Hrev_master [page 67] [Emergency Care Journal 2017; 13:7123] A call to improve delirium care: The Italian experience Ciro Paolillo,1 Giovanni Ricevuti2 1Emergency Department, University Hospital of Udine; 2Geriatrics and Emergency Medicine, University of Pavia, Italy Thousands of tiny little creatures, some on horseback, waving arms, carrying weapons like some grand Renaissance bat- tle, were trying to turn people into zombies. Their leader was a woman with no mouth but a very precisely cut hole in her throat. John Kaplan, Pulitzer Prize-winner describes his experience of delirium during recovery for pneumonia. Delirium is a common and serious prob- lem among acutely ill and elderly patients. The condition is ubiquitous, has no bound medical specialty and crosses over both hospital and community settings. Delirium occurs in up to half of the frail older patient population admitted to hospital and up to 80% of critically ill intensive care unit patients. High prevalence is also common in nursing homes and long-term care facilities. Delirium has been recognised since the time of Hippocrates, who may have been the first to describe the condition. The old description (confusion, agitation, fluctuat- ing anxiety associated with physical dis- ease) is similar to the modern criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) defining the condition as disturbance in attention and cognition that tends to fluctuate in severity during the day and occurs in the setting of a medical condition. Fundamentally, delirium represents a decompensation of cerebral function in response to one or more patho- physiological stressors. Susceptibility fac- tors have been established as advanced age at first, drugs, cognitive impairment, frailty and sensory impairment (blurred vision and hearing loss). Precipitating factors for delir- ium include noxious insults (stroke, infec- tion, metabolic disturbances, anoxia, tox- ins) and hospitalisation-related factors (catheters, drips, anaesthesia and surgery, unfamiliar environments, immobilising devices or physical restraints). Recent years have heralded an increasing number of sci- entific reports and the establishment of sev- eral international societies with experts worldwide focusing on delirium, such as European Delirium Association, American Delirium Society and Australasian Delirium Association. With their support, the clinical approach to delirium has shifted from ad hoc treatment to primary prevention, sys- tematic screening and early detection. Despite its long history, high prevalence, the true incidence rate of delirium remains severely underestimated. Healthcare profes- sionals are unable to identify the syndrome in up to 75% of cases, and delirium is only appropriately coded in 0.2% of cases, which may be attributable to several reasons. For instance, healthcare staff use a wide variety of generic and non-specific terms and phrases to describe delirium, such as psy- chomotor agitation, confusional state and aggressive/disturbed behaviour, leading to diagnostic imprecision. Another reason is that excellence in delirium care is not gen- erally considered to be a core element of the skills of a physician. Assessment of deliri- um is not included in draft guidelines on acutely ill patients (such as NICE guide- lines, for example) and also absent from the overwhelming majority of university train- ing curricula for internal and acute medi- cine. Thus, owing to insufficient medical knowledge, along with a combination of unpredictable and atypical clinical presenta- tions, accurate diagnosis of this condition presents a significant challenge to health- care providers. Undetected delirium is fur- ther associated with numerous negative consequences, including disease complica- tions and increased lengths of hospital stay, loss of function, high risk of falls, increased mortality, prolonged institutional care after hospitalisation, long-term cognitive impair- ment and post-traumatic stress disorder.1 In 2016, a network of Italian national sci- entific societies (geriatricians, emergency physicians, internists, anaesthesiologists, sur- geons, psychiatrists and toxicologists) was convened with the aim of developing a collab- orative multidisciplinary initiative consensus on delirium in elderly hospitalised patients. Task force members were identified by the presidents and governing boards of each scien- tific society. After several shared layouts, in 2017 the final draft was approved by all soci- eties.2 The main topics on which consensus was reached are outlined below. Inclusion of delirium All groups stressed the necessity of an effective delirium educational intervention system for healthcare workers. The goal is to include routine assessment of delirium in primary healthcare. Encouragement of healthcare professionals to think delirium in differential diagnosis of the confusional state of aged patients is the key for recog- nising the condition. All societies agreed to promote the use of the term delirium as a clinical diagnosis in hospital charts and foremost in discharge reports. This new consensus should provide revolutionary support for first line management of wide- spread delirium in our hospitals. Prevention Experts from all the Scientific Societies unanimously highlighted the importance of identifying patients at risk for delirium and developing direct preventative strategies that target specific risk factors (mainte- nance of fluid and electrolyte balance, pain treatment, adequate brain oxygen delivery, regulation of