Delirium: a high incidence, serious and costly complication

Delirium (or acute brain failure) affects over 3 million hospitalised patients in Europe and over 2 million hospitalised Americans every year. It is a potentially fatal medical emergency that regularly leads to long-term cognitive impairment (dementia), results in longer hospital admission, and directly contributes to higher healthcare costs. Further, it is a frightening experience for patients, as they often experience horrific hallucinations. Though delirium is in the mind, it is by definition caused by physical disorders. To treat delirium, it is important to acutely address those physical causes, because the longer a delirium episode lasts, the more damage is done (Pandharipande et al., 2013, N Engl J Med).  
Delirium is
extremely common, affecting 1 in 8 hospitalised elderly, 1 in 4 cardiac surgery patients, and 1 in 2 patients in the Intensive Care Unit (ICU).
As high age is one of the major risk factors for delirium, this problem will only grow as the world's older population continues to grow at an unprecedented rate.
To date already 40% of the patients admitted to hospitals are 65 years or older. 


The problem: today, delirium is detected in only 30-50% of the cases


It is important to detect all delirium cases as early as possible, to prevent escalation and downstream complications, and to ensure that all patients get the treatment they deserve. 
Despite its frequency and impact, delirium is not recognized by physicians and nurses in about 70% of the cases. To improve recognition, checklists have been developed. Hospital departments that actively use the checklists in everyday clinical settings, show an improved detection rate of nearly 50%, but still 50% is missed. Especially the hypoactive ('silent') type of delirium proofs to be often overlooked.   
 

In most hospital departments nurses are tasked with delirium detection / daily screening. Judging (changes in) the mental status of patients -who are unknown to the nursing staff prior to their admittance- proofs to be difficult. Furthermore, the checklists exclude non-communicative patients while many patients have limited communication abilities (due to for example mechanical ventilation on the ICU, or cultural and language barriers). So checklist scoring varies from nurse to nurse, from shift to shift. Checklists rely on the observations and questions of nurses, they are by nature subjective and have proven to be insensitive.
Hence delirium remains underdiagnosed and undertreated, which impairs patient outcome
.



















International delirium guidelines confirm the need
for improved and early detection

USA: American Geriatric Society guideline on postoperative delirium, 2014:
 
“Delirium is reported to remain undiagnosed in more than half of cases.”
  "
Delays to initiation of treatment have been found to result in prolongation of delirium, which is
   associated with worse cognitive and functional recovery, and higher inpatient morbidity and
   mortality."

USA: American Society of Critical Care Medicine guidelines for delirium, 2013:

   “Monitoring critically ill patients for delirium with valid and reliable delirium assessment tools
    enables clinicians to potentially detect and treat delirium sooner, and possibly  
    improve outcomes."


United Kingdom, National Institute for Health and Care Excellence NICE guideline delirium, 2014:
    Delirium is a serious condition that is associated with poor outcomes. However, it can be
     prevented and treated if dealt with urgently.”

Germany
S3-Leitlinie zu Analgesie, Sedierung und Delirmanagement in der Intensivmedizin, 2015:
    
“The systemic monitoring of pain, sedation and delirium, targeted protocols for the management
    of sedation, analgesia and delirium are associated with lower incidence of nosocomial infections,
    a reduction in the duration of ventilation and lenght of ICU stay (LOS), lower mortality and lower
    resource consumption.
   The monitoring should be performed r
egularly (8-hourly) and be documented. 

European Society of Anaesthesiology evidence-based and consensus-based
Guideline on Post Operative Delirium, 2017:
  "Early diagnosis of POD is critical to trigger focussed and effective treatment."
  "On the postoperative ward, POD should be monitored at least once per shift
    due to the fluctuating course of POD."

If detected in time, delirium can be treated

There are clear guidelines on how to treat the condition, see for example the guidelines: 
* Postoperative delirium of the American Geriatric Society (USA, 2014)
* Pain-Agitation-Delirium guidelines of the Society of Critical Care Medicine (USA, 2013),
* Delirium: prevention, diagnosis and management' of the National Institute for Health and Care
  Excellence NICE (UK, 2010)
Early detection has a clear clinical follow-up, enables shorter episodes of delirium and overall improved patient outcomes.
Three basic clinical actions are required:

 

 

 

 

Informative 8 minute movie (German-spoken) "delirium after an operation":  
https://www.youtube.com/watch?feature=player_embedded&v=XegW_WfvzoY
at point 3.10 min, Prof. Dr. Claudia Spies (Charité Berlin) states: 
10% of the delirium cases are recognised, 90% goes unnoticed.
This has long term consequences for the patients, it often leads to long term cognitive impairment.