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CG103 Delirium prevention with Professor John Young

Professor John Young, Head of the Academic unit of Elderly Care and Rehabilitation at the Bradford Institute for Health Research and chair of the delirium guideline development group discusses the importance of delirium prevention and ways in which it can be achieved, with Katie Worrall, Implementation lead for the NICE clinical guideline on Delirium.

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This podcast was added on 13 Oct 2010

Podcast transcript

CG 103 Delirium

Transcript of podcast

Recording 28 September 2010. Bradford.

Delirium: preventing delirium with Professor John Young

Q1 Interviewer: Hello and welcome to the NICE podcast about the delirium clinical guideline. In particular this podcast will be focusing on Delirium prevention.

I am Katie Worrall, a nurse and the implementation lead for this guideline. With me is John Young professor of elderly care and chairman of the guideline development group who produced this guideline.

Professor Young, why is it so important to prevent delirium and what can be done to prevent it?

JY: Thank Katie. I think the first important thing for people to really recognise is the delirium is much more common than they might initially appreciate. It is very common across the whole healthcare system and one of the underpinning issues  is it is very poorly recognised and that is why the guideline development group were very anxious that people starting thinking delirium and that is why we had a motto really which was ‘think delirium’ to try and raise awareness of the condition

I think the second thing to be really aware of is that delirium is a pretty unpleasant illness for the sufferer there has been lots of really good descriptions about what it is like to suffer from delirium and people report it being like in a waking dream where they are disconnected from reality and contrary to what all the text books might tell you, it is actually very very common for patients to have complete or partial recollection of this unpleasant experience when the delirium resolves. So it is pretty unpleasant really for the patients and their families.

Not only that but quite commonly after an episode of delirium, particularly in frail older people, the person never becomes the same person again. That is to say the delirium leaves a legacy behind and we know that the outcomes are poor associated with delirium. We know that there is increased mortality and that there is either a deterioration if they have pre existing dementia or not uncommonly the delirium heralds the onset of dementia such that if you look back after an episode of delirium, if you look back six months downstream you realise that the episode of delirium actually seemed to be triggering the dementia. So it is a pretty nasty condition, it can leave people pretty badly affected.

Now because of these outcomes, particularly the relationship with dementia, we know that the resources required for managing the longer term situation for these people is quite expensive. They have an increased length of stay in hospital and an increased use of long term care. (and) Really because of all these things, because of the distressing nature of it and the fact that it is an unpleasant illness, and the fact that it consumes a lot of resources, all of those things come together and make us realise that prevention would be a highly attractive proposition. (and) When the guideline development group reviewed the international literature in this area, it turns out that prevention is an eminently possible strategy for the NHS.

There are a variety of possible prevention strategies but the one where the evidence base seemed particularly reassuring and influential was in what we call complex multi-component interventions

Now these sound complicated but they are actually very straightforward and simple, and in a sense the multi-component prevention interventions for delirium are really synonymous with just providing good quality care in the hospitals and in the long term care setting. For example we know that if a patient is a risk of delirium because they have an underlying dementia we know that if they come in to hospital it is really important to make sure these people are regularly reoriented into the place that they are in, the time of day it is and who the people are around them just so that they don’t lose contact with the real world around them. (and) Also having conversations which help stimulate them, just very simple things like reading the newspapers, explaining what is going on in the news, very low tech type interventions. We know from the evidence base that this seems to be very powerful in preventing delirium. Other examples would be really assiduous attention to dehydration and bowel care. Making sure that they have got their spectacles on and their hearing aids. From a medical point of view it is absolutely vital to carry out a very rigorous drug review because we know that many drugs are associated with an increased risk of delirium so it makes sense if someone has come in to hospital or is newly transferred to long term care that a very rigorous drug hygiene is carried out. Just to reduce the drug burden to reduce the risk of delirium occurring.

From a general care point of view another example would be trying to maintain the mobility of the person because we know that also seems to be a very important component of these multi-component interventions

Overall, if we were to deploy these multi-component interventions across the patch, it seems likely from the research evidence base that we would be able to prevent one in three episodes of delirium and there is no doubt from the health economic modelling that was conducted that this would be a highly cost effect strategy for the UK NHS. So that is why, particularly in this podcast, why we are really trying to push the idea of delirium prevention. Perhaps for the nurses who are listening, an analogy for you is that of pressure ulcer formation because obviously these days it is now absolutely routine and fundamental that patients have pressure ulcer assessments when they have contact with healthcare systems. But years ago that was not so and what happened was the NHS was very prepared to treat and manage pressure ulcers but not to invest in their prevention at all. (and) Very slowly over about ten years in the 1990’s this situation was reversed so that it became absolutely fundamental to prevent pressure sores and very gradually they pretty well disappeared and it is now quite unusual to see pressure ulcers.

So we have the same situation really in terms of delirium. Our main focus hither to in the heath service has been on the treatment and management of delirium but we are missing the opportunity for prevention in the same way that we missed the opportunity for many years to prevent pressure sores. So that is really the main message from this podcast is that we need to focus much more strongly on prevention. (and) That requires professionals to think differently about this very important condition but also requires a system wide approach within hospitals, within care systems and within the long term care settings, care homes and nursing homes. It requires managers to be working to create a system of care, it requires practitioners to be changing the way they do things and I think also fundamentally it requires involvement of patients and carers to help develop the sorts of care systems which they feel will give them better care experience that will include prevention of delirium.

So thank you very much for listening to this podcast and I hope you find it helpful and I hope it will give you some introduction to the very important implementation tools that are part and parcel of the NICE guideline for the management and prevention and treatment of delirium

Interviewer: Thank you very much John. As John said we hope that you have enjoyed this podcast. For more information about the delirium clinical guideline and access to the implementation tools which will help support implementing this guideline please visit www.nice.org.uk/guidance/CG103 

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