Fighting delirium: Small changes have big impacts

A unique care provider team led by orthopaedic surgeons and geriatricians have come together to tackle the rates of delirium in a post-operative unit at Victoria Hospital, London Health Sciences Centre (LHSC). 

A first-of-its-kind research study through Lawson Health Research Institute, they are aiming to reduce the overall incidence of delirium for patients recovering from hip fractures using a series of simple yet effective changes to the environment and coordination of care. 

Delirium is an acute confusional state that occurs because of an underlying physiological problem such as illness or injury. Symptoms of delirium differ from person to person, including memory problems, hallucinations, issues connecting to their surroundings and changes in sleep patterns. However, the key symptom of delirium is difficulty concentrating, also known as inattention.

Signs and symptoms of the condition typically crop up within hours or days and can be triggered by a number of different factors, including surgeries with anesthesia and drug interactions.

“We were involved in a project to improve the quality of care for patients following a hip fracture, and one measure where we saw significant room for improvement was delirium,” explains Dr. David Sanders, Lawson Associate Scientist and LHSC Orthopaedic Surgeon. “We wanted to look at how we could better support patients and families through the experience, with a focus on preventing delirium.”

Up to 50 per cent of people with a hip fracture can be confused and show signs of delirium, which can have a negative impact on their ability to recover.  

Dr. Sanders notes that delirium can be incredibly difficult and even disturbing for patients, and can be terrible for families as well. “We have patients telling us that the feelings of confusion and other delirium symptoms were by far the worst part of their stay and a major hurdle to recovery.” 

Dr. Jenny Thain, Lawson Associate Scientist and LHSC Geriatrician, is part of the research team bringing together their wide range of expertise to address the problem and test solutions. 

“It is difficult because we don’t know how long the delirium will go on for. For some people it lasts a few days, but for others it can persist for weeks or even months. I see families dealing with this for 6 months or longer, and it is devastating for them,” says Dr. Thain. 

There are three types of delirium, marked by either drowsiness, hyper-activity or a combination of both. 

“When we have someone who is drowsy and confused, it is difficult to initiate physio and rehab activities, and they are more likely to spend time in bed increasing the risk of pressure sores. They may not eat or drink enough, becoming dehydrated and lacking in the nutrition needed for recovery,” explains Dr. Thain. 

Individuals with more hyper-active symptoms are confused, wander around, can’t follow instructions and are disoriented. Dr. Thain notes that for these patients, it jeopardizes their ability to return to previous levels of function. “The ultimate goal is to make it home, but if you’re suffering from delirium it is a major challenge with medication, personal care and other issues that are then more difficult to manage.” 

The team is taking a multifaceted approach to help reorient and reassure patients, as well as speed up their recovery. 

• A dedicated eight bed unit with each room painted a different colour, either light blue, teal pink or orange. The different colours helps to differentiate the spaces and help the person understand where they are and which room is theirs. 
• The unit has digital clocks that are easy to read and indicate both the time and day of the week. Symptoms of delirium can be worse at night or when patients aren’t able to tell what time of day it is. 
• Assessments will be provided on the unit by geriatricians for all patients, helping to assess risk factors and provide personalized strategies. 
• Working with anesthetists to reduce the use of medication during the operation and providing a standardized pain management plan that helps avoid medications that are likely to induce delirium and provide recommendations for managing issues like sleep difficulties. 
• Trying to get patients up and walking as soon as possible after surgery, and exposing them to natural light when possible. 
• Reducing the use of catheters, which has shown to contribute to symptoms of delirium. 

“When you put all of these interventions together, we feel confident that we’ll be able to reduce the overall incidence of delirium for patients,” says Dr. Sanders. “The changes as part of the study are relatively easy and affordable to implement. We see this as being something that can be quickly integrated into different units and centres across the country and beyond.”

The study is expected to last for about a year, and the researchers will be analyzing rates of delirium, average length of stay in the unit, rates of complications and patient-reported outcomes such as pain, quality of life and satisfaction. 
Here in London, Ontario, they are starting with Victoria Hospital and then will look to implement the changes at University Hospital following the results of this initial study.