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      Commentary: Prevention and management of delirium in older Australians: The need for the integration of carers as partners in care

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          Abstract

          Despite being the most common hospital-acquired complication (35.7 per 10,000 admissions) in Australia, with a healthcare cost of $8.8 billion, assessment of hospital-acquired delirium remains ineffective. 1 , 2 Delirium is a common and often preventable condition characterised by a sudden decline in a person's baseline mental function, evident by confusion, and changes to behaviour and level of consciousness. 3 Studies report undiagnosed rates of delirium as high as 66% in older adults, and up to 87.5% in cases where dementia is also present. 3 , 4 Delirium is a serious condition associated with increased mortality and morbidity, functional decline, falls, hospital-acquired pressure injuries, longer hospital admissions and early entry to residential aged care, which impacts on patients, carers and health professionals. 5 However, routine screening is not consistently practiced, and health professional's understanding and recognition of delirium is poor. 4 While prevention is the most effective strategy, outcomes for patients with delirium can be improved by early recognition and intervention. 4 Carers (e.g. family members, friends) are best placed to identify subtle changes in cognition and behaviours from what is ‘normal’ for the person, particularly for people living with dementia, because they have knowledge about their previous mental state. 6 Yet, carers are often not included in hospital patient assessment processes, or encouraged to be active participants in care, and this has been compounded by the COVID-19 pandemic. 7 This commentary highlights the importance of integrating carers as partners in delirium prevention and management in environments where there are high admission rates of older adults with increasingly complex conditions. Australian National Standards for Delirium Clinical Care guide and support safe and quality care for patients at risk of delirium through meaningful partnerships with carers. 8 There is evidence that partnering with carers improves healthcare and patient/carer satisfaction with care. 9 Delirium develops quickly and signs and symptoms can fluctuate. Several screening tools (e.g. Confusion Assessment Method and ‘Sour Seven’ Delirium Identification Questionnaire) have been developed to enable carers to identify delirium risk factors and symptoms. Carer inclusive delirium education and training on risk factors, symptoms and prevention are reported to reduce delirium incidence rates, length of hospital stay and readmissions. 9 Alarmingly, up to fifty percent of patients with unresolved delirium, experience persistent symptoms for months post discharge, contributing to ongoing cognitive and functional impairment. 3 Transition to permanent states of cognitive impairment may follow. 5 Integration of carers as partners in care during hospitalisations may ameliorate this high-risk transition period post-discharge. Involving carers provides a voice and meaningful communication with health professionals. 7 A framework to prioritise acting on carer concerns and maximising knowledge and sensitivity to changes in the older adult's condition may improve health outcomes. 8 However, there are challenges to building effective partnerships, for example, staff workloads and organisational pressures reduces contact time with carers. Carers often report a lack of communication with health professionals. 7 Carers may have poor wellbeing, experience high levels of psychological distress and less satisfaction with life because of their caregiving role. 9 There is also limited agreement on how and when to involve carers in delirium care, and existing models of care have minimal focus on their partnership. Research presents innovative opportunities for effective carer partnerships in hospital delirium prevention, focusing on recognition, collaboration and support. 7 , 9 , 10 Recognition of the need for carers to remain part of the care planning process is necessary to build a culture of mutual trust and respect. 7 Sharing carers’ experiences with health professionals is key to establishing partnerships. The World Health Organisation advocates for empowering and engaging carers into care, and the Carer Recognition Act 2010 and the Charter of Healthcare Rights 2019 were endorsed by the Australian Government to increase engagement of carers in healthcare services, but they are yet to be fully translated into practice. Interventions including training modules on collaboration and communication strategies have been instrumental in supporting partnerships. 4 , 7 , 10 Providing carers with counselling, social prescriptions, peer-support and carer-directed support packages improves psychological wellbeing of carers. Carers value partnerships when health professionals acknowledge their caregiving role and provide resources to address their needs. 7 , 9 To ensure appropriateness of the resources, especially for diverse older Australians, such as Culturally and Linguistically Diverse and lesbian, gay, bisexual, transgender and queer carers, shared decision making is ethically important and essential. To address the impact of hospital-acquired delirium, we call for recognition of carers as partners and health professional's time and investment in environmental modifications that signify carers are welcomed and enabled regarding risk factors and early diagnosis of delirium. Innovative models of care for hospital-acquired delirium assessment and management, that recognise and value a partnership approach with carers of older adults are warranted to achieve better health outcomes. Contributors Conceptualisation of the model of care whereby the integration of carers are supported to partner with health professionals in delirium management- Aggar, Craswell and Bail. Concept of Paper - Aggar and Hamiduzzaman. Critical Review & Writing of Paper - all authors contributed equally. Declaration of interests We declare no competing interests.

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          Delirium in elderly people.

          Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium. Copyright © 2014 Elsevier Ltd. All rights reserved.
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            The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study

            Abstract Introduction Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. Methods We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. Results We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19–26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. Discussion The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.
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              Economic impact of delirium in Australia: a cost of illness study

              Objectives To estimate the economic impact of delirium in the Australian population in 2016–2017, including financial costs, and its burden on health. Design, setting and participants A cost of illness study was conducted for the Australian population in the 2016–2017 financial year. The prevalence of delirium in 2016–2017 was calculated to inform cost estimations. The costs estimated in this study also include dementia attributable to delirium. Main outcome measures The total and per capita costs were analysed for three categories: health systems costs, other financial costs including productivity losses and informal care and cost associated with loss of well-being (burden of disease). Costs were expressed in 2016–2017 pound sterling (£) and Australian dollars ($A). Results There were an estimated 132 595 occurrences of delirium in 2016–2017, and more than 900 deaths were attributed to delirium in 2016–2017. Delirium causes an estimated 10.6% of dementia in Australia. The total costs of delirium in Australia were estimated to be £4.3 billion ($A8.8 billion) in 2016–2017, ranging between £2.6 billion ($A5.3 billion) and £5.9 billion ($A12.1 billion). The total estimated costs comprised financial costs of £1.7 billion and the value of healthy life lost of £2.5 billion. Dementia attributable to delirium accounted for £2.2 billion of the total cost of delirium. Conclusions These findings highlight the substantial burden that delirium imposes on Australian society—both in terms of financial costs associated with health system expenditure and the increased need for residential aged care due to the functional and cognitive decline associated with delirium and dementia. To reduce the substantial well-being costs of delirium, further research should seek to better understand the potential pathways from an episode of delirium to subsequent mortality and reduced cognitive functioning outcomes.
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                Author and article information

                Contributors
                Journal
                Lancet Reg Health West Pac
                Lancet Reg Health West Pac
                The Lancet Regional Health: Western Pacific
                Elsevier
                2666-6065
                15 September 2022
                October 2022
                15 September 2022
                : 27
                : 100598
                Affiliations
                [a ]Southern Cross University, Queensland 4225, Australia
                [b ]University of the Sunshine Coast, Queensland 4556, Australia
                [c ]University of Canberra, ACT 2617, Australia
                [d ]University of Saskatchewan, Saskatoon, Canada
                [e ]Primary Care Community Services
                Author notes
                [* ]Corresponding author: Southern Cross University, Gold Coast, Queensland 4225, Australia. christina.aggar@ 123456scu.edu.au
                Article
                S2666-6065(22)00213-9 100598
                10.1016/j.lanwpc.2022.100598
                9485061
                971782c1-06b2-4528-8cd6-73b72e40334b
                © 2022 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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