Delirium in long-term care

Delirium is common in long-term care settings. Adults living in institutional long-term care (LTC) are at a particularly high risk of delirium. An episode of delirium can increase the risk of admission to hospital, the development or worsening of dementia, and can increase mortality. It is associated with considerable distress for patients, families and carers. Preventing delirium and improving its recognition and management could be a key driver to improving quality of health and social care.

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PiTSTOP Study: A pilot cluster randomised trial of Stop Delirium in care homes for older people

The PiTSTOP study is a pilot cluster randomised trial of the Stop Delirium intervention. The Stop Delirium intervention is a multi-component educational package, involving multiple strategies aimed at changing practice to prevent delirium. It was delivered to 14 independent sector care homes over a 16-month period. Specialist delirium practitioners delivered three interactive educational sessions and facilitated working groups with care home staff. A ‘delirium champion’ was also trained at each home. The intervention aims to modify key resident and environmental delirium risk factors (pain, infections, dehydration, poor nutrition, constipation, polypharmacy, sensory impairment, limited mobility and sleep disturbance) by improving the quality of care. The control homes in the study received care as usual.

The pilot study found delirium prevalence over a 1-month period to be 4% in the intervention group and 7.1% in the control group. The study found the proposed outcome measures to be feasible; however, the approach appeared to under-estimate delirium. A definitive trial of delirium prevention in long-term care is needed.

Research team: Najma Siddiqi, Francine Cheater, Michelle Collinson, Amanda Farrin, Anne Forster, Deepa George, Mary Godfrey, Elizabeth Graham, Jennifer Harrison, Anne Heaven, Peter Heudtlass, Claire Hulme, David Meads, Chris North, Angus Sturrock, John Young

Follow the link to the PiTSTOP Trial paper (PDF , 364kb)

Funding acknowledgement and disclaimer
This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit Programme (PB-PG-0610-22068). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Interventions for preventing delirium in older people in long-term care: Cochrane Review

This Cochrane systematic review assessed interventions for preventing delirium in older people living in long-term care (LTC). The types of LTC included in the review are residential homes, and nursing homes.

The review included three randomised trials. Two trials were complex, non-pharmacological interventions, and one was a feasibility trial of a non-pharmacological intervention. One trial was a software-based intervention to identify medications that could contribute to delirium risk and trigger a pharmacist-led medication review. The review found the medication intervention probably reduced delirium episodes in older people, in LTC. One trial was a hydration-based intervention; ensuring individual fluid intake goals were maintained. The review was unable to determine if the hydration intervention reduced delirium due to the risk of bias and serious imprecision. The feasibility trial was an educational intervention, aimed at identifying risk factors for delirium and developing bespoke solutions within care homes. It was not possible to determine the effect of this intervention on delirium episodes due to risk of bias and imprecision.

Future trials of non-pharmacological delirium prevention interventions for older people in LTC are justified, to help inform the provision of evidence-based care for this vulnerable group.

Research team: Rebecca Woodhouse, Najma Siddiqi, Jennie Lister, Jenni Burton, Namrata Rana, Yan Ling Pang

Follow the link to the Long-term Care Cochrane Review (PDF , 489kb)

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A prospective observational study to investigate utility of the Delirium Observational Screening Scale (DOSS) to detect delirium in care home residents

The aim of this study was to investigate whether a simple screening tool for delirium, that has been shown to be reliable in the detection of delirium in the hospital setting, might have utility in the detection of delirium as part of routine care in (UK) care homes, and whether it can be used to assess delirium severity. The study involved 9 UK residential and nursing homes. The 25-item DOSS was completed daily by care home staff and compared with the CAM, which was performed twice a week by trained researchers. The Sensitivity and specificity for delirium detection were optimised at a DOSS cut point of ≥5 (sensitivity 0.61 (95% CI: 0.39-0.80) and specificity (0.71 95% CI: 0.70-0.73)). Positive and negative predictive values were 1.6 and 99.5%, respectively. The low sensitivity of the DOSS limits clinical utility for detection of delirium as part of routine care for care home residents, although a negative DOSS affords confidence that delirium is not present.

Research team: Elizabeth Teale, Theresa Munyombwe, Marieke Schuurmanns, Najma Siddiqi, John Young.

Follow the links to the DOSS Trial Protocol (PDF , 536kb) and the DOSS Trial Paper (PDF , 244kb)

Funding acknowledgement and disclaimer
This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit Programme (PBPG-1112-29068). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.