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The Pinch Me Pod – an MDT approach to delirium in hospital settings
This is the ‘Pinch Me Pod’, a podcast resource from the Northern Health and Social Care Trust, to help explore the topic of delirium in detail, and what the multidisciplinary team can do to recognise and manage delirium in the hospital setting.
Dr Stephen Collins, Doctor in Elderly Care Medicine, hosts this podcast series, alongside a panel of staff from across the acute hospitals in Antrim and Causeway, in Northern Ireland. Over the course of six episodes, we explore what delirium looks like for us in our own day-to-day work and the significant impact this condition has on patients, families and staff. As well as the lessons we have learned, we also discuss lots of tips on how you might be able to improve the level of care you provide to patients with delirium in your own work setting. We hope that this podcast will begin to answer some of the questions you may have and help you navigate the medical minefield that delirium can sometimes feel like.
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Pinch Me Pod Episode 1 - What Is Delirium
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This is the Pinch Me Pod, a podcast resource from the Northern Health and Social Care Trust to help you and your colleagues manage delirium better in the hospital setting.
Hello and a huge welcome to our new podcast series all about the topic of delirium. For those of you working in hospital settings with older adults, delirium is almost certainly something that you see each and every day on the wards. This acute confusion can be unsettling and a bit scary for families and friends of patients.
And for us as the healthcare staff looking after these patients, it can often be quite challenging to manage at ward level. So what can we do to be better at recognizing and managing delirium in the patients that we see? Well, we hope that this podcast will begin to answer these questions and help you navigate the medical minefield that delirium can sometimes feel like.
My name is Stephen and I'm a doctor working in elderly care and stroke medicine in Causeway Hospital. And along with a team of extremely wise and experienced friends, I'd love for this podcast to help you explore what delirium looks like for us in our own day to day work and the lessons we've learned, as well as lots of tips on how you might be able to improve the level of care you provide to patients with delirium in your own work setting.
Over the course of six episodes, we intend for this podcast to be a reliable overview of the topic of delirium. And it thankfully won't just be me you'll be listening to. This podcast and all the planning that has gone into it has been a massive collaborative effort from lots of different members of our hospital multidisciplinary teams in Antrim Area Hospital and Causeway Hospital with a whole host of voices ready to share their wisdom with you from right across the entire Northern Trust area here in Northern Ireland.
And the first person I'd like to introduce is Dr. Darshan Kumar. Darshan, could you please help kick things off for us? By tackling the main question that is probably in the minds of everyone listening to this podcast, what is delirium?
Delirium is a sudden and severe change in brain function that causes a person to appear confused or disoriented, or to have difficulties maintaining focus, thinking clearly and remembering recent events. And this occurs typically with a fluctuating course. As I said, it's relatively common and often our patients have an underlying medical cause for this. Older patients over 65 years usually are at highest risk of developing this. Whilst this is a sudden or severe change in brain function, it can have different names and it's often confusing and is also labelled as an acute confusional state as such.
Because of this, delirium can be frightening for the patients or for the caregiver or family. As I said, there's usually an underlying health condition or a medical condition, which means delirium can be treated, with treating the underlying cause, but this takes a variable course. It can be a few days to hours for it to resolve, or sometimes it can be longer, taking weeks to months for it to fully resolve.
This automatically becomes an enormous impact for health care and also to the patients themselves, because patients with delirium may experience prolonged hospitalization and a decreased ability to function independently, and they are at high risk for requiring care in a long term facility.
Thank you, that was really helpful. Now, I feel it might be worth spending a few minutes thinking about the people who are most at risk of delirium and Jackie, you're going to take us through that. And before you do that, can you please introduce yourself?
My name is Dr. Jackie Greer and I work in the Care of the Elderly team in Antrim Hospital. So, delirium is a very common condition that we see right across our hospital from the youngest through to the oldest, on our medical, our surgical wards, and also quite often in our ICU settings. Certainly, on the medical wards where I work, we would see it very commonly and about a quarter to thirty percent of those patients would have a delirium as part of their hospital admission.
