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

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.1Pezzullo L Streatfeild J Hickson J Teodorczuk A Agar MR Caplan GA. Economic impact of delirium in Australia: a cost of illness study.BMJ Open. 2019; 9e027514Crossref PubMed Scopus (39) Google Scholar,2Australian Commission on Safety and Quality in Health CareACSQHC Analysis of the Admitted Patient Care National Minimum Data Set, 2019–20. Public Hospitals only, which meet the Robust Condition Onset Flag Coding Criteria, All Care Types (unpublished). ACSQHC, Sydney2020Google Scholar 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.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar 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.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar,4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar 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.5Gibb K Seeley A Quinn T et al.The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.Age Ageing. 2020; 49: 352-360Crossref PubMed Scopus (53) Google Scholar However, routine screening is not consistently practiced, and health professional's understanding and recognition of delirium is poor.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar While prevention is the most effective strategy, outcomes for patients with delirium can be improved by early recognition and intervention.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar 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.6Shulman RW Kalra S Jiang JZ. Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses.BMC Geriatr. 2016; 16: 1-8Crossref PubMed Scopus (21) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.8Australian Commission on Safety Quality in Health Care. Delirium Clinical Care Standard. ACSQHC, Sydney2021Google Scholar There is evidence that partnering with carers improves healthcare and patient/carer satisfaction with care.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar Alarmingly, up to fifty percent of patients with unresolved delirium, experience persistent symptoms for months post discharge, contributing to ongoing cognitive and functional impairment.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar Transition to permanent states of cognitive impairment may follow.5Gibb K Seeley A Quinn T et al.The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.Age Ageing. 2020; 49: 352-360Crossref PubMed Scopus (53) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.8Australian Commission on Safety Quality in Health Care. Delirium Clinical Care Standard. ACSQHC, Sydney2021Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar Carers may have poor wellbeing, experience high levels of psychological distress and less satisfaction with life because of their caregiving role.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar,10McKenzie J Joy A. Family intervention improves outcomes for patients with delirium: systematic review and meta-analysis.Aust J Ageing. 2020; 39: 21-30Crossref Scopus (16) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar,7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,10McKenzie J Joy A. Family intervention improves outcomes for patients with delirium: systematic review and meta-analysis.Aust J Ageing. 2020; 39: 21-30Crossref Scopus (16) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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.ContributorsConceptualisation 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. 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.1Pezzullo L Streatfeild J Hickson J Teodorczuk A Agar MR Caplan GA. Economic impact of delirium in Australia: a cost of illness study.BMJ Open. 2019; 9e027514Crossref PubMed Scopus (39) Google Scholar,2Australian Commission on Safety and Quality in Health CareACSQHC Analysis of the Admitted Patient Care National Minimum Data Set, 2019–20. Public Hospitals only, which meet the Robust Condition Onset Flag Coding Criteria, All Care Types (unpublished). ACSQHC, Sydney2020Google Scholar 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.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar 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.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar,4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar 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.5Gibb K Seeley A Quinn T et al.The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.Age Ageing. 2020; 49: 352-360Crossref PubMed Scopus (53) Google Scholar However, routine screening is not consistently practiced, and health professional's understanding and recognition of delirium is poor.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar While prevention is the most effective strategy, outcomes for patients with delirium can be improved by early recognition and intervention.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar 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.6Shulman RW Kalra S Jiang JZ. Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses.BMC Geriatr. 2016; 16: 1-8Crossref PubMed Scopus (21) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.8Australian Commission on Safety Quality in Health Care. Delirium Clinical Care Standard. ACSQHC, Sydney2021Google Scholar There is evidence that partnering with carers improves healthcare and patient/carer satisfaction with care.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar Alarmingly, up to fifty percent of patients with unresolved delirium, experience persistent symptoms for months post discharge, contributing to ongoing cognitive and functional impairment.3Inouye SK Westendorp RG Saczynski JS. Delirium in elderly people.Lancet. 2014; 383: 911-922Summary Full Text Full Text PDF PubMed Scopus (1815) Google Scholar Transition to permanent states of cognitive impairment may follow.5Gibb K Seeley A Quinn T et al.The consistent burden in published estimates of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.Age Ageing. 2020; 49: 352-360Crossref PubMed Scopus (53) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.8Australian Commission on Safety Quality in Health Care. Delirium Clinical Care Standard. ACSQHC, Sydney2021Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar Carers may have poor wellbeing, experience high levels of psychological distress and less satisfaction with life because of their caregiving role.9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar,10McKenzie J Joy A. Family intervention improves outcomes for patients with delirium: systematic review and meta-analysis.Aust J Ageing. 2020; 39: 21-30Crossref Scopus (16) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar 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.4Lee SY Fisher J Wand AP et al.Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings.Eur Geriatr Med. 2020; 11: 1-32Crossref PubMed Scopus (22) Google Scholar,7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,10McKenzie J Joy A. Family intervention improves outcomes for patients with delirium: systematic review and meta-analysis.Aust J Ageing. 2020; 39: 21-30Crossref Scopus (16) Google Scholar 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.7Cohen C Pereira F Kampel T Bélanger L. Integration of family caregivers in delirium prevention care for hospitalized older adults: a case study analysis.J Adv Nurs. 2021; 77: 318-330Crossref PubMed Scopus (3) Google Scholar,9Boltz M Resnick B Chippendale T Galvin J. Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.J Am Geriatr Soc. 2014; 62: 2398-2407Crossref PubMed Scopus (50) Google Scholar 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. ContributorsConceptualisation 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. 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. We declare no competing interests. This study did not receive funding.

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