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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 - Ep 2 - Triggers for 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.
Brilliant to have you join us again for episode two of our delirium podcast series. If you have already listened to our first episode, you'll know my voice already. I'm Stephen, a doctor working in elderly care medicine in Causeway Hospital. And a significant proportion of the patients that I and we in this room have the pleasure of spending our working days with are affected by delirium in one way or another.
Through the six episodes of this podcast, we hope to help you dig a bit deeper into the often misunderstood and mismanaged topic of delirium. In our first episode, we spent some time defining what delirium is, thinking how patients with delirium might present to us in a hospital setting, and talking through what assessments we can do to diagnose delirium.
Then moving on from that, in today's second episode, we want to explore some of the different triggers for delirium and some methods for preventing it. What causes this acute confusional state in patients? How can someone who is normally as ‘sharp as a tack’ be so suddenly thrown off by delirium? Can other medical conditions make someone more likely to experience delirium? Do medications ever play a part? And what about people living with dementia? Can they get delirium too?
These are some of the questions we are going to be looking at answering for you on today's episode. And to help us do that, we have the same crowd of friendly faces. We have got Julie, Darshan, Orla, Nicola, Darren and Jackie. And we are joined by a new friend today, and that is Julie Magee, a pharmacist here in the Northern Trust.
So to start in today's episode, we will ask if a couple of the doctors in our team could help us think through the medical conditions that might trigger delirium and how multi morbidity can play a part.
So Jackie and Darshan, you're going to take us through this. Who would like to go first? Darshan, thank you.
To put a holistic view to this, I think if we look at physiology as a trigger factor. So we talked about patients presenting off their physiological baseline. You can also look at physiological conditions. And then you can look at abnormal physiology because of underlying medical or surgical health illness as such.
There are multiple components which come together to cause this condition. Even what we might think of as a very straightforward chest infection or infective illness has associated inflammatory responses. You can have associated hypoxia, electrolyte disturbances, dehydration, and all of these elements will contribute to the likelihood that someone will develop a delirium.
Frailty is definitely an increased risk factor for developing delirium, and increasingly we're aware of not just the concept of physical frailty, but cognitive frailty in older patients, which makes them much more vulnerable to these stressors and much more likely to have altered cognition and episodes of delirium associated with illness.
So quite often there are these multiple factors, and part of our challenge is to try and identify what is contributing to drive the delirium and treat and intervene where we can. Some triggers may be very obvious, like an infection perhaps, but sometimes the triggers are a little more difficult to identify, and on occasion we never really get to the bottom of why someone has developed a delirium. But even in those cases, it's very important to identify that the patient is experiencing delirium and to manage them according to the delirium care pathway to improve their outcomes.
It's the misconception that somebody has to be physically or have a medical illness as such is wrong.
An older person who has cognitive frailty, if you take them out of their normal environment and their normal day to day activities, the very fact of bringing them into a very busy hospital environment can be a trigger itself for a delirium.
One other thing where I feel we are guilty as clinicians is we are good at prescribing. We start patients medications, but we tend to be slow in putting a stop date to that.
As Dr. Darshan Kumar says, we're not always brilliant at reviewing medications as doctors. And thinking about whether or not we should stop certain medications that may be doing more harm than good. As I mentioned in the intro earlier, we're joined today by Julie, the lead pharmacist for care of older people in the Northern Trust. And here's what Julie has to say about the role medications can play in delirium.
Medications can be a trigger, you know, for delirium itself, so medication review is really important in someone that has new confusion or a delirium, and this should ideally be done by a pharmacist where available. It's important to consider if any medications are new and could be a trigger for delirium, or similarly, if something has been stopped abruptly, it could also trigger a delirium. Some medications have an anticholinergic burden, which can lead to CNS effects, like confusion, agitation, delirium hallucinations. And some examples of these that would have high anticholinergic burden would be amitriptyline, solifenacin, tramadol, hyoscine, but there's lots of them out there. So you need to be very cautious when you're starting or altering these medications in at risk patients, for example, older patients, those with frailty, cognitive impairment, or if they've had a previous delirium.
