We talk a lot about delirium after hip fracture, but what can we do about it?

Dr. Susan Freter is an Associate Professor of Medicine at Dalhousie University, and a staff geriatrician at the Nova Scotia Health Authority in Halifax, Canada.  She has a special interest in delirium prevention and management in orthopaedic patients.  

Geriatricians talk a lot about post-operative delirium.  It is common after surgeries, especially in people with a lot of risk factors (or we could say, especially in the presence of frailty), and even with recovery it makes for a bad experience.  The occurrence of hip fracture, which mostly befalls patients who are older and frail, demonstrates this routinely.  We know that taking extra care with at-risk patients can help to prevent delirium.  Taking extra care can manifest in different forms: educating the caregivers, paying attention to hydration (is the patient actually drinking the cup of water that is plonked down in front of them?), paying attention to constipation (preferably before a week has gone by), making sure hearing aids are in the ears, and using medication doses that are geared for frailty, rather than for strapping 20 year olds. But how can what we talk about be translated into what we do? Does the ‘doing’ actually work in practice? Continue reading

Heatwave! Acting on the weather forecast to reduce morbidity and mortality in frail older people

Duncan Forsyth has been a consultant in geriatric medicine, at Addenbrooke’s Hospital, for 27 years. A believer in global warming, he noticed that staffing levels in hospital were often inadequate to ensure adequate hydration of his patients during any heat-wave and that admissions due to acute kidney injury were especially prevalent in care home residents and frail older people receiving substantial packages of home care. He advocates incorporating the weather forecast in to the risk stratification for hospitalised patients, care home residents and those receiving three or more home care calls per day; in order to promote a review of potentially nephrotoxic medication

As you look forward to enjoying the (hopefully) warm summer weather, spare a thought for those less fortunate than yourself, who are frail; less able to increase their fluid intake; who are dependent upon others for provision of drinks; and at risk of acute kidney injury due to the potentially nephrotoxic drugs that they are prescribed. A leader article in the BMJ 2009 (Olde Rikkert, et. al) highlighted the dangers of heat waves and dehydration in frail older people and the resultant excess mortality in this population. Continue reading

Take time to talk! The importance of an informant history

Adam Dyer is a Final Year Medical Student in Trinity College Dublin. Dr. Sean Kennelly (MB PhD FRCPI) is a Consultant Physician in Geriatric and Stroke Medicine in Tallaght Hospital (Dublin, Ireland) and a Clinical Senior Lecturer in Medical Gerontology at Trinity College Dublin (TCD). The following work was presented as a platform presentation at the 64th Irish Gerontological Society Meeting in Killarney, Ireland (October, 2016).

Imagine you’re seeing a consult or you’re on a post-take ward round. How often do we examine a patient and identify cognitive deficits, see that the CT brain scan report and the MMSE score are readily on hand, but then ask staff about the patient’s premorbid cognition and function and are met with blank expressions?

An important factor which complicates the presentation of older people to acute hospitals is the presence of impaired cognitive status (either in the form of dementia, delirium or both). Continue reading

Accurate delirium screening when there is no carer available – impossible, right?

Suzanne Timmons is a geriatrician working in Mercy University hospital, Cork and a senior lecturer in University College Cork. She has a big clinical and research interest in delirium and dementia care in hospitals.

delirium-flatDelirium  is common in older people admitted to hospital, and is a serious condition that needs to be identified quickly on admission. But many busy hospital staff still don’t routinely screen older people for delirium, even when they have known dementia (dementia puts people at very high risk of delirium: see the Cork Dementia Study).

In this study, we tested out five simple cognitive tests to see if they could be used to screen for delirium. The tests were: the Six-item Cognitive Impairment Test (6-CIT; measuring attention, orientation to time, and short-term memory); the Clock-Drawing test; Spatial Span Forwards (pointing to a sequence of squares in a certain order); reciting the months of the year backwards (MOTYB); and copying a shape containing two intersecting pentagons. Continue reading

East Midlands Dementia Day 2016

Liz Charalambous is a qualified nurse on a female, acute medical HCOP (Health Care for Older People) ward at Queen’s Medical Centre, Nottingham University Hospital Trust. She attended the East Midlands Dementia Day on 6 December 2016. She tweets at @lizcharalambou and is a regular guest blogger for the BGS. Opinions expressed in this blog are solely Liz’s own and do not express the views or opinions of her employer or any other organisation. 

major-oak-sherwood-forestThe East Midlands Dementia Day on 6 December 2016 at Nottingham City Hospital proved to be an inspiring and informative event. Organised by dementia specialists, Professor Rowan Harwood and Dr. Karen Harrison-Dening, the day welcomed expert speakers from Nottingham and further afield.

