confusion in hospital patients dr nicola lovett ... · in these cases, sometimes people are looked...

Alzheimer’s Research UK Oxford Network Open Day – March 2018

Confusion in Hospital Patients

Dr Nicola Lovett, Geratology Consultant OUH

I'm one of the geratology consultants working here at the John Radcliffe. This is a really wonderful

opportunity for us to tell you about the changes we have made to try to improve care for patients

with dementia coming into our hospital. I'm going to talk briefly about the spectrum of cognitive

diseases that we see in our hospital in patients. I'm going to also how we found out about the number

of patients who are coming in with these problems. The importance of early identification for these

patients, and strategies that we are looking at of improving identifying these patients who are at risk

with problems.

This is a similar slide to those which have been shown before. What we see patients coming in with.

A wide range of cognitive issues, with thinking and with memory. With normal ageing, there may be a

slight decline, but not too much of a decline.

We see patients all the way through. Coming from the very, very mild form, at the preclinical stages

where actually, often the patient knows that they're not functioning at 100%. To all intents and

purposes, the clinicians and families and relatives haven't picked up on this. Things may just perhaps

be a little bit slower. We then move on to the mild cognitive impairment stage. This is when friends

and relatives are picking up that perhaps people are slightly more forgetful. or struggling finding the

right words. It's often at this stage the patient is starting to go to their GP or present to services, and


being identified as having dementia. Then we've got people who come into hospital, already being

diagnosed with dementia.

Within that dementia diagnosis there's a huge spectrum. We have people with a very mild disease

who are able to function normally and continue at home. Going right through to very severe disease.

In these cases, sometimes people are looked after in nursing homes and institutionalised care.

One of the other problems that we commonly see in hospital is delirium. The word delirium is derived

directly from the Latin meaning "deranged" or "off track". It's something you commonly see in

hospital. It's very underreported under-recognised in some settings. You often see 2 distinct forms,

there's an interplay between both of them. The common forms are the hypoactive delirium, where

patients are very sleepy, very drowsy very hard to rouse and engage. Then the other form is much

more obvious to people where they are hyperactive. These are patients who are very agitated, very

confused wandering around, often trying to climb out of bed, or kicking at bedclothes is something

that we see.

The important thing about delirium, is that it's an acute state of mental confusion. It's acute in onset,

it comes on suddenly, and it fluctuates and varies over time. There are lots of different things that can

precipitate delirium. Even if you cure the thing that's causing the delirium, a waterworks infection or

chest infection, sometimes the delirium can persist sometime after the initial problem's been sorted.


It's important though, that we don't think of these problems with memory and thinking as single

entities. There's a lot of overlap, a lot of interplay and a lot of change between them. We know that

patients who have dementia, when they come into hospital they are much more likely to either come

in with a delirium, or develop a delirium during their admission. Also, patients who have a delirium

may not have been diagnosed with a dementia or mild cognitive impairment previously are much

more likely to go and develop a dementia in the next years and months of their lives. Memory, thinking

and cognition in hospital will fluctuate hugely throughout an illness, so you will get ups and downs.

Generally, over time the level of cognition tends to decrease with repeated insults.

It's becoming increasingly more recognised, as being important to tackle dementia early-on. Over the

last couple of decades, the government have really engaged with this. They've published a national

dementia strategy and the national dementia audit trying to engage the public and hospitals in

managing these patients better.


In response to this, The Royal College of Physicians published this document “Hospitals on the edge?

A time for action” in 2012. In this document they are identifying that nearly 2/3 of people being

admitted to hospital were over the age of 65. There are an increasing number of frail patients coming

through the front doors and an increasing number of patients with dementia. They also highlighted in

this report that actually, the hospital building, the services and the doctors were ill-equipped to be

able to manage with this demand. As a result of that, there's been a lot more emphasis on how we

can improve our care.


We're faced with many challenges in hospital. When it comes to thinking about the cognitive

problems out patients see. We know it's common, but how common is common? We need to find out

exactly what's going on. As I said before, it's often under-recognised and under-reported. That’s a

problem we have particularly with delirium and with seeing hypoactive deliriums.

Actually the rate of memory problems in hospitals varies hugely across the specialties and across the

settings. People coming into hospital with planned knee operations for example, tend to have very

low rates of problems with their memory and thinking. If we look at patients coming in through the

accident & emergency department with medical and surgical emergencies they have very high

rates of cognitive problems.

The aim of the research we decided to undertake in Oxford was to actually work out the actual

numbers of people coming through the front door of the hospital with emergency admissions who


had problems with their memory and thinking. We wanted to improve the recognition and

identification of these patients so that we could improve their care and their outcome.

We know it's important to identify patients with cognitive problems early. These patients tend to stay

in hospital longer and therefore acrue the problems of being in hospital for longer. Much more likely

to run into problems with hospital wide pneumonias. Problems with decreased mobility. We know

they have a high rate of mortality. We also know that, on discharge often patients who have memory

and thinking problems have bigger packages of care in the community, and often end up going into

residential homes and nursing homes.

It's important we recognise these people early, to provide the best management we can. It also gives

us an opportunity to talk with families, patients’ relatives and GPs so that we can plan for the future

and make sure that people are plugged into the right services going forward. Particularly with

dementia, there are some factors that are modifiable. If we know you're at risk of dementia, we need

to take good care of you, make sure you're not getting constipated, make sure the electrolytes are in

the bloods are OK, make sure you're well hydrated, with good nutrition. These are all factors that we

can deal with for people when they come into hospital, as long as we realise they are at risk. This also

helps us plan the way we deliver services to the rest of the hospital.


