Abstract
Introduction
Out-of-hours (OOH) services provide emergency primary care outside normal GP hours, serving patients with higher health needs. Delirium affects 25% of hospitalised older adults, causes distress to patients and carers, and leads to poor outcomes. However, little is known about delirium presentations and prevalence in OOH services. We aimed to investigate delirium occurrence and management using case records from an OOH service in South-West England.
Methods
The OPEN database contains 33,345 consultations of patients ≥65 attending the OOH service between April 2019–March 2020. We screened consultations for delirium symptoms during April and July 2019, and January 2020. Records were reviewed by two GPs independently using DSM-V criteria to identify probable or possible delirium. We validated our search strategy by reviewing a random sample of 100 consultations initially classified as “search-negative” and assessed inter-rater reliability. Patient characteristics were compared using Chi-squared tests.
Results
Of 4,288 consultations with patients ≥65 in the study periods, 394 (9.2%) involved possible or probable delirium. A further 76 (1.8%) had end-of-life delirium and were excluded from further analysis. Patients with delirium were similar in age to those without, but more likely to live in residential care (29% vs. 14%, p<0.001) and have dementia (46% vs. 11%, p<0.001). 67% of delirious patients required home visits, compared to 22% without delirium (p<0.001). Delirium was not available as a coded diagnosis; only 6% of cases were coded as “Acute Confusion,” whilst 20.9% were coded “Urinary Tract Infection”. Patients with delirium were admitted to hospital twice as often as those without (21% vs 10%, p<0.001).
Conclusions
Delirium is a common OOH presentation, representing ~10% of consultations with patients ≥65. These patients often have cognitive impairment, require home visits, and are more likely to be hospitalised. Improved recognition and coding could support better management and service planning
Comments
This is really interesting…
This is really interesting work that highlights the high number of older adults in the community with delirium and the complexity of the OOH GP work load. The session on Wednesday 'Dementia in Hospital' highlighted the challenge around how to best label confusion in an acute setting where there is uncertainty as to whether the person has dementia/super-imposed delirium with dementia/delirium etc. The lack of coding in the GP system may reflect a similar challenge? Thank you.
Next steps
Helpful piece of work.
I would be really interested to know, in the light of the high incidence of delerium, what changes (beyond improving coding in GP systems) might be most beneficial to test next (in terms of better clinical management and improved service planning) and whether you have any plans to do this.
thank you