Early Detection and Intervention for Patients with Delirium Admitted to the Department of Internal Medicine: Lessons from a Pilot Initiative

Abstract

<b><i>Introduction:</i></b> Older patients who arrive to the emergency room with delirium have a worse prognosis than others. Early detection and treatment of this problem has been shown to improve outcome. We have launched a project at our hospital to improve the care of patients who arrive delirious to the medical emergency room. The present article describes lessons that can be learned from this pilot initiative. <b><i>Methods:</i></b> All patients older than 70 years admitted to the department of internal medicine were screened for delirium in the emergency room using the 4AT screening tool. Data of patients with a 4AT score ≥5 (or with incomplete score) were transferred to the geriatric unit of the hospital. On the ward, the presence of delirium was confirmed by a geriatric nurse that validated that the patient could walk with support and ordered mobilization and physiotherapy (M&P). <b><i>Results:</i></b> Over the 2 and a half years (10 quarters) allocated for the pilot project, 1,078 medical patients with delirium were included in this survey. In 59.3%, the diagnosis of delirium could be confirmed only after admission. Due to budgetary constraints, only 54.7% received the allocated specific intervention – early M&P. Since it was decided that randomization was not appropriate for our initiative, we found that patients who received M&P had lower (better) 4AT scores on admission, and lower mortality. No significant difference was found between the patients who received M&P and the others in length of hospitalization and discharge to nursing homes. Retrospective comparison of the two groups did not enable to determine whether M&P was given to the patients for whom it was most effective. <b><i>Conclusions:</i></b> It is often not possible to verify in the emergency room that the cognitive decline is indeed new, that is, is due to delirium, and measures must be taken to verify this point as soon as possible after admission. Due to numerous constraints, the availability of early M&P is often insufficient. Whenever resources are scarce and randomization is avoided, adequate criteria should be found for allocating existing dedicated staff to patients for whom early mobilization is likely to be most beneficial.

A systematic review and meta‐analysis: Assessment of hospital walking programs among older patients

“…A non‐exhaustive search of PubMed for studies published between December 2020 and December 2021 identified two additional studies. An RCT on a geriatric ward of an Italian hospital tested a hospital walking intervention among older patients and measured LOS as a secondary outcome (Gazineo et al, 2021), and an experimental study on a geriatric ward of an Israeli hospital assessed a walking program among older hospitalized patients with dementia and measured LOS (Oliven et al, 2021). Neither study showed a significant reduction in hospital LOS with increased mobility during hospitalization.…”

Validation of a viable delirium detection test performed by nurses and physicians during routine patient care

“…Of these, the CAM (Confusion Assessment Method) and 4AT (Attention, Abbreviated mental test, Alertness, Acute onset Test) have been most thoroughly validated and are accepted as valid diagnostic tools for delirium (13)(14)(15). Nevertheless, we (21) and others (22,23) found that in the real world, both CAM and 4AT usually require more than a few minutes to provide reliable results, and due to their heavy workload, residents are often reluctant to perform daily mental assessments in each elderly patient.…”

Validation of a viable delirium detection test performed by nurses and physicians during routine patient care

“…Of these, the CAM and 4AT have been most thoroughly validated [ 13 – 15 ]. Nevertheless, we [ 21 ] and others [ 22 , 23 ] found that in the real world, both CAM and 4AT usually require more than a few minutes to provide reliable results, and residents are often reluctant to perform daily mental assessments in each elderly patient.…”