And make sure you do consider risk and benefit before you commence or change any of these medications. And it is so important to just take the opportunity to review all the medicines, calculate their overall anticholinergic burden score and try and reduce this by de prescribing where clinically appropriate.
Really helpful reminder from Julie there on the importance of assessing the anticholinergic burden on patients. To try and quickly summarize that, anticholinergic medications are drugs that block the action of a neurotransmitter called acetylcholine in the body. And common side effects of these include urinary retention, constipation, dry mouth, and delirium, which is why they are one of the main groups of medications we need to be mindful of when we're reviewing drug charts for our patients.
So if we see concerning medications such as these being given long term, what can we do? Are there any tips for us when it comes to deprescribing? Here's Julie again.
If you're adding something in, maybe manage the expectation with the patient as well. So say they maybe had a fracture, rib fracture, fractured neck of femur, whatever it might be, and you start them on a strong opioid, which long term could be detrimental, as long as you explain to them that this is going to be short term, you know, we expect it only to maybe be two weeks, a month, whatever you might think it'd be, depending on what the pain is or what they've broken.
And then just to have a clear plan on discharge for the GP to review it at that set time and try and reduce it to get it off again. So the expectations are there from the start, because you'll see people coming in and they've maybe been on a painkiller for five years post a surgical procedure and the patients just kept getting that on repeat from their GP and maybe hasn't realized that that shouldn't have been long term.
Quite often, when you're prescribing, if you think about what you want that to be for, how long you want it to be for, make sure that communication is clear.
But if we do make the decision to deprescribe and stop a medication, how do we do that? Can we stop all medications immediately? Back to Julie.
There's some medicines that can be just stopped right away and then there's others that will need to be slowly titrated and it's very individual patients. You know, if someone's been on something for 10 years versus someone who's been on something for a couple of months, you know, depending on how, how slowly you want to taper some of those things off. And try not to do too many changes at once because then if, if there's adverse effects or something happens to them, you need to know which medicine that you've changed that's caused that issue.
Here's Dr. Jackie Greer again. I think quite often we get very fixated on whatever the presenting problem is when someone comes into hospital and we really should take it as an opportunity to cast the net a bit wider and review the medications and try and make some positive changes when someone's in under our care.
It really is important that we make the most of the window of opportunity that we have, to bring about positive change while looking after patients in hospital. But there are many more triggers for delirium than medications alone. Now, time to hear from another Julie. Julie Munn, who is lead nurse for professional practice in medicine and emergency medicine in the Northern Trust. Here she is to talk us through the PINCH ME memory aid that lots of us use when managing cases of delirium.
Yes, well the importance, again, of the fundamentals of care cannot be emphasised enough and these are noted in our PINCH ME triggers. We're looking at our pain. There's not many people that come into hospital that they're not in pain. Have we this prescribed on our medicine charts early, if it's needed and required?
Infection, again, it's early intervention, getting those simple urine tests in case they have UTI, and medication and treatment can commence early in their pathway. Looking at their nutrition, we all need our nutrition to get better. Observing, recording and documenting and highlighting any issues there, do we need support of our dietician and observing intake? Because again, the lack of that can lead on to our problems with constipation, dehydration. So we need to look at all of those. The recording of bowel charts, simple steps, so that we can observe any need for any medical intervention.
Looking at our medications review, which Julie has already talked about. These patients have arrived into a new environment, there's different routines, there's noise. Some may have had several moves before they get to their correct ward. So we need to take all these things into consideration. And it's about nurturing and enabling our staff and empowering them to have it embedded in their culture that the delirium pathway is instigated for all our patients. That we utilize our activity trolleys and our resources that we have. That delirium is brought into our inductions with our new staff so they know what's expected, that we involve our LINK staff who get bespoke training and have up to date information that they can come back and disseminate that to our teams.
It's about people knowing where the delirium pathway is so they can instigate it. The effective communication and daily review of those triggers and documenting those and discussing them together and planning the best way forward, managing our patients at risk of delirium and those patients with delirium. It's enhancing those patient outcomes and delivering those high standards of patient centred care that will make their pathway and journey a more comfortable one.