The day began with Professor Rowan Harwood  who presented an overview of dementia and its increasing importance from a public health and societal perspective. Painting the picture of the reality of dementia with stark statistics of multiple comorbidities; dementia in care homes and in hospital; and the reality of carer and family support for people with the disease, stressed the urgent need for further research. Continue reading

Which screening tool(s) should clinicians use for the detection of delirium in older, hospitalised patients?

Kirsty Hendry is a research assistant based at Glasgow Royal Infirmary having recently completed her PhD at the University of Glasgow. In this blog she discusses her recent Age and Ageing paper looking at screening of delirium in older, acute care in-patients. Kirsty can be contacted at Kirsty.Hendry0@gmail.com

A&ADelirium, suggested to be the most common psychiatric disorder suffered by older hospitalised individuals, has a low clinical awareness. This is despite existing guidelines such as those produced by the National Institute for Health and Care Excellence (NICE) and Healthcare Improvement Scotland (HIS) being in general agreement that delirium screening is important in older hospitalised patients.  Continue reading

Challenging the depiction of delirium in the media

The media’s portrayal of vulnerable elder people as ‘perpetrators of assaults’ shows us just how far we still have to go.

Dr James Woods is a registrar in Geriatric and General (Internal) Medicine in South East Scotland. He tweets at @jmwoods87

Earlier this week BBC Radio 5 Live ran a piece with corresponding BBC website article reporting on figures obtained from an NHS Protect report on physical assaults against NHS staff in England. The headline and corresponding analysis focused on patients over 75 years old as the most frequent ‘perpetrators of assaults’ against NHS staff. If you care about the healthcare needs of older people and want to see them treated with dignity and respect (which if you are reading this blog you probably do) then this makes for distressing reading. Continue reading

Delirium research in care homes: Trojan Horses and Holy Grails!

Najma Siddiqi is a Clinical Senior Lecturer in Psychiatry who works at the University of York & Hull York Medical School; and Bradford District Care NHS Foundation Trust. She discusses her Age & Ageing paper ‘The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people’.

aaDelirium (often called ‘Acute Confusional State’) is a common and serious illness among older people. It can be very distressing for patients, their families, and for healthcare staff; and can lead to worsening dementia, hospitalisation and death.

There is relatively little research on delirium in general, but this is particularly true of delirium in the care home setting. Continue reading

What happens to patients with abnormal cognition picked up by in-hospital dementia screening – Results from GP questionnaires

Sarah Pendlebury is Associate Professor in the NIHR Oxford Biomedical Research Centre and the Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford and Consultant Physician and Clinical Lead for Dementia and Delirium at the Oxford University Hospitals NHS Foundation Trust. Research and audit interests include cognitive impairment associated with cerebrovascular disease and the interactions between vascular disease, neurodegeneration, co-morbidity and delirium and in the use of short pragmatic cognitive tests in patients with stroke and acute illness. Here she reports on an audit of the actions undertaken by GPs in response to letters informing them of in-hospital identification of cognitive impairment in their patient, which will be presented at the upcoming BGS Spring Meeting in Liverpool.

dependent-826332_960_720Dementia and delirium are prevalent in older patients with unplanned admission to hospital and are associated with death and increased dependency, but many confused patients do not have a dementia diagnosis prior to admission. Routine dementia screening for older people (>75 years) hospitalised as an emergency is mandatory in England with onward referral for specialist assessment in those identified as at-risk (dementia CQUIN). Continue reading

Report from the 2015 EDA / BGS Delirium conference

BGS Logo CMYKAlice Verran is a second year Foundation doctor at Croydon University Hospital; in this blog she reports back from the recent BGS / EDA meeting on delirium.

A conference jointly hosted by the European Delirium Association and the British Geriatric Society; the perfect union of experts and professionals with an interest in delirium. Not just discussions about delirium in the elderly, but a host of talks on delirium in other contexts such as children in ITU and alcohol withdrawal.

Continue reading