Feedback on the Clinical Practice Guidelines for the Management of Delirium in Older People in...
1
DOI: 10.1111/j.1741-6612.2009.00351.x 98 Australasian Journal on Ageing, Vol 28 No 2 June 2009, 98 © 2009 The Authors Journal compilation © 2009 ACOTA Blackwell Publishing Asia Letter to the Editor Feedback on the Clinical Practice Guidelines for the Management of Delirium in Older People in Australia Dear Editor, Delirium is common and can have serious outcomes [1]. A sum- mary of the Clinical Practice Guidelines for the Management of Delirium in Older People in Australia was published in the September 2008 issue of this Journal [2]. These Guidelines apply to all Australian health-care settings, including residential care. We held a training workshop with the managers of, and general practitioners (GPs) who visit, residential aged care facilities (RCFs), as part of an ongoing controlled trial. Eleven GPs and seven RCF managers attended to facilitate improved team work. One of the tasks given to three separate teams of six people was to design a care pathway for identification of delirium within an RCF. Participants were given what we expected to be helpful resources, including details of cognitive assessment tools and recommendations from Box 2 in Tropea et al. [2], summarised as: • Structured process in place to screen and diagnose. • Formal cognitive assessment on admission. • Each of tools recommended require training. All groups agreed that all (not just some) residents in aged care facilities are at risk of delirium. There was consensus that the best time to assess baseline cognitive functioning was at least 6 weeks after admission to allow for the person to settle into their new surroundings. Most importantly, all groups agreed that the identification of possible delirium by RCF staff was based on behaviour change. Participants thought tools to screen for delirium in residential care should be based on noting sudden changes in behaviour in residents that carers typically know well. One group thought such a tool should ask staff to list possible reasons for the noted change in behaviour. Cognitive assessment using the tools recommended in the Guidelines [1] was thought to contribute little to the detection of delirium in residential care. Our experience with this small sample of GPs and managers suggests that work is urgently needed to further clarify the optimal way of screening for sudden changes in behaviour, including those described as delirium, by carers, and investiga- tion of the causes with the assistance of professional staff. Although Section 1.8 in the full Guidelines refers to sudden changes in behaviour as indicating the need for further inves- tigations, new screening tools, based on recognising sudden change in behaviour (rather than cognitive assessment per se), may be required. Recommendations about the timing of base- line cognitive assessments in residential care may also need to be reconsidered. There appears to be a significant opportunity to develop existing guidelines to enhance their relevance to residential care settings. Sincerely, Geoff Jones DIRECT Team, WA Centre for Health and Ageing and Department of Health, Western Australia Nick Bretland Canning Division of General Practice, Western Australia Rachel Lowry and Kelly Banz DIRECT Team, WA Centre for Health and Ageing, Western Australia Christopher Beer WA Centre for Health and Ageing and School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia References 1 Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People . Victorian Government Department of Human Services. Available from URL. http:// www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf Accessed 28 November 2008. 2 Tropea J, Slee J-A, Brand CA, Gray L, Snell T. Clinical practice guidelines for the management of delirium in older people in Australia. Australasian Journal on Ageing 2008; 27: 150–156.
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Transcript of Feedback on the Clinical Practice Guidelines for the Management of Delirium in Older People in...
DOI: 10.1111/j.1741-6612.2009.00351.x
98
Australasian Journal on Ageing, Vol 28 No 2 June 2009, 98© 2009 The Authors
Journal compilation © 2009 ACOTA
Blackwell Publishing Asia
Letter to the Editor
Feedback on the Clinical Practice Guidelines for the Management of Delirium in Older People in Australia
Dear Editor,
Delirium is common and can have serious outcomes [1]. A sum-mary of the Clinical Practice Guidelines for the Managementof Delirium in Older People in Australia was published in theSeptember 2008 issue of this Journal [2]. These Guidelines applyto all Australian health-care settings, including residential care.
We held a training workshop with the managers of, andgeneral practitioners (GPs) who visit, residential aged carefacilities (RCFs), as part of an ongoing controlled trial. ElevenGPs and seven RCF managers attended to facilitate improvedteam work. One of the tasks given to three separate teams ofsix people was to design a care pathway for identification ofdelirium within an RCF. Participants were given what weexpected to be helpful resources, including details of cognitiveassessment tools and recommendations from Box 2 in Tropeaet al. [2], summarised as:
• Structured process in place to screen and diagnose.• Formal cognitive assessment on admission.• Each of tools recommended require training.
All groups agreed that all (not just some) residents in aged carefacilities are at risk of delirium. There was consensus that thebest time to assess baseline cognitive functioning was at least6 weeks after admission to allow for the person to settle intotheir new surroundings. Most importantly, all groups agreedthat the identification of possible delirium by RCF staff wasbased on behaviour change. Participants thought tools toscreen for delirium in residential care should be based onnoting sudden changes in behaviour in residents that carerstypically know well. One group thought such a tool should askstaff to list possible reasons for the noted change in behaviour.Cognitive assessment using the tools recommended in theGuidelines [1] was thought to contribute little to the detectionof delirium in residential care.
Our experience with this small sample of GPs and managerssuggests that work is urgently needed to further clarify the
optimal way of screening for sudden changes in behaviour,including those described as delirium, by carers, and investiga-tion of the causes with the assistance of professional staff.Although Section 1.8 in the full Guidelines refers to suddenchanges in behaviour as indicating the need for further inves-tigations, new screening tools, based on recognising suddenchange in behaviour (rather than cognitive assessment per se),may be required. Recommendations about the timing of base-line cognitive assessments in residential care may also need tobe reconsidered. There appears to be a significant opportunityto develop existing guidelines to enhance their relevance toresidential care settings.
Sincerely,
Geoff JonesDIRECT Team, WA Centre for Health and Ageing and Department of Health, Western Australia
Nick BretlandCanning Division of General Practice, Western Australia
Rachel Lowry and Kelly BanzDIRECT Team, WA Centre for Health and Ageing, Western Australia
Christopher BeerWA Centre for Health and Ageing and School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
References
1 Delirium Clinical Guidelines Expert Working Group.
Clinical PracticeGuidelines for the Management of Delirium in Older People
. VictorianGovernment Department of Human Services. Available from URL. http://www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf Accessed 28November 2008.
2 Tropea J, Slee J-A, Brand CA, Gray L, Snell T. Clinical practice guidelinesfor the management of delirium in older people in Australia.
AustralasianJournal on Ageing
2008; 27: 150–156.
ajag_351.fm Page 98 Wednesday, June 10, 2009 1:16 PM
