Delirium and dementia: taking the right pathway

Over the past five years Dr James George, a consultant physician in medicine for the elderly, from North Cumbria University Hospitals Trust, has worked towards identifying the main key pathways of harm for patients with dementia or delirium. The Who Cares Wins report1 published by the Royal College of Psychiatrists in 2005 states that in an average District General Hospital, with around 500 beds, it should be expected that around 5,000 people aged over 65 will be admitted every year. Three thousand of these will have a mental health disorder. On average, older people will occupy around 330 out of every 500 beds. Around 220 of these will have a mental health disorder, 96 will be suffering depression, 102 will have dementia and 66 will be suffering from delirium. The report was put together to draw attention to the neglected clinical problem of mental disorder affecting older people admitted to general hospitals and urged acute hospitals, older peoples mental health services and commissioners of health and social care to work together to improve outcomes for this sector of the population. Reiterating the importance of this, Dr George said that there are actually four times as many older patients with a mental health disorder in a typical district general hospital, than there are in an average psychiatric hospital. Dementia is very common in hospitals, but often goes unrecognised. A recent audit, for example, has shown that only 50% of people entering hospital with cognitive impairment will be assessed on admission. It is important for clinicians to check a patient’s history and it is important to consider that dementia can present as falls, heart attack, stroke, pneumonia, weight loss and delirium. Delirium can increase the risk of mortality in hospital by around 50% and can double the length of stay. It can also leave the patient with long-term psychological issues and can progress to a state of persistent cognitive impairment. Around 30% of acute hospital admissions will be suffering delirium and at least half of these cases will go unrecognised. Around half will also have underlying dementia and many more will go on to develop delirium after admission. Delirium is a syndrome presenting as acute, fluctuating confusion and changes in arousal (either hyperactive or hypoactive or mixed) with an underlying physical cause. The National Institute for Health and Clinical Excellence (NICE) guidelines state that, in 30% of patients with delirium, the condition is preventable with a multi-component intervention. “These guidelines essentially promote good, basic patient care,” said Dr George.

 Harmful pathways

Dr George went on to identify some key harmful clinical pathways for patients with delirium and dementia. “The most common iatrogenic event leading from delirium in elderly patients is that of over-sedation and this can also lead to an increased risk of falling.” A further common harmful pathway can occur when a patient with dementia or delirium is admitted to hospital because of a fall. Dr George explained: “They come into A&E and are often catheterised. Because blood and protein is found in their urine, they are put onto a course of antibiotics, as it is thought they have a urinary tract infection. In fact, blood and protein on a dipstick is a frequent finding in any older person admitted to hospital and does not necessarily imply a urinary tract infection. The antibiotics are administered for many days, which can disturb the patient’s normal gut flora, enabling other microorganisms, such as Clostridium difficile to take hold. This pathway can result in the patient suffering a complication from an infection that they did not have.” Additionally, the catheter results in reduced mobility and low self-esteem. According to Inouye (1999) one-third of hospital patients are treated with inappropriate drugs and 50% of adverse drug reactions occur in elderly patients.2 Dr George continued: “Another harmful pathway is the failure by clinicians to recognise delirium and dementia, giving the patient the wrong label and in many cases the wrong treatment. A poor attitude to elderly care and lack of empathy with older patients may contribute to misdiagnosis. “The rapid pace of hospital care is yet another harmful pathway for the elderly patient, with the hospital environment often being unsuitable for older people.” Dr George used his own facility to demonstrate some of the issues that can face the elderly patient on admission to hospital. He said: “We would expect around 50 admissions in a 24-hour period. With only 30 beds this can mean that the same bed is used for more than one patient in this time. We receive around 170 phone calls every day at the main desk – usually from concerned relatives – which often requires a doctor or nurse to speak with the caller. An average patient is moved at least three times. Most arrive via A&E, and are moved around an acute admission ward before being sent to a specialist ward. This involves multiple doctor and nurse handovers, at which point patient information and details can be lost. Rapid transit of patients through a series of high tech clinical areas is not necessarily a marker of real progress. “Nurses in all wards, across the country, are often very busy which can lead to the ‘urgent’ overruling the ‘important’ on many wards. Unfortunately, it tends to be the younger, more active patients that will demand the attention of the nurse, leaving the quiet, elderly patient, who may be suffering from hypoactive delirium, at risk of neglect.” The Francis Inquiry (2010) summed up many of the problems. It stated: ‘It appears from the evidence presented at the oral hearings that many patients suffered from an acute confusional state, or delirium. This appears in a high proportion of elderly people admitted to hospital with serious illness. The evidence suggests that some medical staff did not understand the diagnosis and in some instances treated it as bad behaviour rather than as a medical condition.’3