bladder/bowel function, early mobilisation and appropriate environmental stimuli) or risks correlated to the care set- ting (anaesthesia, surgery and postoperative pain). There was a growing consensus of opinion on the importance of creating an interdisciplinary collaboration between cli- nicians to develop models aimed at reduc- ing the incidence of delirium. Diagnosis Think delirium was proposed as the mantra for evaluating confused aging hospi- talised patients. The experts recommend the use of the 4AT test for delirium screening in clinical practice for several reasons, includ- ing brevity (it usually takes less than two minutes to complete), ease of administra- tion and no requirement for special training or physical responses (Table 1). The 4AT test could also be included in routine nurs- ing assessments. If diagnosed, delirium should be considered a high medical priori- ty and the appropriate tests initiated without delay to determine the triggering cause.3 Emergency Care Journal 2017; volume 13:7123 Correspondence: Ciro Paolillo, University Hospital of Udine, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy. Tel.: +39.0432.552360. E-mail: ciropaolillo@gmail.com Key words: delirium; older adults; prevention; polypharmacy; hospital; cognitive impair- ment; antipsychotic; quality improvement Received for publication: 5 October 2017. Accepted for publication: 20 February 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright C. Paolillo and G.Ricevuti, 2017 Licensee PAGEPress, Italy Emergency Care Journal 2017; 13:7123 doi:10.4081/ecj.2017.7123 Non -co mmerc ial us e o nly [Emergency Care Journal 2017; 13:7123] [page 68] Treatment options No specific treatments for delirium are currently available. Treatment begins with a careful and thorough research of diseases and conditions that underlie the onset of delirium. Numerous acronyms have been used to remember the most frequent causes. The current recommendation is DELIRI- UMS proposed by Flaberty. (Table 2) Behavioural therapy and appropriate non- pharmacological approaches are the stan- dard initial treatment options. In cases where pharmacological measures are neces- sary (i.e. symptoms put the patient or others at risk of harm or are bothersome to the patient and interfere with essential thera- pies), the judicial use of low-dose haloperi- dol or atypical antipsychotics is recom- mended. Benzodiazepine therapy is advo- cated only in selected patients with a history of abstinence from alcohol or benzodi- azepines.4 Intercommunication among patients, caregivers and family members It may be beneficial to query family members or caregivers for additional per- spectives on medical history, predominant mood and affect, and physical and social functioning of dementia patients. Knowledge of the patterns of certain pre- existing conditions could help with antici- patory planning. Moreover, family mem- bers may be helpful in settling and reassur- ing agitated patients. Regular engagement and communication with patients and their families regarding changes in medication and care is therefore recommended. Conclusions The Federation of Societies has provid- ed an invaluable opportunity for different disciplines to collaborate on research and educate a broader audience for prevention of disease. We believe that the newly devel- oped consensus will provide significant benefits to facilitate improvements in the diagnosis and management of delirium. References 1. Maldonado JR. Acute brain failure. Pathophysiology, diagnosis, manage- ment, and sequelae of delirium. Crit Care Clin 2017;33:461-519. 2. Bellelli G, Morandi A, Trabucchi M et al. Italian intersociety consensus on pre- vention, diagnosis, and treatment of delirium in hospitalised older persons. Intern Emerg Med 2018;13:113:121. 3. Bellelli G, Morandi A, Davis DHJ et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014;43:496-502. 4. Flaberty JH, Yue J, Rudolph JL. Dissecting delirium. Phenotypes, con- sequences, screening, diagnosis, pre- vention, treatment and program imple- mentation. Clin Geriatr Med 2017;33:393-413. Opinion Report Table 1. The 4AT test. 1. Alertness Observe the patient. If asleep, attempt to wake with speech or gentle touch Normal (fully alert, but not agitated, throughout assessment): 0 on shoulder. Ask the patient to state their name and address to assist rating. Mild sleepiness for <10 seconds after waking, then normal: 0 Clearly abnormal: 4 2. Abbreviate mental test 4 Age, date of birth, place (name of the hospital or building), current year. No mistakes: 0 1 mistake: 0 2 or more mistakes/untestable: 2 3. Attention Ask the patient: Please tell me the months of the year in backwards order, Months of the year backwards: starting at December. To assist initial understanding one prompt of Achieves 7 months or more correctly: 0 What is the month before December? is permitted. Starts but scores <7 month/refuses to start: 1 Untestable (cannot start because unwell, drowsy, inattentive): 2 4. Acute change or fluctuating course Evidence of significant change or fluctuation in: alertness, cognition, No: 0 other mental function (e.g. paranoia, hallucinations) Yes: 4 arising over the last 2 weeks and still evident in last 24hrs Results 4 or more: possible delirium 1-3: possible cognitive impairment 0: unlikely delirium Table 2. Delirium causes. Delirium causes Drugs Eyes, ears Low oxygen insults Infection Retention of urine or stool Ictal Underhydration, undernutrition Metabolic Sleep deprivation DE LI RI UM S Non -co mmerc ial us e o nly