World Delirium Awareness Day Four Years On: Where has it taken us?
Today marks the fourth World Delirium Awareness Day, this year via the hashtag #WDAD2021.
The ambition of World Delirium Awareness Day #WDAD is:
- To raise awareness of delirium globally.
- To establish optimal delirium care for people wherever and whenever they experience it.
Where did #WDAD come from?
2006 saw the formation of European Delirium Association (EDA). It provides a platform for clinicians enthusiastic about delirium to share knowledge and work collaboratively. The EDA plays a key role in delirium education at local and international level, as well as directing policy and co-ordinating research efforts. Following this closely, the American Delirium Society was founded in 2011, with our Australian counterparts forming the Australasian Delirium Association in 2012. More recently in 2019, the Latin American Delirium Interest Group was established. Together, these groups formed the International federation of delirium societies, ‘iDelirium’. Out of this global effort #WDAD was created.
A ‘day’ may be easy to designate, but creating a movement for sustainable change takes time, patience, and nurturing. It is with enormous pride that we look back at just how far we have come since 2017.
What milestones are we celebrating today...and what milestones are we yet to arrive at?
One of the first achievements following the inaugural #WDAD was the 2017 publication of the combined guidance (Social Care Institute for Excellence and NICE) on ‘recognising and preventing delirium in care homes’. Delirium is common in care home residents1 and the guidance has offered support for professionals in this sector to better prevent, recognise, treat, and support residents during and after an episode of delirium. Delirium toolkits are now being widely developed for use in the community enabling us to deliver patient care both in and out of hospital settings.
2019 saw the launch of the SIGN guidelines on delirium with NICE updating its guidance (first published in 2010) in the same year. Both advocated for the need to screen for delirium using a validated tool2, to identify and treat causes, and also to support patients and carers. In the UK, over 90% of hospitals now utilise a validated tool to assess for delirium and 85% of UK hospitals utilise standardised treatment guidelines or pathways to support patients when delirium is detected3. This is an important milestone because it demonstrates wide clinical implementation of delirium screening (moving beyond validation studies) as well as implementation of treatment pathways. Electronic systems are further enhancing patient access to screening and support4.
In 2019 doctor, occupational therapy, physiotherapy and nursing societies across Europe joined to publish the ‘interdisciplinary statement of scientific societies for the advancement of delirium care across Europe’. This statement recognises the critical importance of a multidisciplinary approach to delirium treatment and identifies attitudinal, cultural and organisational barriers to optimising care. To meet these needs there has been emphasis placed on improvements in undergraduate and postgraduate education in delirium across all the professional arenas. Events such as the Heath Education England 2021 #WDAD ‘Marchathon,’ which culminates today with 36 hours of non-stop education, is a welcome development to celebrate.
The Network for Investigation of Delirium uniting Scientists (NIDUS) is now providing international collaborative and multidisciplinary networks to accelerate delirium research. Following the conference in 201910, a roadmap has been created to identify research priorities. The Geriatric Medicine Research Collaborative (GeMRC) is also harnessing the skills of doctors in training in the UK to drive delirium research forward.
The DECIDE study (2020) has advanced our understanding of the relationship between episodes of delirium and subsequent cognitive decline, identifying a relationship between delirium severity and length and subsequent cognitive decline at 12 months5. Since 2017 the Cochrane Collaborative have published six systematic reviews of a growing evidence base: including,
- The roles of cholinesterase inhibitors6
- Interventions for preventing intensive care unit delirium in adults7,
- Interventions for preventing delirium in older people in institutional long-term care8
- Delirium management in terminally ill adults9.
During the COVID-19 pandemic, we saw a significant increase in the burden of delirium on patients, carers, and the healthcare system. The collaborative approach that we can now harness through our networks enabled us to quickly demonstrate that delirium was a common presenting aspect of COVID 19 in older people11 and it was added to the list of presenting features12. Indeed ‘new confusion’ has been included into the National Early Warning score in the UK since 2017 (NEWS-2) which rightly highlights delirium as an early sign that a patient may be deteriorating.
Clearly there is much here to celebrate, and much has been achieved at a fantastic pace. There are, however, still some milestones to consider.
We look forward to one day celebrating the abolishment of all physical and chemical restraint for patients globally, as we know that these measures contribute to significant harms for patients.
We envisage a society where people with cognitive vulnerability are supported to live well and flourish within our communities. To do this we need to accelerate the development of services that allow rapid assessment and support to people developing delirium in their homes. We need to ensure that assessments are timely, and occur in locations that will best support people who can find the sensory onslaught of hospital environments challenging. We also need to fully assess and address the needs of carers. We are excited to see the provision of follow-up and support services that offer both physical and cognitive rehabilitation to those recovering from delirium13. Our goal is that these services will become seamless, and recognise the continuum of cognitive frailty from delirium to dementia.
All decisions around treatment and policy priorities needs to be evidence-driven. A recent comprehensive review usefully summarised the state of the delirium field14. An urgent research priority is to develop consensus approaches to defining delirium presence and severity. We also look forward to developing a better understanding of the pathophysiology underlying delirium, including consideration of the neural substrates underpinning potential aetiological subtypes.