There are some risk factors which have been identified to be particularly associated with developing delirium and the four big risk factors that have been identified are, number one those that are older in age and those over 65 in particular are at an increased risk of developing delirium during their admission.
Secondly, those who have pre-existing problems with their memory or dementia have an increased risk of developing delirium during their admission. Thirdly, those that are acutely unwell and obviously most of the patients who are in our hospital settings would be acutely unwell and fall into this category would be at increased risk of developing delirium.
And the fourth big risk factor would be those who had fallen and fractured their neck of femur. So each of those four big risk factors would increase your risk of developing delirium about four or five times compared to somebody who didn't have those risk factors.
I always like to talk about a fifth big risk factor, which is frailty. It increases your risk of developing delirium by two or three times. So it's not just quite as strong as the others, but it's a very significant risk factor for developing delirium. And it's probably one of the reasons that we see delirium, more incidences of delirium in our hospital settings and in the community because of the increasing numbers of older frail patients with comorbidities.
The other big thing which is really important to ask about is if someone has had a previous episode of delirium because this is very strongly associated with having a further episode of delirium during your hospital admission. So it's really important to get that history when you're assessing the patient.
Another colleague of ours is Orla Matthews. Orla is the Dementia Service Improvement Lead for Hospital Settings in the Northern Trust, and she explains that the underlying cognitive impairment we see in patients with dementia, makes those people more likely to develop delirium.
When we think of the disease activity around various dementias, whether it's Alzheimer's disease, and you have those amyloid protein plaques or Lewy body disease, the main theme of diseases that cause dementia is inflammation.
So we know when that inflammation is already there and active, and someone has then an acute illness that causes that systemic inflammation, then they're going to put them at risk. So systemically, anatomically, they're more at risk of developing delirium. If they're already experiencing issues with orientating themselves to time and place and person, or already having experiences of adaptive paranoia or behaviours to try and cope with the cognitive impairment they're living with, then you're going to see those behaviours associated with delirium more prevalent as well.
So now we have had a summary of what delirium is. And we thought a little bit about the people who might be more at risk of developing delirium. What about how these patients present? What signs can we observe? Here's Julie Munn, lead nurse for professional practice in medicine and emergency medicine.
Within the acute environment, we see many patients presenting with delirium on admission, but others may also develop those symptoms of delirium during their stay with us in the hospital. Being off their baseline physically and cognitively, confused, rambling, having difficulties with communicating.
It's about staff being aware of, of the types of delirium, and there is the three subtypes. You're hypoactive delirium, you're hyperactive, and of course your mixed delirium. You know, from a nursing perspective especially, it's about the fundamentals of care whenever we're looking after these patients. It's about us treating patients and families how we would want ourselves and our own families to be treated. And within those fundamentals, we are all so busy nowadays, It's those basics of adequate fluids. Have they got their glasses on? Have they got their hearing aid? You know, how are we promoting sleep very much today? There's a lot of deconditioning of patients. You know, we need to get these patients up and about and let them move and be interactive and support them as best we can. And I suppose a lot of that is staff education as well. It's about utilizing the resources we have, like our delirium pathway.
Having that for every patient that comes in so that they are assessed. And we can monitor their care and report our findings, linking with our MDT team and with regards to their care, if we need any pharmacological interventions. All those things are further down the line, so definitely the fundamentals are so important.
One of the things mentioned by Darshan when defining delirium at the start of this episode was that it is acute onset and fluctuating. Jenny Preston is a doctor working with the Mental Health Liaison Service team in Antrim Area Hospital and here she is to help explain to us what acute and fluctuating might look like when we see these patients arriving in hospital.
Whenever we're up on the ward speaking to people, they will describe, they weren't like this last week, I've never seen them like this before, and it's extremely worrying, and it can make you as a clinician or as any healthcare professional feel quite anxious about it, but it could still be a delirium, and also fluctuating, so that means it can change within a morning, within a day, within a few days of how they present. That can mean they're confused, they don't know what day it is, what year it is, at 10 o'clock in the morning and at 4pm that afternoon they might know. And whenever we say those words that's the kind of patient and picture that we're describing.
