Hospital-acquired delirium is a relatively common condition encountered by hospitalists that continues to pose several ongoing challenges, particularly in the realms of diagnosis and management. In this session, Blair Golden, MD, MS, an assistant professor of medicine at the Wisconsin School of Medicine and Public Health in Madison, Wis., and Eduard Vasilevskis, MD, MPH, a professor of medicine at the University of Wisconsin-Madison, reviewed methods to improve accurate and timely diagnosis of delirium as well as current best practices in prevention and management. They also presented evidence regarding potential gaps in patient and family comprehension of delirium and how that should influence appropriate counseling techniques.
Preventing delirium from developing in the first place is the best first standard of practice for any hospital clinician. Early mobility remains the gold standard for delirium prevention, with a study in 2018 showing a number needed to treat with early mobilization of just 14 patients (95% confidence interval, 11 to 20) to prevent one case of hospital-acquired delirium. Once delirium has developed, however, prompt recognition has historically been challenging. A study published in Intensive Care Medicine in 2009 showed a dramatic under-recognition of delirium by healthcare workers, with an accurate diagnosis of delirium obtained by only 35% of registered nurses and 28% of medical doctors. A prior study in 2001 indicated that hypoactive delirium was the most common risk factor for under-recognition by healthcare providers.
Several tools have since been further developed and clinically tested to improve accurate delirium recognition by clinicians in the inpatient setting. The hallmark of each of these tools is an assessment of attention. Regardless of delirium type, inattention remains the most prominent diagnostic feature of delirium in addition to an acute change in the level of consciousness. The Brief Confusion Assessment Method (B-CAM), Ultrabrief Two-Item (UB-2) Bedside Test, and 4AT Delirium Test all use the same request for the patient to name the months of the year backwards, starting with December. The sensitivity for these tests has been reported in the 80% to 90% range, with specificities over 70%, and each test taking less than five minutes to administer.
There also appears to be significant room for improvement when it comes to patient and family education around delirium. Using the online crowdsourcing marketplace Amazon Mechanical Turk, the presenters conducted a national cross-sectional survey of on-demand participants on 15 delirium-focused questions that covered three key knowledge areas: risk factors, symptoms, and management. A total of 397 participants responded who met the inclusion criteria (at least 18 years of age, living in the U.S., and English speaking). The mean score for accuracy was 74% in the risk factor category, 57% in the symptom identification category, and 47% in the management category. Most demographic factors were not associated with low knowledge, although lower household income was associated with a low composite knowledge score in multivariate analysis. There was no association identified between a self-declared history of delirium and self-confidence scores. Most respondents were not confident in their understanding of delirium, and many respondents were not aware that delirium is preventable, particularly with early mobilization, or that it develops suddenly and usually improves.
The presenters also shared results of a single-institution retrospective analysis on disparities between discharge instructions and the discharge summary for patients who had a diagnosis of delirium identified during their hospitalization. Despite often detailed descriptions of the delirium presentation and management in the patient discharge summaries, about 64% of corresponding discharge instructions had no mention at all of delirium. Discharge summaries that recommended outpatient neurocognitive evaluation did not consistently translate this recommendation into the patient discharge instructions if it was associated with a diagnosis of delirium. The results of this study imply a level of discomfort among providers in discussing a diagnosis of delirium directly with patients, even though effective communication could improve awareness and guide future prevention through the identification of modifiable risk factors.
Key Takeaways
- Early mobilization remains the gold standard for delirium prevention, with a number needed to treat only 14 patients to prevent one case of hospital-acquired delirium.
- Bedside assessment tools for delirium take less than five minutes to perform and significantly improve the accurate recognition of delirium, with inattention being the most prominent diagnostic feature in addition to an acute change in the level of consciousness. Naming the months of the year backward is the most utilized assessment tool to diagnose inattention.
- Evidence suggests a need for improvement in the quality of discussions regarding a diagnosis of delirium, modifiable risk factors, and future implications with patients and families at the time of hospital discharge.
Dr. O’Neill is an academic hospitalist and assistant professor of internal medicine, and physician lead of the medical aid in dying program at the University of New Mexico Health in Albuquerque, N.M.