Delirium research in care homes: Trojan Horses and Holy Grails!
Najma Siddiqi is a Clinical Senior Lecturer in Psychiatry who works at the University of York & Hull York Medical School; and Bradford District Care NHS Foundation Trust. She discusses her Age & Ageing paper 'The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people'. Delirium (often called ‘Acute Confusional State’) is a common and serious illness among older people. It can be very distressing for patients, their families, and for healthcare staff; and can lead to worsening dementia, hospitalisation and death. There is relatively little research on delirium in general, but this is particularly true of delirium in the care home setting. This is despite the fact that residents of care homes are likely to be at particularly high risk of delirium by virtue of the high prevalence of dementia, older age, poor mobility and physical illness. Delirium can be prevented. Studies in hospital patients have shown a reduction in delirium of one-third using multi-component interventions targeting its risk factors –which essentially involve the provision of basic good quality care. We know that care homes face significant challenges in delivering high quality care. In earlier work, we argued that focusing on delirium could be the ‘Trojan Horse’ to drive up the quality of care in care homes. These links 'Stop Delirium Project' and 'Stop Delirium! A complex intervention for delirium in care homes for older people' take you to the materials and summary report of this work to design ‘Stop Delirium!’ -a bespoke delirium intervention for care homes. In the ‘PiTSTOP study’ we sought to address key aspects of trial design for the particular circumstances of care homes in order to prepare for a full trial of Stop Delirium!. Although we found most aspects, such as recruitment and data collection, were feasible, measuring delirium within the practical and legislative constraints of a trial in care homes was challenging. Residents, often, could not be assessed for reasons related to their delirium risk; and the high prevalence of dementia made delirium diagnosis particularly complex. So reliably determining delirium in care home trials and other settings with high dementia prevalence remains the elusive ‘Holy Grail’ for delirium research. A definitive trial of delirium prevention in long-term care is much needed, but will require some further design modifications and pilot work to address this challenge.