What about those three subtypes of delirium though? Hyperactive, hypoactive and mixed delirium. What do each of those look like? What are the warning signs that we should be looking out for? Here's Jenny again.
So hypoactive, this patient can present as sleepy, lethargic, quiet, not seeming to want to engage, probably not causing the staff to come to them a lot because they're very sleepy and lethargic in the corner of the ward. And sometimes when we get referrals to our team, the referral could look like they're worried the person might have low mood, but it could still be a delirium and That's where our team will come in and assess them. Then hyperactive, so these patients can present in an agitated state, very restless, require a significant amount of management at a ward level, and these patients can also present with hallucinations. Visual hallucinations. They can be seeing people on the ward. They can be extremely distressing. They might see people who they think are coming to attack them. They might be hearing things happening on the ward. That's a very common feature that they think unpleasant things are happening on the ward.
And we can get referrals then that say new hallucinations, new paranoia, and it can still be a delirium. And that's where our team would come and assess them. And then helpfully, we can also have a mixed picture. So then we could have a patient who has features of both of those occurring at the same time.
But what about confusion or behavioural changes in patients with a background of dementia? Is it okay for us to just assume that the confusion they're presenting with is because of their dementia? Or can they experience delirium too? Here's Orla once again.
Sometimes we are not that good at identifying what a person baseline is, especially if a cognitive impairment already exists like a dementia and staff can make a presumption that because someone's living with a dementia that the confusion that they are presenting with is something that has already been in existence and is a baseline. We really, really need to listen to our carers, to our family members, and actually even to our other colleagues across HSE.
Nicola and I have carried out a few audits before. We've actually seen really, really good examples where NIAS staff, it's documented on their ‘flimsy’, where they've had a conversation with the family member, and they're actually saying this person is off their baseline physically, you know, they're not walking as well, they're not eating as well, and their family members have told us they've been more confused the last few days, they're off their food, they're more irritable. All those signs that we see and recognize in delirium.
And NIAS are identifying that and then the person's coming into the hospital and we aren't documenting that and we're not going through the process. You know, we need to be looking at that at the baseline and getting a good grip and really, really listening to your next of kin; Mummy's more confused than usual. Or daddy's been really irritable and just not himself recently. We need to be thinking, is this a delirium?
So, If delirium is something that we need to make sure we don't miss, how exactly can we assess for it? Well, thankfully we have a regional delirium care pathway based on NICE clinical guidelines and this is available on all wards and on the Northern Trust intranet by clicking on business areas and going to the delirium tab. Nicola Loughlin is our delirium nurse coordinator for medicine and emergency medicine in the Northern Trust and here she is to help talk us through how we can use the delirium care pathway to assess our patients.
The first step is identifying who is at risk of developing delirium and it includes the four big risk factors that Dr Grier discussed earlier. The second step then is screening for delirium using what we call the SQID, S Q I D, The single question in delirium, which really is, is the person more confused than usual? And on admission, family and friends, you know, or carers may be best placed to answer this question. Or if the person has been on the ward for several days, then the staff may be able to answer this.
That rapid change in the person's mental function often means that delirium could be present. So if the answer to the SQID question is no, but the person has risk factors for delirium, then the person remains at risk of developing delirium. And it's important to remember that a delirium can develop at any stage during their admission.
Interventions to prevent delirium occurring should be implemented and these measures are outlined in the pathway also. But if the answer to the SQID question is yes, then further assessment is required to identify and diagnose delirium.
So we now know what a SQID is, a single question in delirium, and we've just heard that if the answer to the question, is this person more confused than normal, is yes, then we need to assess further. But how do we do that? Here's Nicola again.
When the NICE guidelines were updated in January 2023, there were clear recommendations given on the type of tool to use in the assessment of delirium, and that tool's called the 4AT, and it's a relatively short tool, just looking at the level of alertness, the AMT4, level of attention and acute onset and fluctuating course.
