The Future Hospital: a blueprint for effective delirium care

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Development of an international undergraduate curriculum for delirium using a modified delphi process

Background

delirium is a medical emergency affecting approximately 30% of hospitalised older patients. Recent work examining UK undergraduate medical curricula highlighted inconsistencies in the delivery of teaching on delirium. The aim of this project was to develop consensus agreement on a delirium curriculum for medical undergraduates.

Methods

a modified Delphi process was used to determine consensus amongst experts in an iterative manner. Experts at the European Delirium Association Conference (London, 2015) were invited to participate. Participants were asked to consider: (i) What should be taught? (ii) How should teaching be delivered? (iii) Who should deliver the teaching? (iv) Where should the teaching be delivered? (v) When should the teaching be delivered? Delphi rounds continued until consensus on curriculum content (defined as 80% agreement) was achieved.

Results

consensus was reached after three rounds. A recurrent theme was the need to involve patients, families and carers to help drive attitudinal change. The final curriculum, along with data pertaining to agreement with each curriculum item during the Delphi process, is presented.

Conclusion

this Delphi process enabled an international group of experts from a broad range of specialties, to reach consensus agreement on the components of an undergraduate curriculum for delirium. The curriculum represents an important step in the development of delirium education within medical training. Despite competing demands of increasingly crowded undergraduate curricula, delirium, given its relevance to 21st century healthcare, must be prioritised. We call on Medical Schools to consider integrating this delirium curriculum into their degree programmes.