What did we actually do? We looked at all of the medical patients coming in on the medical firm that

I work with. Coming through A & E or being referred by their GP. We screen them on admission to see

whether they had a delirium We looked at them every day during their admission to see whether they

went on to develop delirium. We used national and international recognised criteria to diagnose this

delirium We also looked to see whether they had a known diagnosis of dementia on admission,

through GP records and hospital records. During their admission we performed cognitive tests. We

also collected a lot of other data, looking at their functional status, markers of frailty and what needs

they had on discharge. We had quite a lot of data to gather.


At this point we had just over 500 patients. The work is ongoing; we are collecting more data, we're

repeating it again. We're coming up to the 900 mark at the moment The data that I have today is from

500 patients. The average age was just under 68 It was slightly more female than male.

Of that, we found that the overall number of patients who had a delirium was about 20% But if you

look, the older you get the more likely you are to have a delirium. Just over one third of the patients

aged over 75, in the Oxford hospital, coming through the front door with a medical emergency had a

delirium. You were much more likely to get it the older you got.


This graph represents that again. You can see the number of patients coming through much higher in

the older ages. The black bars represent those with a delirium. You can see that as you get older you're

more likely to come into hospital and you are more likely to have a delirium. Thinking about dementia,

we noted that just over 21% of patients over 75 years old had a previous diagnosis of dementia before

they came into hospital.

Actually, when we performed a memory test on people when they are in hospital, we found it to be

over 50% of patients having memory problems. Not all of those patients with memory problems

identified on these tests had dementia. There's an interplay between delirium and people being

unwell in hospital and being at home in the community.


However, this does raise problems that they're probably at risk, and we do need to think about it. We

did try to do our final cognitive assessments on people when they're in stable zones coming towards

discharge. So not feeling too unwell to participate. I think actually, although we are diagnosing 20%

of people with dementia, it's probably higher.

Just to summarise those results. Looking at the patients over 75 years of age coming into the medical

intake of the John Radcliffe. Over 1/3 are found to be confused. one fifth we knew already had a

dementia. Over a half of them had some problems with thinking and memory tests. This really does

impact on treatment, and decisions that we are making with patients and their families when they

come in. We know it's important because cognitive impairment is associated with poor outcomes.


We have those results, what did we do? We changed the way we chart patients and we changed the

way we do the admissions pro-forma. This is a copy of the paper pro-forma.

We can see at the top, underneath the name the first thing that comes up is reminding the junior

doctors bringing the patient in to assess the memory. That's the first thing they should be doing on

every patient when they come in over the age of 75. We're asking for them to fill this in so we can

identify patients who are at risk.


We're moving away from paper, and we're going to electronic patient records We've made a pop-up

box, that's going to flash up on screen every time the doctor opens a record for someone who's an in-

patient, over the age of 75. This will keep coming up until they fill it in So they have to fill this in.

The difficult thing with that though, is that the score that we use to identify delirium is a CAMS score,

the Confusion Assessment Method. It's a very well-recognised score and very valuable. The only

problem is, the first questions it asks you Is this acute in onset? and does it fluctuate over time?"

At 2 o'clock in the morning, when I'm in the emergency department and a patient’s in front of me

without a relative or a carer, how do I know if this is acute? and how do I know if it's changing? While

continuity of care is really important and looking after the same person, that is very difficult with the

service demands of the provision that we have now.

This score is useful, but not ideal to identify people as early as they come through We decided to have

a more pragmatic view to see whether we could develop a different type of score.


We went back to the NICE guidelines, the National Institute for Clinical Excellence guidelines in

delirium and looked at some of the factors that they pulled out and they said was important with

patients with delirium.

We took some of those factors and developed our own score that we call the NICE score and we

published this data in Age and Ageing last year. This score looks at important factors that we know for

delirium. It looks at Age, Cognitive impairment, Severe illness, Infection and Visual impairment. The

doctor clerking someone at 2 o'clock in the morning in A&E should be able to identify all these factors

quite easily without asking or phoning a relative or a care home.


We validated this form and compared it to other risk scores for delirium we found that it's very

reliable, it's very sensitive, and it's as good as existing scores and in some cases better than existing

scores. We know that if you score more than 5, you have a 75% chance of having a delirium. This

should hopefully prompt the Dr to say "this patient's at risk of delirium, do they have it?" Yes, or no?

Even if they don't have it, we need to think about it, they may well develop it and more complications

to improve their care while they are in hospital.

We're continuing to develop this score. We're moving away from paper to electronic patient records.

Hopefully, by the end of the year, when we are using electronic patient records, we're hoping that our

score will work in the background. of that, so that the Dr will be typing in all their initial criteria when


the patients come in and then, hopefully at the end of that it will flash up and say "we've already

calculated your score, this patient is at risk of delirium or not" therefore health visitor approves their

care.

As I mentioned before, we're still collecting data, we're nearing the 900 patient mark now. We're also

looking at the long-term outcomes for patients who've been identified as having delirium the rates of

readmission, mortality rates, and we're working on that at the moment.

We are also developing the score as a NICE score app, so that other Drs in other hospitals can have it

on their mobile phones, be able to try and get the risk of if the patient is at risk of delirium.

That's some of the work that we've been doing. I hope you've found some of this interesting. I'll be

around to answer questions later if there's anything else I'd just like to say thank you to everyone

who's participated in this It's been a huge amount of work and there've been a lot of people who've

been involved.

confusion in hospital patients dr nicola lovett ... · in these cases, sometimes people are looked...

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