“It was the feeling of I couldn’t escape… a lot of it was the terror being downstairs, shut in underneath something I couldn’t get out.”
“It was terrifying not knowing who were the good people and who were the bad people.”
“I thought I was dying, I honestly and truly thought I was going to, I was on the way out, I thought this is it.”
These quotes show how traumatic the experience of delirium can be for patients and their families. Delirium is a common and distressing medical emergency, affecting at least 15% of patients in hospitals. Until recently it has been a neglected, undetected condition. Care has therefore often been absent or inadequate. The failure to make a diagnosis not only meant that treatment was often poor, but also that patients and their carers were not given proper information, adding to their distress.
Delirium is also linked with multiple medical complications, including falls – some studies have shown that delirium is implicated in 50% of falls in hospital, immobility, prolonged length of stay, new admissions to care homes and mortality. The financial costs of delirium are also very large, placing greater strain on healthcare systems.
“Scotland has seen a sea change in delirium care in the last few years… The focus has always been pragmatic. In 2012 the SDA began a collaboration with Healthcare Improvement Scotland to work strategically to improve delirium care in Scotland. It has been a very productive partnership.”
Thankfully, there have been increasing efforts to improve care of those with delirium over the last 20 to 30 years. This has been stimulated by reports such as Who Cares Wins (2005) and the NICE Guidelines on Delirium (2010), important studies and innovations in clinical care, and the founding of new international bodies devoted to delirium, such as the European Delirium Association (2006).
Scotland has seen a sea change in delirium care in the last few years. This began with the formation of the Scottish Delirium Association (SDA) in 2011, led by Dr Linda Wolff. The SDA is an interdisciplinary group of healthcare professionals set up to gather and create resources for better delirium care. The focus has always been pragmatic. In 2012 the SDA began a collaboration with Healthcare Improvement Scotland to work strategically to improve delirium care in Scotland. It has been a very productive partnership. Together we promoted greater delirium awareness, ran multiple teaching sessions, implemented delirium detection centred on the 4AT and created new resources such as the TIME bundle for delirium treatment, and a widely used information leaflet for patients and carers. The positive effects of this work have been seen in increasing rates of delirium recognition across Scotland. The work has also been influential internationally.
However, while this initiative has certainly made a difference, it was clear that there was still a lot of variation in clinical care in Scotland. From this recognition came the proposal that there should be a new Scottish Intercollegiate Guidelines Network (SIGN) guideline on delirium, to provide a resource that could be applied and audited across the healthcare system. Over the last three years, SIGN (part of Healthcare Improvement Scotland), the SDA and other interested professionals and lay people have worked together to produce this guideline and we are delighted that it is being launched on World Delirium Awareness Day. We hope that this will allow for greater awareness and dissemination of the guideline.
I have greatly enjoyed the process of working with co-chair Ajay Macharouthu, the superb guidelines committee, and the excellent SIGN team led by Ailsa Stein. The rigorous SIGN process means that we are confident that for the key questions we have found and summarised the available evidence, producing recommendations based on this evidence or with expert consensus when there was insufficient evidence to inform recommendations.
These guidelines provide an opportunity for us to lift delirium care in Scotland to the next level, making it normal care that delirium is detected, early treatment is provided, and that patients and families are kept informed of the diagnosis. We are optimistic that, building on the work of the SDA and Healthcare Improvement Scotland that the guidelines will catalyse a national effort to serve all of our patients with delirium to a high standard.
Professor Alasdair MacLullich is Co-chair of the SIGN Guideline Development Group
For more information on the signs and symptoms of delirium, visit: www.sign.ac.uk