusion identifier (the symbol on the CCP) is applied to the medical notes and a magnetic identifier is applied above the bed. The CCP subsequently guides healthcare staff to assess the cause of the confusion in order to reach a cognitive diagnosis, to avoid moves unless in the patient’s interest and to focus on assessing the patient’s needs for care planning and discharge planning throughout the inpatient stay.

The CCP prompts healthcare staff to work in partnership with the patient and their carer from the outset of their admission by: exploring the patient’s needs and preferences via a document called ‘Important Things About Me’, as well as using the Carer’s Agreement and Carer’s Passport.

Delirium could accelerate dementia-related mental decline

When hospitalized, people can become acutely confused and disorientated. This condition, known as delirium, affects a quarter of older patients and new research shows it may have long-lasting consequences, including accelerating the dementia process. | via ScienceDaily

 

 

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New research by UCL and the University of Cambridge shows delirium may have long-lasting consequences, including accelerating the dementia process. Episodes of delirium in people who are not known to have dementia, might also reveal dementia at its earliest stages, the research found.

Scientists looked at three European populations — in Finland, Cambridge and UK-wide — and examined brain specimens in 987 people aged 65 and older. Each person’s memory, thinking and experience of delirium had been recorded over 10 years towards the end of their life.

When these were linked with pathology abnormalities due to Alzheimer’s and other dementias, those with both delirium and dementia-changes had the most severe change in memory.

Journal Reference: Daniel H. J. Davis et al. Association of Delirium With Cognitive Decline in Late Life  A Neuropathologic Study of 3 Population-Based Cohort Studies JAMA Psychiatry, January 2017