SINGAPORE - Tan Tock Seng Hospital (TTSH) will roll out a care bundle developed by its nurses to better detect and prevent delirium among its older patients to all its wards as early as the end of the year after a successful two-year trial.
Delirium, in which patients are confused, disoriented and cannot think or remember clearly, impacts nearly 30 per cent of older patients globally at some time during hospitalisation. But the condition is hard to detect because it bears similarities to dementia, and delirious patients behave differently, said advanced practice nurse and team lead of the delirium care bundle project Jennifer Li Yuan.
Dr Lim Jun Pei, a consultant at TTSH’s Department of Geriatric Medicine and co-lead of the initiative, said the gold standard in diagnosing the condition is the confusion assessment method. But the assessment takes about half an hour and, given its laborious nature, is hard to use as a screening tool across the board.
In 2019, the hospital introduced the delirium care bundle in a surgical ward after feedback from staff that the number of patients becoming delirious in such wards was quite high, said Ms Li, who worked with three other nurses on the project.
She added that up to 50 per cent of elderly patients globally suffer from delirium after surgery.
As part of the care bundle, nurses use a screening tool called 4AT, developed by the University of Edinburgh. The two-minute test has four assessment portions in which patients are asked questions such as their age, date of birth and the current year, and also to recite the months of a year backwards. Those who score four or more points are suspected of having delirium, and are referred to doctors for treatment.
Those who are at risk of developing delirium will be started on an intervention protocol to improve cognition and prevent functional decline.
This includes reminding them who they are and why they are in hospital, engaging them in activities such as puzzles or board games and ensuring they have enough sleep and hydration.
A pilot study between 2020 and 2021 showed earlier and more accurate identification of delirium among elderly surgical patients. Out of the 220 at-risk patients screened, 51 or 24 per cent were diagnosed to have delirium with 88 per cent accuracy. Previously, less than 16 per cent of patients in the surgical ward were detected.
Delirium can be triggered by infections, surgery, side effects of medication, pain and serious illnesses. Those at risk include patients aged 65 and older, those who have brain diseases including dementia or stroke, and the frail and immobile.
Ms Li said delirium needs to be treated promptly or patients may have to stay in hospital longer, and face more complications and a higher risk of being admitted into a nursing home prematurely.
Dr Lim said delirium can also affect a patient’s ability to receive care. “Those who are delirious can sometimes remove tubes or dressings, and these behaviours are harmful to themselves.”
Educational and training programmes are under way at TTSH to equip nurses, healthcare assistants, caregivers and surgical team doctors with the skills and knowledge of delirium assessment and patient management.