Improving detection to decrease delirium

• This World Delirium Awareness Day (12 March) Dr Penny Casey RN PhD, explains how we can look out for delirium symptoms in our consumers and loved ones.
• Delirium is the sudden onset of a new confusion that involves a change in someone’s thinking or behavior that’s outside of what would have been seen with them previously.
• Up to 50 percent of people in hospital, and particularly older people in hospital, can experience delirium during their stay.
• Common triggers include new, multiple, or a change in medications, becoming sicker during the hospital stay, malnutrition, dehydration, sleep deprivation and poorly managed pain.

“Delirium is the sudden onset of a new confusion that involves a change in someone’s thinking or behaviour that’s outside of what we would have seen with them previously. If you’ve had delirium once before, you’re more at risk of getting it again.”

For World Delirium Awareness Day (12 March) Dr Penny Casey RN PhD, explains how we can look out for delirium symptoms in our consumers and loved ones.

“Up to 50 percent of people in hospital, and particularly older people in hospital, can experience delirium during their stay and intensive care units it’s closer to 80 percent,” she said.

Those people most at risk of developing delirium include those who:
– Are aged over 65 years;
– Aboriginal or Torres Strait Islander people aged over 45 years;
– Have underlying cognitive impairment that may or may not have already been diagnosed;
– Have had a hip fracture in the past year;
– People who have had delirium in the past; and
– People who present to hospital with a severe medical illness.

“Many things can trigger delirium in those who are at risk. Common triggers we think of are having new, multiple, or a change in medications, becoming sicker during the hospital stay, such as becoming septic or developing organ failure, malnutrition, dehydration, sleep deprivation and poorly managed pain- any of these situations can trigger delirium in people in hospitals. These are things that as clinicians, loved ones and patients we all need to be aware of so that we can prevent delirium,” Dr Casey said.

Eastern Health has embraced the need to improve care in delirium. Dr Casey has dedicated her research to finding ways to increase detection after seeing her own mother contend with the challenges of delirium.

“When the Delirium Clinical Care Standard for Australia was launched back in 2016, Eastern Health was already on the front foot, designing a policy and procedure and a clinical pathway. We already had questions in the vital signs chart to help staff detect delirium, and they were quick to implement validated screening and assessment tools.

“Eastern Health has made significant strides in research and care improvement. Between 2016 and 2018, we conducted three point prevalence surveys to assess delirium prevalence, revealing gaps in reporting and data accuracy. This groundbreaking work highlighted the need for more robust tracking, a challenge we continue to address,” she said.

Eastern Health has also been involved in interprofessional education for health professionals to help them better recognise and respond to delirium.

“We ran a study across five pilot wards and eight test wards where delirium had the highest rates of occurrence, to help improve the knowledge and skills of our staff, and we found that after doing that, we saw an increase in screening rates at admission for delirium, which is critical for its early detection.

“Eastern Health participated in the Model PC project, a study led by the University of Notre Dame in New South Wales, which implemented delirium monitoring in palliative care in four impatient palliative care units nationally. The study identified gaps in evidence-based practice and introduced a simple addition to daily assessment charts to track delirium and patient distress due to delirium. This led to significant improvements in delirium care at the end-of-life, including a reduction in inappropriate antipsychotic use,” Dr Casey said.

Often those who know the patient best, tend to notice even the most minute differences in our loved one. Dr Casey notes that if you see a change in someone’s thinking or behaviour that you think is unusual, you are encouraged to let the treating team know.

“I think one of the simple questions to ask yourself, whether you’re a clinician or a family member or even a patient, is, ‘is this person more confused today than they were yesterday or the day before?”’ And if the answer to that question is “yes,” then have they been confused like this before? We’re usually good at picking up when our loved ones are behaving a little bit abnormally. That can be a critical early sign that delirium is imminent and that we need to be investigating and implementing delirium care straight away.”