A Nuanced Way to Measure Delirium Severity

Delirium is a common, serious and potentially preventable problem for older adults. Studies have shown it is associated with both adverse outcomes in hospitalized patients (Journal of the American Geriatrics Society) and substantial economic burden (JAMA Surgery) for the nation’s health care ecosystem.

While clinicians have several tools at their disposal to determine whether patients are delirious, researchers at Brigham and Women’s Hospital are going a step further by focusing on the severity of delirium. With a more nuanced delirium rating tool, they say, clinicians will be able to assess prognosis, treatment response, recovery time, nursing burden and staffing needs, and provide appropriate patient-centered care.

Tammy T. Hshieh, MD, MPH, a geriatrician in the Brigham’s Division of Aging, has been studying delirium in older patients since medical school. She says the field has advanced significantly since the original Confusion Assessment Method (CAM) screening tool was developed in the 1990s.

“CAM has been a useful tool, but it can only provide a yes/no diagnosis,” Dr. Hshieh says. “By measuring delirium at a more granular level, we’ll be in a better position to know whether interventions are making a difference with these patients.”

Domains of Delirium Severity Study

Dr. Hshieh and colleagues Dena Schulman-Green, PhD, of New York University; Sharon Inouye, MD, MPH, of Hebrew SeniorLife/Harvard Medical School; and Rich Jones, ScD, of Brown University recently published a study in the Journal of the American Geriatrics Society. The study defines content domains for a new delirium severity instrument called DEL-S-AD for individuals with mild-to-moderate Alzheimer’s disease and related dementias (ADRD).

“People with ADRD are a unique and vulnerable population,” Dr. Hshieh says. “Often, dementia can cloud the severity of their delirium, making it difficult for clinicians to accurately diagnose them.”

The study engaged a multidisciplinary panel of members with expertise in delirium and dementia. Goals included determining which content domains from a previously developed framework, DEL-S, were useful in characterizing delirium sensitivity in ADRD.

After a two-round review process, panel members endorsed DEL-S content domains including cognitive, level of consciousness, inattention, psychiatric-behavioral, emotional dysregulation, psychomotor features and functional. They excluded six of the original subdomains that they considered unhelpful in the context of ADRD: cognitive impairment, anxiety, fear/sense of unease, depression, gait/walking and incontinence. The study was funded by a grant (no. R01AG044518) from the National Institute on Aging to multi-principal investigators Drs. Inouye and Jones.

As part of the ongoing Better Assessment of Illness (BASIL) study, Dr. Hshieh and her colleagues are validating the pilot DEL-S-AD tool at three sites: a nursing home (The New Jewish Home in New York City), a medicine service unit (Beth Israel Deaconess Medical Center in Boston) and an elective surgery service (University of Florida).

“The Brigham is quite good at translating research to the bedside to make it clinically applicable,” Dr. Hshieh says. “We look forward to seeing how this new tool will impact our ability to improve patient outcomes.”

The new DEL-S-AD tool may prove particularly useful in optimizing care for geriatric patients undergoing surgery.

Collaborating for Excellence in Geriatric Care

The Brigham applies a multidisciplinary approach to caring for geriatric patients undergoing surgery through its Surgical Center for Geriatric Excellence.

“Surgeons and geriatricians at the Brigham work closely together to ensure we identify and intervene with patients who are at high risk for delirium and poor outcomes after elective surgery,” she says. “We then collaborate with anesthesiology, physical therapy, nursing and other clinical colleagues to pre-habilitate patients for surgical success and rehabilitate them after surgery to avoid the onset of delirium, which most typically happens at post-op day 2.”

Pre-habilitation measures include reviewing and modifying patients’ medications, checking heart and lung functions, and conducting cognitive evaluations to identify those who are at high risk for delirium and who may need extra support and care after surgery. The presurgical evaluation of cognitive impairment is particularly important because postsurgical patients with the condition may not know to ask for pain medications when appropriate, resulting in a pain spiral that can cause delirium.

Multidisciplinary care teams at the Brigham mobilize patients as early as post-op day 0, removing catheters as soon as possible and stressing proper hydration and nutrition. Many of these interventions are nonpharmacologic and align with the American Geriatrics Society’s Hospital Elder Life Program. According to Dr. Hshieh, these postoperative nonpharmacologic interventions have helped decrease the incidence of delirium and improve overall outcomes for geriatric patients receiving orthopaedic surgery.

“From our leadership to individual clinicians and researchers, the Brigham is very ‘geriatric-friendly’ and open to collaborating with colleagues in different subspecialties,” Dr. Hshieh says. “We’re a passionate group that is dedicated to the grassroots, bedside efforts that make a real difference in improving patient outcomes.”

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