Improving the diagnosis of delirium and dementia
in elderly care patients in a district general hospital.
Thomas Thorp, Donald McGowan - Lancaster Royal Infirmary, University Hospitals of Morecambe Bay - [email protected]
Methods & Standards
- A retrospective audit. Casenotes were identified via medical secretaries.
- Notes were reviewed for evidence of cognitive testing, evidence of confusion, and formal diagnoses made in response to abnormal cognitive function.
- Standard 1) all patients should have cognitive screening.
- Standard 2) all cognitively impairment patients should receive a diagnosis
The prevalence of delirium on a typical geriatric ward is 33%. The National Institute of Health and Clinical Excellence (NICE) recommends that all patients at risk of delirium should be screened for cognitive impairment on admission. Previous audit at Royal Lancaster Infirmary revealed only 30% elderly patients had cognitive assessment and only 15% received a diagnosis of dementia or delirium.
Our objective was to improve cognitive screening and the diagnosis of delirium and dementia on two elderly medicine wards in this hospital.
- The number of patients screened for cognitive impairment improved from 44% in the pre-intervention audit to 66% and 72% in first and second post-intervention audits respectively.
- The number of patients identified as ‘confused’ who had cognitive testing was maintained at 88% in both first and second post-intervention audits.
The number of confused patients given a diagnosis improved from 66% to 94% from the first to the second post-intervention audit.
- There were 3 audits and 2 interventions:
- The pre-intervention audit identified the prevalence of cognitive screening methods and detection of delirium and dementia in 44 patients July to August 2010.
- All junior doctors on the elderly care unit then had a one hour educational seminar based on the NICE delirium guidelines at the end of August 2010.
- A further audit of 50 patients was repeated between September and November 2010 (first post-intervention audit).
- A 20 minute seminar highlighting the NICE guidelines and audit results took place in December 2010 to a new group of junior doctors.
- A further 29 notes were reviewed in February 2011 (second post-intervention audit).
Conclusions & Recommendations
- Educating junior doctors working on elderly care wards improves the detection of delirium and dementia.
- Extend routine cognitive testing of at-risk patients to non-geriatric wards.
- Continued education of junior doctors rotating through our department
- Establish delirium prevention measures (as described by Inouye et al, NEJM 1999; 340:669-676)
NICE clinical guideline 103. Delirium: diagnosis, prevention and management. July 2010.