When we look through the PINCH ME causes of Pain, Infection, Nutrition, Constipation, Hydration, Medications, and Environmental changes, there might be some we are better at tackling than others. And Orla Matthews, our Dementia Service Improvement Lead, feels that pain isn't something that is always managed as effectively as it could be.
In terms of that, PINCH ME, absolutely fantastic acronym, I think, for staff to try to think through. You're thinking P I N CH. I love an acronym. It works really, really well when you're sort of going down your checklist.
That P at the start, I have to say, I have a huge bee in my bonnet about that. We do not manage pain well at all in the hospital settings. I think sometimes we focus on, you know, causation in terms of what we need to prescribe, and we can focus a lot thinking about trauma, you know, do they have a fracture? Is there a soft tissue injury?
But when we're thinking of our older patients in particular, our frail patients, our sick patients, I mean, anyone, if there's a decision to admit in a hospital setting, someone is unwell, and even when you have a chest infection, COVID, a flu, you are going to experience pain. You're going to experience that myalgia. You know, that's why when you have a flu and you are at home in bed, you get that long bone pain because those white cells are being overly produced in your bones to try and fight that infection. You've got your cytokine storms, it's causing micro inflammation all around your muscle tissue. So you get all over body pain, even if it's just a chest infection.
And we are not prescribing adequate pain relief. I'm not talking, you know, strong painkillers, opioids, things that would be more detrimental to people at risk of delirium. Basic QID, paracetamol. And Nicola and I sometimes do feel frustrated when we go on to a ward and there's a person who has a clear delirium and those fundamentals of care, you know, MSSU’s have been sent off to test for urine and all those different things we are looking at and no one has thought that this person actually needs pain relief, or they've been prescribed PRN pain relief in ED and it's never been given.
They might have the feeling, they might be more irritable, there's other signs that you're looking for that might be saying this person's in pain, they might be rubbing their hip, they might be wincing when they're standing up, but you might say, are you sore? And they might deny it, they might say no. Our older patients tend to feel like they don't want to be bothering staff, so they'll not ask for pain relief.
It really is crucial when we're seeing to patients with delirium that we ask the simple questions. Is this person in pain? Could they be constipated? When did they last go to the toilet? Have they been drinking less and refusing food? Have there been any temperature spikes or a new cough suggesting a potential infection?
By regularly working our way through the PINCH ME Mnemonic, regardless of which role we have in the multidisciplinary team, we could all help out with identifying and treating delirium at an earlier stage. However, this might not always be easy to do if someone has an underlying cognitive impairment. What if your patients can't tell you correctly whether they've had something to drink or whether they've been to the toilet? Here's Orla again.
We know that we need to look for those triggers in delirium, but we know when someone is living with a cognitive impairment, whether it's an acquired brain injury from a stroke or from trauma, or a learning disability or a dementia, then we have an extra layer of having difficulties in terms of us being detectives and trying to really scratch through the surface and trying to figure out what's causing this delirium in order for us to manage it. So, in episode one Stephen I had spoken about why people with dementia are more prone to develop a delirium and it's because of that disease activity that's already occurring.
But, you know, there's good ways of sort of identifying could this be a delirium on top of a dementia? And again, that's why it's really, really important to look at that baseline information to speak to family members, to speak to Next of Kin, to try and use that assessment that Nicola was speaking about, single question in delirium, you know, so, so easy, Is this person more confused than usual?
I would say it's sometimes not necessarily easy to differentiate between it. We do know that delirium is an acute onset, whereas dementia tends to be slower. That delirium fluctuates much more within a day, whereas dementia tends to be steadier. People can have patterns within their changes in cognition.
And we know that people with delirium tend to experience inattentiveness or a lack of concentration much more than people with dementia, especially when they're in their earlier stages. So just out of interest, I think it's important to talk about Lewy body dementia because that particular dementia can actually look a bit like delirium when it presents, so it is rapid. It's a sudden onset and you get that fluctuation as well. So those things can make it difficult for us to look at triggers in terms of is this delirium or actually is this an emerging dementia? And so again that baseline data and that history from our family members is so so important.