Treatment studies are also urgently needed. There are only three randomised controlled trials testing multidomain delirium treatment and current treatment are largely based on expert consensus. We need to better understand how and when to best implement treatment. We know that delirium prevention can be effective15, but there are very few studies examining the implementation of delirium prevention strategies into routine care.
Finally, mainstreaming of effective delirium education for all stakeholders is an urgent priority. Education will be effective in increasing knowledge of this condition but also crucial in improving delirium care16. Currently, delirium education is sparse in both undergraduate and postgraduate curriculums17. Introduction of good quality delirium education for all remains an absolute priority.
There is much to look forward to in the coming years as we seek to understand this condition better. It is also imperative that we provide all healthcare workers with the education and training that they need to provide the best care for people. Delirium is preventable and treatable, and with the right support people may not only recover sooner but also have reduced disease severity.
The work of #WDAD is just beginning.
1. Siddiqi, N., Clegg, A., & Young, J. (2009). Delirium in care homes. Reviews in Clinical Gerontology, 19(4), 309.
2. 4AT validation: Shenkin, S.D., Fox, C., Godfrey, M. et al. Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Med 17, 138 (2019). https://doi.org/10.1186/s12916-019-1367-9
3. Zoë Tieges, Jacqueline Lowrey, Alasdair M. J. MacLullich (2021) What delirium detection tools are used in routine clinical practice in the UK? A Freedom of Information investigation of UK hospitals medRxiv 2021.01.12.21249699; doi: https://doi.org/10.1101/2021.01.12.21249699
4. Emma Vardy, Niamh Collins, Umang Grover, Rebecca Thompson, Alexandra Bagnall, Georgia Clarke, Shelley Heywood, Beverley Thompson, Lesley Wintle, Louise Nutt, Sarah Hulme, Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital, Age and Ageing, Volume 49, Issue 4, July 2020, Pages 672–678, https://doi.org/10.1093/ageing/afaa069
5. Richardson, S. J., Davis, D. H., Stephan, B. C., Robinson, L., Brayne, C., Barnes, L. E., ... & Allan, L. M. (2020). Recurrent delirium over 12 months predicts dementia: results of the Delirium and Cognitive Impact in Dementia (DECIDE) study. Age Ageing.
6. Yu A, Wu S, Zhang Z, Dening T, Zhao S, Pinner G, Xia J, Yang D. Cholinesterase inhibitors for the treatment of delirium in non-ICU settings. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD012494. DOI: 10.1002/14651858.CD012494.pub2
7. Herling S, Greve IE, Vasilevskis EE, Egerod I, Bekker Mortensen C, Møller A, Svenningsen H, Thomsen T. Interventions for preventing intensive care unit delirium in adults. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD009783. DOI: 10.1002/14651858.CD009783.pub2
8. Woodhouse R, Burton JK, Rana N, Pang Y, Lister JE, Siddiqi N. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD009537. DOI: 10.1002/14651858.CD009537.pub3
9. Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD004770. DOI: 10.1002/14651858.CD004770.pub3
10. Oh, E. S., Akeju, O., Avidan, M. S., Cunningham, C., Hayden, K. M., Jones, R. N., ... & Xie, Z. (2020). A roadmap to advance delirium research: Recommendations from the NIDUS Scientific Think Tank. Alzheimer's & Dementia, 16(5), 726-733.
11. Zazzara MB, Penfold RS, Roberts AL, Lee KA, Dooley H, Sudre CH, Welch C, Bowyer RCE, Visconti A, Mangino M, Freidin MB, El-Sayed Moustafa JS, Small KS, Murray B, Modat M, Graham MS, Wolf J, Ourselin S, Martin FC, Steves CJ, Lochlainn MN. Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults. Age Ageing. 2021 Jan 8;50(1):40-48. doi: 10.1093/ageing/afaa223. PMID: 32986799; PMCID: PMC7543251.
13. Rahman S, Byatt K. Follow-up services for delirium after COVID-19-where now? Age and Ageing. 2021 Jan. DOI: 10.1093/ageing/afab014.
14. Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers. 2020 Nov 12;6(1):90. doi: 10.1038/s41572-020-00223-4. Erratum in: Nat Rev Dis Primers. 2020 Dec 1;6(1):94. PMID: 33184265.
15. Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub3
16. Lee SY, Fisher J, Wand APF, Milisen K, Detroyer E, Sockalingam S, Agar M, Hosie A, Teodorczuk A. Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings. Eur Geriatr Med. 2020 Feb;11(1):1-32. doi: 10.1007/s41999-019-00278-x. Epub 2020 Jan 14. PMID: 32297244.
17. Copeland C, Barron DT. Delirium: An essential component in undergraduate training?. Nurse Educ Today. 2020 Feb;85:104211. doi: 10.1016/j.nedt.2019.104211. Epub 2019 Oct 19. PMID: 31756592.