IN our hospitals today, around one in four older inpatients suffers from delirium – new or increased confusion due to illness, medications or operations. It is one of the most common hospital-acquired complications and increases nursing care needs and the duration and costs of hospital and post-hospital care. Delirium also increases risk of death, causes distress for patients and carers, is associated with future dementia, and is estimated to cost Australia $8.8 billion per year.
So why aren’t we doing more about it?
An invisible problem?
Studies in Australia and the UK show that only a fraction of cases are recognised by health providers. Delirium is most common in older adults and, paradoxically, is so common that health professionals may think it is “normal” for older people to be confused after surgery or with serious illness, or attribute it to dementia.
The appearance of delirium varies between people (some can be very sleepy, others very agitated) and over time (fluctuation is a hallmark feature), and there is no diagnostic blood test. Despite being a consequence and marker of serious physical illness, this “acute brain failure” is classified as a psychiatric disorder, and the hallucinations and delusions that cause patients such distress (which may manifest as agitation or aggression) remain shrouded in stigma. And there is still no medicine that treats or prevents delirium.
Delirium can be prevented … but it’s not easy
There is moderate certainty evidence from several studies that almost half of hospital-acquired delirium can be prevented through non-drug interventions. The landmark Hospital Elder Life Program evaluation targeted key delirium risk factors of dehydration, immobility, lack of cognitive stimulation, hearing and vision problems, pain and poor sleep – all too commonly made worse in hospital. The principles of the Hospital Elder Life Program have been adapted to different settings, with consistent findings of reduced delirium in clinical trials of these multicomponent interventions. Shorter hospital stays and lower post-hospital care needs mean that these programs have been shown in international studies to be cost-effective. An Australian cost-effectiveness analysis is needed.
Getting these principles into practice and sustaining them is not easy, and while we know what the important strategies for delirium prevention are, we know less about how to do them consistently.
Our research helps address this evidence–practice gap through design and evaluation of a multicomponent program called Eat Walk Engage. We recognised that these “simple” or “fundamental”’ cares – good nutrition and hydration, graded mobility and exercise, and meaningful social and cognitive engagement – are complex to deliver in busy, throughput-focused acute care wards. They require a person-centred approach, cooperation between multiple disciplines, improvement skills and advocacy, and often need an extra pair of hands.
We used a specially trained facilitator to support ward staff to reflect on their current care, and work as a team to prioritise and implement delirium prevention strategies informed by “what matters” to older people on that ward, assisted by a trained multiprofessional assistant.
In a cluster randomised trial in four Queensland hospitals, this approach reduced odds of developing hospital-acquired delirium by 47%. This means that there were three fewer cases of delirium for every 20 patients who were managed on an Eat Walk Engage ward compared with control wards.
What should we do next?
At a policy level, the Australian Delirium Clinical Care Standard (version 2) provides guidance for hospitals and health care providers, and creates an expectation that delirium will be prevented, recognised, safely managed, and discussed between health professionals and with families. Recognising and naming delirium is a critical first step. Clinicians and academics must advocate for education about this common complication at undergraduate and post-graduate level for all our health care disciplines, and clinicians should use valid and readily accessible screening and diagnostic tools such as the Ultra-Brief Confusion Assessment Method (UB-CAM) delirium tool, now available as an app on Apple and Android mobile devices.
But recognising delirium after it occurs is not enough.
We must identify patients who are at increased risk (including older people, those with pre-existing cognitive impairment, and those with previous episodes of delirium) in any situations where they are likely to develop delirium (eg, acute illnesses or injuries, major surgical procedures).
We must focus firmly on improving access to structured prevention programs as the intervention with the strongest evidence for patient benefits. Eat Walk Engage is an effective and scalable Australian delirium prevention program, and the Queensland Government has already made a substantial investment in statewide expansion since 2019, reaching more than 20 000 older Queenslanders every year. Our statewide program team has developed facilitator and ward staff training and resources, patient interviews, care process monitoring and reporting tools, and networked communities of practice which support continuous patient-led improvement across sites, providing an example that could be replicated in other states.
We also need to work with consumers and communities to increase awareness of this common and distressing condition. We need their help and leadership to develop better information resources, including discussing the risk and implications of delirium in consent for major surgical procedures, and understanding how family carers can help the clinical team prevent and manage delirium.
Alison Mudge is a physician at the Royal Brisbane and Women’s Hospital and Conjoint Professor of Medicine in the Greater Brisbane Clinical School, Faculty of Medicine at the University of Queensland.
Prue McRae is the Program Manager of Eat Walk Engage at the Royal Brisbane and Women’s Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.