Patients with delirium – sudden confusion – when admitted to hospital are much more likely to die within 30 days and have a longer hospital stay, new research shows.
The landmark study of more than 82,000 emergency admissions in Salford, Greater Manchester and Lothian, Scotland, highlights the need to improve delirium detection and treatment.
One in four older patients (over 65) admitted to hospital as an emergency also experiences delirium, a state of mental confusion that starts suddenly and is usually triggered by a physical condition of some sort.
Delirium is highly distressing for patients and their carers and is known to be linked to long-term cognitive impairment and increased risk of death – but remains mostly undetected.
The new study, published in the journal Age and Ageing, used the 4 As test (4AT; www.the4AT.com)*, a delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay, and home time (days at home in the year following admission). The test was carried out as part of normal care for emergency admissions in older patients over around three years and results were recorded on the electronic health records at the hospitals – Salford Royal, and three hospitals in the Lothian region of Scotland.
The study involved data from 31,266 individual patients (some had more than one admission). All admissions in Lothian were to medical wards, and in Salford 83% were medical and 17% surgical. There were 1,936 inpatient deaths at 30 days. The risk of death within 30 days was 5.5-times greater for patients with delirium than those without in Edinburgh and 3.4-times greater in Salford. Length of stay was more than double in patients with delirium.
Improving outcomes
Consultant Geriatrician at Salford Royal Dr Emma Vardy (pictured) co-led the study. She said: “This study is really important because it shows that by assessing patients for delirium on admission to hospital that we can predict outcomes. If we can do that then we can work towards improving those outcomes by ensuring we always assess for delirium in older people on admission to hospital and changing for example how we provide care.
“We have been doing other work across Greater Manchester and seeing whether we can safely care for selected patients with a delirium at home, and there is early evidence from other research that this may be better for patients in reducing the harm that delirium can cause.”
Co-lead Alasdair MacLullich, Professor of Geriatric Medicine at the University of Edinburgh, said: “Delirium has historically been a neglected condition with most cases going undetected, leading to poor quality care. This study shows that we can detect delirium in normal practice. This is the first step towards providing better care and improving bad outcomes.”
- The 4As test (4AT; www.the4AT.com) is recommended in multiple guidelines globally for delirium assessment and its development was led by Alasdair MacLullich, Professor of Geriatric Medicine at the University of Edinburgh. It is a simple, quick and well-validated bedside tool which helps practitioners detect delirium in day to day practice.
- Dr Vardy is also clinical advisor to Dementia United, Greater Manchester Health and Social Care Partnership, which has piloted a toolkit that incorporates structured assessment and management to safely manage delirium in the community. Teams implemented the 4AT screening tool and applied it to all relevant patients who entered their care, enabling cases of delirium to be identified at the earliest possible opportunity. This is a link to the paper.