And it's the typically acute onset of delirium that makes it inappropriate for us to make a diagnosis of dementia for patients when they're unwell in an acute hospital setting, as Darren Bridges, our Mental Capacity Act lead, explains.
That can be actually a big thing we encounter from a social work perspective as well. In terms of families having a loved one admitted to hospital and they feel that their loved one has an undiagnosed dementia. But then we're diagnosing a delirium. And whenever then it comes to the discharge part of it, it rules out so many options for us because we don't have that diagnosis. We can't look at a dementia registered care home.
And it's explaining to families why we can't make that decision in hospital and give that diagnosis of a dementia in hospital because we believe there's a delirium there. That we're hopeful that cognition will improve, that this picture will change, and that we need that longer timescale for a diagnosis of dementia, where we're hoping that some of the presentation that we're seeing is going to subside with the delirium.
Here's Jackie once more. So the PINCH ME mnemonic is great. It's a really useful tool for us to try and remember the things to look for when we're reviewing patients, but also the delirium pathway has a little section which essentially goes through each of those elements and the fundamentals of care as Julie talked about. So just, it's a really useful tool that has a little amber section called the delirium preventative strategy and each day nursing staff in particular but also medical staff are encouraged to look at each of those fundamentals of care and make sure they are being addressed.
And by working through those fundamental areas that make up our PINCH ME memory aid we will hopefully do the basics better and improve patient specific care. And to wrap up our discussion on doing the basics well here's Orla and Darren one more time.
We often think that delirium is complex. It certainly is. You know, I think any care of our patients that come into hospital, the patient profile is changing, there's comorbidities, there's complex social background. The care that we deliver is complex, but sometimes there's actually areas that are quite simple and easy to change in terms of the care that we provide. And I think that's something that is a goal that's achievable.
Yeah, I think we're really good actually, or more so now, of identifying a patient as experiencing a delirium. Less good at identifying why.
So just before we finish up today's episode, I want to bring Nicola Loughlin back, our delirium nurse coordinator in the Northern Trust to ask if it's ever possible to prevent a delirium.
Absolutely, Stephen. Delirium can be prevented in some instances and the literature certainly tells us that this is possible. And a good knowledge of the risk factors enables staff to be proactive and implement the preventative care strategies, and all the triggers that we've talked about today, are potentially modifiable risk factors.
It means that we can take those interventions and the PINCH ME and, you know, try to prevent delirium emerging. And even going through some of those again, you know, one of the biggest things that we see in the hospital is the amount of moves that people have across our wards and within our wards, you know, is it possible to prevent some of those, because often it's one move too many for some people. And are we remaining vigilant to new clinical factors emerging while somebody's in under our care to ensure that prompt assessment and treatment? And we also need to keep promoting orientation, thinking about the environmental factors which are not ideal in an acute hospital.
Working together with the person's family and carer is so important as care partners and understanding that life history of the person that we're caring for as well. Another big thing is sensory optimisation. You know, simply, has somebody got their glasses in with them in the hospital? Have they got their hearing aid in? Is the batteries working? Lots of things that we can do that actually can prevent somebody, you know, moving in to a delirium. So lots of things we've talked about today just to be recapping on. And these interventions can help minimize the development of delirium, you know, so a focus on prevention is so, so important.
Whilst also doing the daily screening using the SQID, the single question in delirium that we keep referring to, you know, to help with that early identification and prompt management for those patients who go on then to develop a delirium.
Brilliant. Thank you so much for that, Nicola. I don't know about all of you listening at home or in your cars or while you're doing the cooking, but I have learnt a lot from listening to all of our friends here today.
And there is a lot more still to come. That is the good news. So this is only the second episode of six. Next time we will be coming back to discuss the management of delirium, which is a big, big topic. So I'm sure you will all want to tune in once again for that. And we hope you're as excited about coming back as we are.
So we will see you next time.