So the rest of the pathway really provides an aid memoir for the management of delirium and again we'll refer back to that in subsequent podcasts in relation to this. But overall we're trying to nurture a culture where we're really thinking about delirium, thinking about who's at risk, what symptoms are present, given that the serious consequences of delirium and the delirium care pathway gives us that framework to do this consistently.
One thing brought up by Nicola there was the 4AT assessment tool made up of four areas all beginning with letter A and just to recap those areas are, 1 alertness ie is the patient less alert than normal, 2 the AMT4 test which we'll come back to in just a moment, 3 attention how attentive is the patient For example, can they say the months of the year backwards? And 4, Acute change. Is there evidence of a new change in alertness or cognition that has only come on in the past couple of weeks?
But what about that AMT 4 part of the assessment? What exactly is the AMT 4? Here's Darshan again to help explain.
AMT 4 is an abbreviated mental test and it's just looking at a quick four questions to know the patient's orientation as such. It's the patient's age, date of birth, place, and the current year, and it gives a quick snapshot of the patient's orientation.
While the SQID is a great starting point in assessing for delirium, Jackie reminds us that while looking for new confusion, it's also important to check for things like drowsiness.
Nicola very rightly said that one of the starting questions that we ask is the SQID, which is, is this person more confused than usual? But it's also probably useful to consider, is this person sleepy or less responsive than usual? Because that just helps us to detect hypoactive delirium, which is quite often overlooked.
Moving on then, where does mental capacity come into all of this? Often on the hospital wards we'll hear colleagues saying that people need capacity assessments done because of their confusion. How do we judge whether or not our patients have capacity to make certain decisions for themselves? To help walk us through this, here's Darren Bridges, the Mental Capacity Act lead for acute hospitals in the Northern Trust.
With delirium, it's an acute presentation of confusion, and what we're finding is people are more confused, so, like those questions in the AMT 4, we're finding patients are disorientated, they're not entirely sure what's going on. And really, we want patients to be in a position where they can make decisions for themselves.
But to make that decision for themselves, they have to have capacity. So we're looking at that under what's called the functional test. And that functional test really focuses on four key areas. So that's their patient's ability to communicate their wishes. Can they tell us what they want to happen? Are they able to say what their views and wishes are?
Can they understand the information that we're giving to them? Does it make sense to them? Are they able to understand what we're telling them? And are they able to appreciate that information as well? So can they use it to weigh up? Can they use that information that we give them to come to a reasoned decision?
And the final part of that is around retention. So can they hold that information for long enough to make a decision? We're not talking about carrying this over for days or weeks. We're talking about the space of maybe 10 minutes and coming to that reasoned decision. So there are lots of people out there that live their life in unwise ways and make decisions that we may not agree with, and it's their right to do so as long as they've been assessed as being able to make that decision.
So in the case of delirium, if a patient is judged in the ward to be lacking capacity to make a certain decision, will their level of capacity be affected permanently?
What we find a lot of the times with, with patients with a delirium, that we are finding a temporary change to their level of capacity. That we're finding that because of maybe an underlying infection, or it may be as a result of a head injury, or alcohol detox, whatever the cause of their delirium is causing them to temporarily lack capacity. And doing that assessment, there's five key principles within the Mental Capacity Act. What we're really looking for is providing as much support to that patient as humanly possible.
So, as people have been talking about with delirium, the levels of confusion can fluctuate. So it's really important that we're seeing that person at a better point in time in the day. So we're getting the best picture of them at the best time. And we're looking at making sure we're not making any assumptions. So just because, as Orla's been talking about with patients with dementia, we're not assuming that they lack capacity just because of that diagnosis.
We're allowing people to make unwise decisions, as long as they are able to make that decision for themselves. And as long as we're following the core principles of the Mental Capacity Act, we're working in the patient's best interest, then that way we can get good outcomes for service users and patients in the hospital.
