The COVID-19 pandemic has sharpened the focus on delirium for hospitalised patients, their families, carers and healthcare professionals.
Delirium is a sudden change in a person’s mental state. Patients with delirium may seem confused, disorientated and agitated, or quiet and withdrawn. The condition affects 50% or more adult intensive care patients[i], and up to one quarter (23%) of older patients in general medical settings.[ii]
There is growing evidence that delirium is more prevalent among hospitalised COVID-19 patients, and a common presenting symptom in older patients with COVID-19.[iii]
The Australian Commission on Safety and Quality in Health Care (the Commission) today launched the Delirium Clinical Care Standard (2021) at the 2021 Australasian Delirium Conference.
First released in 2016, the clinical care standard aims to prevent delirium in at-risk patients, and improve the early diagnosis and treatment of patients with delirium.
Commission Clinical Director, Dr Carolyn Hullick, an emergency medicine physician with a special interest in aged care, said the seriousness of delirium as a medical condition is still not always recognised, yet outcomes for people with delirium can be improved with the right care pathways.
“The clinical care standard encourages the early recognition of people who are most at risk of delirium, so that steps can be taken to reduce their risk. It also encourages healthcare workers to be alert to changes in behaviour that may be due to delirium,” she said.
“The Delirium Clinical Care Standard has helped to embed the right processes into hospital care. The 2021 standard strengthens the need for patient information and involvement of carers and family, if the person wants this. The patient focus has never been more important than during this pandemic.”
Dr Hullick added: “The COVID-19 pandemic has brought new challenges in caring for people with cognitive impairment or at risk of delirium. To prevent delirium we usually try to keep things as familiar and normal as possible for these patients in hospital. Unfortunately, protective equipment such as masks and shields can be depersonalising and disorienting; while visitor limits can increase feelings of isolation and anxiety in people who are particularly vulnerable.”
The standard builds on other work undertaken by the Commission to improve care for people with cognitive impairment. Despite progress, Dr Hullick said there is still variation across Australia in recognition of delirium and its seriousness may be underestimated.
Patients with delirium have worse health outcomes, including increased risk of death, longer hospital stays, higher risk of falls, a greater chance of developing dementia and an increased likelihood of requiring higher dependency care.[iv]
“I think of delirium as acute brain failure. We treat acute cardiac failure as a medical emergency – we should do the same for delirium, it is a serious medical condition,” Dr Hullick said.
While delirium is one of the most commonly acquired complications of hospital care monitored by the Commission, it is potentially preventable in up to two thirds of hospitalised patients. The cost associated with delirium in Australia is estimated to be $8.8 billion a year.[v]
Patient-centred care to reduce severity of symptoms
Associate Professor Gideon Caplan, President of the Australasian Delirium Association and Director Post-Acute Care Services and Geriatric Medicine at Prince of Wales Hospital Randwick, is officially launching the updated standard today at the DECLARED 2021 conference.
“The Delirium Clinical Care Standard has already contributed to an enormous improvement in care of patients with delirium across Australia, particularly in our hospitals,” A/Professor Caplan said.
“Delirium is a common presentation of COVID-19 in older people, so this pandemic has emphasised that the need for the Delirium Clinical Care Standard is stronger than ever. To keep older people safe and healthy, we must be alert for the first signs of delirium to reduce the spread of COVID.
“Restrictions related to COVID have meant that support people for hospital patients have not always been able to be present, which has been difficult. This is a key challenge for people with dementia who are admitted to hospital, including those transferred from nursing homes,” he said.
“I applaud the work of the Commission in keeping this important standard up-to-date to protect Australians. I know it will make a real difference to the lives of patients, families and caregivers, as well as support healthcare professionals, so they can provide the best care for older people.”
Professor Susan Kurrle, a practising geriatrician who holds the Curran Chair in Health Care of Older People in the Faculty of Medicine and Health at the University of Sydney, also welcomes the updated standard. She chairs the Commission’s Cognitive Impairment Advisory Group and was involved with the award-winning ABC series ‘Old People’s Home for 4 Year Olds’.
“Since 2016, the clinical care standard has supported the delivery of high-quality care for people with delirium. It has demonstrated that there are better ways to care for people with cognitive impairment, who are often our older patients,” Professor Kurrle said.
“The new patient-centred quality statement in the Delirium Clinical Care Standard is a really important addition, as it recognises the importance of carers and family members.
“Family and carers alert us when someone has changed their thinking or behaviour, so help us be alert to and diagnose delirium. They can help support the person with delirium by being a familiar person, giving reassurance, orientation and encouraging the person to eat and drink. This helps prevent delirium. We need to recognise the vital role of the carer or support partner, particularly during COVID,” she explained.
“In these most challenging times for health services – which are especially difficult for people with cognitive impairment in hospital – it is more important than ever to have a patient-centred perspective.”
The standard is endorsed by the Australasian Delirium Association, Australasian College for Emergency Medicine, Australian and New Zealand Society for Geriatric Medicine, Dementia Australia and the Australian College of Rural and Remote Medicine, among other peak bodies and professional organisations.
References
[i] Salluh JI, Wang H, Schneider EB, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ 2015;350:h2538
[ii] Wilson JE, Mart MF, Cunningham C, et al. Delirium. Nat Rev Disease Primers 2020;6(1):1–26
[iii] Mendes A, Herrmann FR, et al. Delirium in Older Patients With COVID-19: Prevalence, Risk Factors, and Clinical Relevance. J Gerontol A Biol Sci Med Sci. 2021 Jul 13;76:e142-e146.
Zazzara MB, Penfold RS, et al. Probable delirium is a presenting symptom of COVID-19 in frail, older adults. Age Ageing. 2021 Jan 8;50:40-48.
O'Hanlon S, Inouye SK. Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing. 2020;49(4):497-498.
[iv] Travers C, Byrne G, Pachana N, Klein K, Gray L. Delirium in Australian hospitals: a prospective study. Current Gerontology and Geriatrics Research 2013; 2013
[v] Pezzullo L, Streatfeild J, Hickson J, Teodorczuk A, Agar MR, Caplan GA. Economic impact of delirium in Australia: a cost of illness study. BMJ Open 2019;9:e027514.
