Delirium: under recognised and poorly treated?

Delirium (sometimes called acute confusional state) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has acute onset and fluctuating course. It is a serious condition albeit potentially reversible if formal diagnosis is made, underlying precipitant/cause identified and prompt treatment delivered. Older people, people with cognitive impairment, dementia and severe illness are more at risk of delirium.

There is an increasing level of focus on the recognition, diagnosis and treatment of patients with clinical features suggestive of dementia presenting to healthcare facilities both in the community and hospitals. This is rightly so in view of the profound level of anxiety associated with this diagnosis and the overall devastating impact dementia has on those affected and their family carers.¹ Healthcare professionals in the community and hospitals will do well in using the opportunity provided in bringing to the fore an equally understated, under recognised and poorly treated syndrome.

It is traditional to talk about dementia and delirium as opposite ends of a spectrum, the former having a chronic progressive course and the later acute fluctuating. However, we do know that delirium not only often coexists but can be a precursor to eventual chronic cognitive decline and dementia. Many patients with delirium can be misdiagnosed with dementia. It therefore suffices to conclude that a successful dementia identification/management strategy must not ignore the ubiquity of delirium in the at risk population (a population that is not dissimilar to those who have dementia) in communities and hospitals. The statistics remind us of this: the prevalence of delirium is 20-30% on medical wards, 10-50% on surgical wards and may be up to 20% in long-term care residents.²

Despite the high prevalence of delirium in these settings, the syndrome remains largely poorly recognised and managed. Delirium must be recognised for what it is, a serious condition associated with negative outcomes including longer hospital stay, higher costs, increased risk of complications and higher mortality, both during hospitalisation and afterwards, loss of independence and increased risk of cognitive decline.^2,3

Formal identification of delirium

The formal identification of delirium, a focused search for potential underlying cause and prompt management should therefore be a marker of quality of care in at risk populations represented predominantly by older patients in hospital medical and surgical wards as well as long-term care residents in the community. Delirium should be brought to the forefront of medical practice. We should move the debate from ‘muted discussions’ of a clinical syndrome with significant high prevalence and far reaching negative outcomes for older patients, their carers and the overall health economy.

The NICE Clinical Guideline 103 and Quality Standard 63 on delirium⁴ represents a viable starting point in the implementation of improvement in relation to the diagnosis/care of patients with delirium in community and hospital settings. If implemented there is a potential for improvements in the detection of delirium, falls in hospital, mortality and patient/carer experience of healthcare. A focal point of the guideline lies in the formal identification of delirium using the Confusion Assessment Method (CAM) tool.

A recent local audit on our general medical ward revealed poor formal identification of delirium in at risk patients in whom indicators for delirium were present. My instinct is that this finding will be similar in a host of general medical and surgical wards across the country. We intend to pilot a project using some of the principles proposed by NICE CG 103 and QS 63 to improve our practice and set up interventions to maximise optimum care for patients at risk of or presenting with delirium.

We have an opportunity to improve the quality of care for older patients and in essence other groups of patients suffering with delirium in community and hospital settings if the tenet of the NICE CG 103 and QS 63 are implemented. Prompt formal diagnosis and documentation in clinical and discharge notes using the CAM tool in at risk patients with clinical indicators is an essential first step in achieving this goal.

References

1. Departmentof Health publication. Living well with Dementia: A National Dementia Strategy 3 February 2009

2. NICE (NationalInstitute for Health and Care Excellence) Clinical Guideline CG 103, Delirium :Diagnosis, prevention and management July 2010

3. Barbara C van Munsterand SE de Rooij. Delirium: A synthesis of current knowledge. Clinical Medicine2014 Volume 14, No 2: 192-5 
4. NICE (NationalInstitute for Health and Care Excellence) Quality Standard QS 63. Delirium,July 2014