With the behaviours that we've talked about, one of the things that we can see quite often is patients particularly wandering, presenting with agitation or aggression, putting themselves at risk of harm, or even trying to leave the ward at times. And it's in that situation, if a patient's deemed to lack capacity, that we're looking at what's called a short term detention.
And that's that patient being subject to what's called the deprivation of liberty, where they're not allowed to leave the ward of their own choosing, and they're under constant supervision. And that's just to keep them safe whilst they're under our care.
Here's Orla again. I think it's interesting, Darren, as well, just that when we think around capacity, that it's not an umbrella term that we apply to someone because we know they're experiencing a temporary cognitive impairment and we need to make sure our staff can help our patients retain their autonomy as much as possible.
So, even if someone has been identified as not having the capacity to make a decision in order to stay in the hospital or to leave and to maintain their safety, there's a deprivation of liberty order in place. But that person can still make decisions as to what pyjamas they want to wear, what food they want to eat, whether they want to get into bed and, and rest during the day.
So we have to be really, really careful that when we talk around capacity, that it's the person's been assessed to have capacity for a specific reason, and that’s what a deprivation of liberty is. And it's great that we have Darren, our MCA team, and our social workers to support our staff whenever it comes to those complex areas.
And Orla is entirely right. So every capacity assessment is decision specific and time specific. And that's really important when it comes to delirium because we are always hoping that this delirium is going to resolve. So just because we've assessed a patient as lacking capacity now doesn't mean that they're not going to regain it in a day, two days, a week from now, whatever the case may be.
And likewise, as Orla is saying, they may lack capacity in relation to certain decisions, but it doesn't mean they lack capacity for everything. They still know what they want to eat for their lunch and what they want to have for their dinner. They still understand a lot of what's going on because with delirium, the cognitive impairment of it varies so much where it can affect people massively or just a little bit. And it's important that we allow service users and patients to make as many decisions for themselves as we possibly can.
All of this helps us see why it's so important that we know how to assess people for delirium because we may well see their delirium improve over time. I asked Darren if an improvement in a patient's delirium should be a trigger for us to consider reassessing their capacity.
That's exactly it. So we see then that behaviour starts to subside, we see changes in behaviour, we see cognition starting to improve. And it'd be really common that the team that I work in would get referrals to come and do reviews with patients who may have regained capacity and that's the ward being proactive to make sure that they're not depriving somebody of their liberty when they no longer need it.
Back to Darshan and Orla once more. Over the years we have been reasonably good in looking at progress of a patient, be it clinically or using biochemical tests. But the one thing which Nicola emphasized on the 4AT, which is in a way assessing how the patient is progressing. So if that is serially undertaken, that tells us how the patient is progressing from a delirium perspective, and if they're improving or things are getting worse.
I think it's really important for us to have a think around why is recognition and assessment of delirium so important. I think it's really important that staff are reminded of the really poor outcomes for people when they have a delirium or an unresolved delirium. We know when people develop a delirium in a hospital setting there are more risk of falls, they are more at risk of death, they are more at risk of developing hospital acquired pneumonias. And we also know that they have poor outcomes in terms of when someone is diagnosed with a delirium in a hospital setting, they have a less likelihood of returning back to their own place of residence. So, developing delirium can lead to really poor outcomes, so not just in terms of your health. But also in terms of your social status, where you live, your residency. And it's for that reason that an assessment of delirium is so, so important, because we know the earlier we recognise it, the earlier we assess it, then the earlier we can manage it and help people have better outcomes.
Brilliant. So many pearls of wisdom from everybody here in the room. Thank you all for chipping in. And I think I speak on behalf of all our listeners in saying that we really look forward to catching up with all of you in our next episode, which is coming very soon, when we will be exploring some of the triggers for delirium. What exactly causes this unsettling, confusional state?
Lots to look forward to in that episode, so make sure you come back and join us for it. In the meantime, please spread the word about this podcast with all your friends and colleagues. We can't wait to spend some time with you again very soon when the podcast returns. Bye for now.