Cian O'Caheny

A medication review is not simply counting tablets. For each medicine ask: what is it for, is it helping, what harm might it cause, and does it still fit the person’s priorities? #medicines nice.org.uk/guidance/ng5

There's a sequence of clinical thinking I see often, and it's usually wrong: Patient is delirious + agitated. Therefore, sedate the patient. Patient becomes quieter. Problem solved? No. The agitation might not be from delirium alone. It might be from pain. From fear. From needing the toilet. From not understanding what's happening. When you sedate a patient whose real problem is untreated pain, you've silenced the symptom without treating the cause. The patient is quieter but is likely still suffering. I sometimes think that sedation reduces the amplitude of observable behaviour, but we don't really know if it is actually making the person's mind calmer and for them to be less distressed. So the sequence should be: Patient is delirious + agitated. Look for underlying causes. Is there pain? Fear? Need for toileting? Discomfort? Address those causes. Agitation improves, often without medication. When you do this, you often find that sedation isn't necessary. The patient whose pain is managed becomes calmer. The patient who understands what's happening becomes less frightened. The patient whose needs are met becomes less agitated. This is important because sedation in delirious patients carries its own risks (aspiration pneumonia, falls). More sedation often means more delirium (usually in the form of hypoactive delirium), not less. And it masks the underlying problem instead of fixing it. It also often means that the duration of the delirium is prolonged. Before describing sedatives do the proper clinical work: *What is the agitation actually about? *Pain? Retention? Fear? Hallucinations? Loneliness? Once you've found the real cause(s), the treatment often becomes obvious, and infrequently needs additional antipsychotics or sedatives. #delirium #geriatrics

"I should have realised sooner." Carers can carry that for years. Delirium is missed daily by trained professionals. A relative who noticed something was wrong at all has often outperformed the system. deliriumsupport.com = a website for families on #delirium

Antipsychotics do not treat delirium. They do not shorten it, prevent it, or fix the cause, and they carry real risks in older people. Find the cause first. Keep the drug for the rare moment nothing else keeps someone safe. #delirium

New Research: Delirium in Hip Fracture Patients Associated with Doubled Mortality Risk I'm pleased to share our new study on delirium and hip fracture, led by @rosespenfold. 91% of all hip fracture patients attending Scottish hospitals had a 4AT delirium assessment tool performed at presentation (N=16,476 ). N=3,386 (21%) had delirium. Key findings: - Delirium was associated with important adverse outcomes including 2-fold higher mortality risks as an inpatient and at one year, and a lower likelihood of returning home following hospital admission. Key implications: - Delirium assessment on initial presentation is feasible at national scale. - Delirium assessment should be performed on presentation of hip fracture. - Hip fracture care without delirium assessment is deficient care. ***Background*** Previous studies have focused primarily on postoperative delirium. This is the first large scale study using routine data to examine delirium ascertained directly with a real-time clinical assessment at the time of hospital admission. ***Methods*** We analysed data from the Scottish Hip Fracture Audit, which covers over 99% of people aged 50+ years hospitalized with acute hip fracture in Scotland. Delirium assessment: 4AT (the4AT.com), which is embedded into routine care and performed by clinical staff. ***Results*** Delirium was present 21% of patients. Patients with delirium were older (mean age 85 vs. 78 years), more likely to be in care homes, and had higher ASA grades. After adjusting for age, sex, pre-fracture residence, and ASA grade, patients with delirium had a 2-fold increased risk of inpatient mortality (adjusted OR 2.26, 95% CI 1.79 to 2.84).The same pattern was observed for one-year mortality (adjusted OR 2.05, 95% CI 1.83 to 2.29). Patients with delirium were less likely to return to their original residence within 30 days (adjusted OR 0.27, 95% CI 0.24 to 0.30) ***Conclusions*** Delirium at hip fracture presentation is a powerful prognostic indicator that can inform shared decision-making with patients and families. Identifying delirium early allows clinicians to address potentially reversible causes and implement appropriate management strategies. Recognition of delirium can help in planning post-acute care needs. Another crucial implication is that we have definitively demonstrated that delirium testing using a validated tool is *feasible in routine practice* in this population. Hip fracture patients must have delirium assessments, and these must be done pre-operatively as well as post-operatively. ***Call to action*** Let's move forward and make good delirium care the norm in hip fracture patients. Let's make system-wide groupthink that it is okay to neglect delirium a thing of the past. Study: boneandjoint.org.uk/article/… #delirium #hipfracture