It is over a year since I last wrote about delirium. Being aware that the new Care Standards for older people in hospital were to be published this month I had a look on the Healthcare Improvement Scotland web platform for these new standards. As yet these standards have not been published, but I did notice the news that “OPAC tools are working”. I followed the links, read the supporting material, and watched all the associated films:
[The costs of films commissioned from the private sector by NHS Healthcare Improvement Scotland has been over £51,000 from January 2014 to February 2015]
A lot has happened in acute care settings for Scotland’s elders since I last wrote. It is wonderful to see in these films such compassion and dedication to care amongst the healthcare teams: from allied health professionals, nurses and doctors. I agree with Professor Jason Leitch that this demonstrates a caring culture.
It was some years ago that I heard Professor MacLullich give a talk about delirium. I was inspired by his thoughtful presentation which outlined the distressing symptoms that can come with states of delirium and the associated increased risk of mortality.
In this post I will not be considering improvement work undertaken on “frailty”. In what follows I intend to further explore the Healthcare Improvement Scotland strapline: “OPAC tools are working” with particular reference to delirium.
In terms of “working”, only two key figures are given by Healthcare Improvement Scotland. The first confirms that there has been 95% “compliance” with “assessment tools” for delirium.
The other key figure demonstrates that length of hospital stay in orthopaedics for older people has been reduced since the introduction of “frailty and delirium assessment tools”:
In what follows the OPAC tools currently being used in hospitals across Scotland to “identify” delirium will be considered. Two specific issues continue to concern me:
(1) the risk of too great a reliance on any “brief” “tool” rather than this being part of an overall assessment; and
(2) the marginalisation of consent.
The 4AT has been revised since I last wrote. It was previously described by its developers as “a new screening tool for delirium and cognitive impairment” (see below):
The latest version (at time of writing) is version 1.2. The developers “have decided to describe” the 4AT now as an “assessment test”:
As an “assessment test” the 4AT requires:
The 4AT “assessment test” is also noted for its:
The four questions that comprise the AMT4 are as follows:
It is important to appreciate that the 4AT test is different from other tools for delirium as it incorporates the AMT4. The AMT4 is a screening tool for cognitive impairment alone. To explain further this test is in effect used to screen for dementia. This is an important point because there has been very wide debate about cognitive screening. Cognitive screening is recommended by neither the UK National Screening Committee nor NICE. Another point is that using brief tests for delirium and cognitive impairment at the same time is an approach novel to the 4AT.
Given that the 4AT test incorporates a test of cognition it is relevant to consider whether our cognitive function can so easily be encapsulated in a “very brief” test. The 95 year old philosopher, Mary Midgley, has said this about “tests”:
Mary Midgley then goes on to say:
Cognitive ageing has become an area of great interest since Professor Lawrence Whalley of Aberdeen University began research in this area and some of his findings are summarised in his book, the Ageing Brain.
Professor Whalley reminds us that the brain is such an incredible biological wonder. Each of us have 100 billion neurons in our brains, and whilst this may change with ageing, it is still the case that our neurons, even on our last day in life, amount to:
Recently this lead Editorial was published in the Lancet:
It repeats the reminder of Professor Whalley that:
To many it appears counter-intuitive that something so complex as human brain function can be reliably assessed in a test that takes less than 2 minutes. In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.
(2) Marginalisation of consent:
“Compliance” with the 4AT “assessment test” is being measured in Scotland by Healthcare Improvement Scotland. My concern here, that I have expressed before, is that such an approach marginalises the right of the individual to consent or otherwise to this assessment.
I have become aware through my own clinical practice that even brief cognitive tests can be distressing to patients and can leave them fearful (the following quote is from a patient undergoing a short cognitive screening test but not the 4AT):
Another reason to be concerned about consent is that our cognitive abilities tend to follow a parabolic distribution through life. It would be a mistake to disregard this when undertaking complex diagnostic considerations.
In March of this year the UK Supreme Court judged that it was for patients to decide whether the risks, benefits and alternative options of assessments or medical interventions have been adequately communicated:
Treatments may bring harms as well as benefits. This is why explanation of risk should be an ethical underpinning in our interactions with a patient.
The Scottish Delirium Association (SDA) has issued delirium pathways for use across NHS Scotland. The “OPAC tools” are generally the starting point in these pathways. The SDA Comprehensive pathway states very clearly:
This pathway outlines environmental and general measures, alongside medical and nursing approaches to manage delirium which has been identified using the 4AT test. If these measures are not in themselves sufficient to improve the state of delirium, the Comprehensive Pathway outlines further interventions:
To try to identify how much of this rise comes from prescribing for those aged 65 years and over, the 0.5mg capsules and 1mg/ml liquid haloperidol are likely to be indicative.
In one Scottish NHS Board (see table below), we find that haloperidol prescribing in those aged 65 years and over in the acute hospital has nearly doubled since cognitive screening was introduced and monitored at NHS Board level.
This is a recent study published in the Lancet:
In these films Healthcare Improvement Scotland outlines that “OPAC assessment tools work, and are working in hospitals across Scotland”. There is no doubt that delirium is a condition associated with significant morbidity and mortality. It is also clear that we have a long way to go in understanding such a complex condition. Given this, my concerns about the over-reliance on brief tools used at outset and the marginalisation of consent are unchanged.
In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.
Update, 5th October 2016. The following was published on the front page of the Scotsman newspaper: "Mental health prescriptions hit ten-year high"
The figures are from the Scottish Government and can be accessed here.